Infections Flashcards
What is the general rule of thumb for treating Staphylococci infections?
Flucloxacillin
What is the general rule of thumb for treating MRSA infections?
Vancomycin
What is the general rule of thumb for treating Streptococci infections?
Benzylpenicillin and Phenoxymethylpenicillin
What is the general rule of thumb for treating anaerobic infections?
Metronidazole
What is the general rule of thumb for treating pseudomonas infections?
Gentamicin
What age are tetracyclines contraindicated for?
Under 12
What do quinolones cause?
Arthropathy (joint diseases e.g. arthritis) - mainly in children
Which antibiotics are hepatotoxic?
Rifampicin and tetracyclines
Which antibiotics are nephrotoxic?
Tetracyclines and nitrofurantoin in eGFR <45
Glycopeptides and aminoglycosides are also nephrotoxic
What bacteria is Leprosy (Hansen’s disease)?
Mycobacterium leprae
Which bacteria causes Lyme disease?
Borella burgdorferi
What is the main characteristic of Lyme disease?
erythema migrans rash (bull’s eye pattern)
Usually visible 1-4 weeks after bite
Which other symptoms present with Lyme disease?
Non-facial (non-organ related) symptoms e.g. fever, swollen glands, malaise, headache, cognitive impairment or paraesthesia (pins and needles)
others: focal symptoms (related to at least 1 organ) e.g. neurological (affecting cranial nerves, peripheral and CNS), joints (Lyme arthritis), cardiac (Lyme carditis) and skin manifestations
What is the treatment for erythema migrans rash with or without non-focal symptoms in Lyme disease?
1st line: oral doxycycline
2nd line: oral amoxicillin
if both can’t be given then oral azithromycin
What is the treatment of cranial nerve or peripheral nervous system involvement in Lyme disease?
1st line: oral doxycycline
2nd line: oral amoxicillin
What is the treatment for symptoms of CNS involvement in Lyme disease?
1st line: IV ceftriaxone
2nd line: oral doxycycline
What is the treatment for Lyme arthritis or acrodermatitis chronica atrophicans (almost like bruising on the skin)?
1st line: oral doxycycline
2nd line: oral amoxicillin
3rd line: IV ceftriaxone
What is the treatment for Lyme carditis in haemodynamically stable patients?
1st line: oral doxycycline
2nd line: IV ceftriaxone (this is the first line treatment if the patient is haemodynamically unstable then doxycycline when stable)
What Is the treatment pathway for skin and soft-tissue infections caused by MRSA?
1st line: tetracyclines alone OR a combination of rifampicin and fusidic acid
2nd line: clindamycin alone
3rd line: glycopeptide - vancomycin in severe cases
4th line: Linezolid in severe cases
If initial treatment fails: fusidic acid or rifampicin with glycopeptide
Complicated cases: tigecycline with daptomycin
What is the treatment of bronchiectasis from MRSA?
Tetracycline or clindamycin
What is the treatment for pneumonia from MRSA?
Glycopeptide or Linezolid
But needs to be given with an antibiotic that covers gram-negative as linezolid only covers gram-positive
What is the treatment for UTI from MRSA?
Oral doxycycline, trimethoprim, ciprofloxacin, or co-trimoxazole
What is the treatment for septicaemia (blood poisoning) associated with MRSA?
Glycopeptide
What is the treatment for prophylaxis of MRSA in surgery?
Vancomycin or teicoplanin alone or in combination with one another
Which bacteria cause UTIs in sexually active women?
Staph saprophyticus
Which bacteria generally causes UTIs?
E.coli
What is considered a recurrent UTI?
2 episodes in 6 months
What is the treatment for UTIs in non-pregnant women?
Either nitrofurantoin if eGFR >45ml/min OR trimethoprim
2nd line: nitrofurantoin (if not used 1st line), pivmecillinam, fosfomycin or amoxicillin
What is the treatment for UTIs in pregnant women?
1st line: nitrofurantoin if eGFR >45ml/min
2nd line: amoxicillin
asymptomatic bacteriuria: nitrofurantoin, amoxicillin or cefalexin (500mg BD 7/7) based on recent culture
What is the treatment for UTIs in men?
Trimethoprim or nitrofurantoin
2nd line: consider alternative diagnosis e.g. pyelonephritis (kidney infection) or prostatitis (inflammation of prostate)
What is the treatment for prostatitis?
1st line: ciprofloxacin or ofloxacin
2nd line: Levofloxacin, or co-trimoxazole
Why severely unwell - IV of:
- cefuroxime
- ceftriaxone
- ciprofloxacin
- gentamicin
- amikacin
What is the treatment of pyelonephritis in non-pregnant women and men?
1st line: Cefalexin, or ciprofloxacin
If sensitivity is known: co-amoxiclav or trimethoprim.
What is the treatment of pyelonephritis in pregnant women?
1st line: cefalexin
In severe cases: IV Cefuroxime
What is the treatment for recurrent UTIs in non-pregnant women?
1st line trimethoprim or nitrofurantoin
2nd line: amoxicillin or cefalexin (125 ON or 500mg 1 dose)
What is the treatment for recurrent UTIs in post-menopausal women?
vaginal oestrogen at the lowest effective dose and review in 12 months b
What is the treatment for catheter-associated UTI in pregnant women?
1st line: cefalexin
2nd line: IV cefalexin
What is the treatment for catheter-associated lower UTI in non-pregnant women and men?
1st line: amoxicillin, trimethoprim or nitrofurantoin
2nd line: pivmecillinam
What is the treatment for catheter-associated upper UTI in non-pregnant women and men?
1st line: cefalexin, ciprofloxacin, co-amoxiclav or trimethoprim
Which bacteria causes Tuberculosis?
Myobacterium tuberculosis (M. tuberculosis, M. africanum, M. bovis or M. microti)
What are the clinical signs of tuberculosis?
Persistent fever
Weight loss
Drenching night sweats
Dry cough
What is the initial treatment for tuberculosis with counselling points for each drug?
Two months of RIPE:
RIFAMPICIN: (enzyme inducer - do not use an oral contraceptive, use IUD)
- counselling: report signs of hepatotoxicity, may colour soft contact lenses and may turn urine an orange/red colour
ISONIAZID: (enzyme inhibitor)
- counselling: report signs of hepatotoxicity, which may cause peripheral neuropathy which is overcome by concomitant pyridoxine (10-20mg daily)
PYRAZINAMIDE:
- counselling: report signs of hepatotoxicity
ETHAMBUTOL:
- counselling: report visual changes immediately
What is the treatment of the continuation phase of tuberculosis?
4 months of 2 agents:
- rifampicin
- isoniazid
(10 months in active tuberculosis of CNS with or without spiral involvement)
What is the treatment regimen when there’s drug resistance to isoniazid in tuberculosis?
Initial phase: 2 months of
- Rifampicin
- Pyrazinamide
- Ethambutol
Continuous phase: 7 months of
- Rifampicin
- Ethambutol
What is the treatment regimen when there’s drug resistance to pyrazinamide in tuberculosis?
Initial phase: 2 months of
- Rifampicin
- Isoniazid (with pyridoxine hydrochloride)
- Ethambutol
Continuous phase: 7 months of
- Rifampicin
- Isoniazid
What is the treatment regimen when there’s drug resistance to ethambutol in tuberculosis?
Initial phase: 2 months of
- Rifampicin
- Pyrazinamide
- Isoniazid
Continuous phase: 4 months of
- Rifampicin
- Isoniazid
How do you treat latent TB?
6 months of isoniazid alone OR
Rifampicin and isoniazid for 3 months
How are immunocompromised (HIV or transplant) patients treated for tuberculosis?
They are treated with first-line and reviewed but for a maximum of 6 months if they have HIV unless there is CNS involvement then this is increased to 12 months
How do you treat extrapulmonary TB?
Initial treatment for 2 months
continuation treatment for 10 months
High dose of prednisolone or dexamethasone then slowly reduce over 4-8 weeks
How do you treat pericardial TB?
Offer a high dose of prednisolone at the same time as the initial treatment and withdraw after 2-3 weeks
How do you treat children with TB?
The same way as adults but monitor ethambutol closely as it is more difficult to test and confirm eyesight
Name 4 triazole antifungals
Triazole antifungals work in the prevention and systemic treatment of fungal infections
- Fluconazole - well absorbed
- Itraconazole - absorbed in acidic environments (stomach), hepatotoxicity common with this drug
- Posaconazole - used after the above two failed
- Voriconazole - broad spectrum for life-threatening conditions
What is the safety warning and main interaction for itraconazole?
cautioned use in patients at high risk of heart failure and hepatotoxicity
Interacts with antiacids as requires acidic pH to be absorbed
what are the safety warnings with voriconazole?
Photosensitivity
Hepatotoxicity
What are the 5 imidazole antifungals?
Used in local treatment of vaginal candidiasis and for dermatophyte infections
Clotrimazole
Econazole nitrate
Ketoconazole
Tioconazole
Miconazole
What is the MHRA warning for oral ketoconazole?
The risk of hepatotoxicity is greater than the benefit of treating fungal infections
Oral ketoconazole for Cushing’s syndrome and topical products containing ketoconazole are not affected by this advice.
What are the two polyene antifungals?
Amphotericin - IV for systemic infections
Nystatin
These are not absorbed when given orally
What is the MHRA warning and safety warning for amphotericin?
Warning of fatal overdoses when mistaking non-lipid and lipid formulations (AmBisome), prescribe by brand as not interchangeable
Associated with nephrotoxicity: anaphylaxis with IV preparations - do a test dose and monitor for 30 mind
What is flucytosine used for?
used in combination with amphotericin for systemic candidiasis and cryptococcal meningitis
What are the cautions for flucytosine?
Can cause bone marrow depression = needs weekly blood counts in prolonged therapy
Can develop resistance = test regularly
What is terbinafine used for?
Fungal nail infections and ringworm where oral treatment is considered appropriate
How do you treat candidiasis if topical preparations have failed?
Fluconazole
If unresponsive - itraconazole
If CNS or invasive - Amphotericin
Resistant - voriconazole
Refractory cases - flucytosine with iV amphotericin
How do you treat cryptococcosis or cryptococcal meningitis?
cryptococcal meningitis: IV infusion amphotericin and IV infusion flucytosine for 2 weeks
THEN oral fluconazole for 8 weeks or until cultures are negative
cryptococcosis: fluconazole only if amphotericin not tolerated
How do you treat mild-to-moderate pneumocystis pneumonia?
1st line: high dose co-trimoxazole
2nd line: atovaquone/ dapsone with trimethoprim by mouth
3rd line: clindamycin and primaquine by mouth but cause considerable toxicity
How do you treat severe pneumocystis pneumonia?
1st line: high dose co-trimoxazole
2nd line: pentamidine isetionate (potentially toxic) - risk of severe hypotension right after treatment
corticosteroids can also be lifesaving
What is the adjunctive therapy if the disease is associated with HIV in moderate-severe pneumocystis pneumonia?
Oral prednisolone for 5 days (alternatively, hydrocortisone parenterally)
- Dose then reduced to complete 21 days of treatment
- corticosteroid should be started at the same time as anti-pneumocystis therapy and no longer than 24-72 hours after
- corticosteroid should be withdrawn before anti-pneumocystis course is complete
What is the treatment for prophylaxis of pneumocystis?
This is given to all patients with history of infection and severely immunocompromised
Do not discontinue if the patient has oral candidiasis, continues to lose weight, or is receiving cytotoxic therapy or long-term immunosuppressant therapy
1st line: co-trimoxazole
2nd line: inhaled pentamidine isetionate is better tolerated than parenteral
3rd line: Dapsone OR atovaquone
How do you treat threadworms?
Treat all members of the family
Single dose of mebendazole then repeat 14 days
- DO NOT give in pregnant women or children under 2
How do you treat roundworm (ascariasis)
Mebenazole for 3 days
If not tolerated = levamisole as a special order
How do you treat tapeworms?
Nicolasmaide (Special order)
- limited to GI side effects
- can give antiemetic before and laxative after to help with the side effects
How do you treat hookworms?
Mebenazole for 3 days
Levamisole for children can be used
What are the side effects of proguanil?
GI side effects - rarely used alone, usually with chloroquine
How do you take proguanil?
1 week before travel and continue treatment for 4 weeks after returning
Can proguanil be given to women who are pregnant?
yes at normal doses
Given with folic acid to avoid neural tube defects
However, not effective in most malarial areas
also safe in breastfeeding patients
What are the cautions and side effects of mefloquine?
Do not use in:
- cardiac conduction disorders
- epilepsy
- psychiatric illness including depression, dizziness
side effects:
- GI
- nightmares
- psychosis
- skin reactions
- vision disorders
How do you take mefloquine?
weekly
2-3 weeks before travel
continue for 4 weeks after returning - licensed for up to 1 year but can be used for 3 years if no signs of harm
Can mefloquine be used in pregnancy and breastfeeding?
Good for high risk countries and if resistant to other drugs
Used in 2nd and 3rd trimester, caution in 1st trimester if benefit is higher than risk
Breastfeeding - risk to patient is minimal
What are the side effects of atovaquone with proguanil hydrochloride?
GI side effects and headaches
How do you use atovaquone with proguanil for malaria?
start 1-2 days before travel and continue for a week after travel
Can atovaquone with proguanil be used in pregnancy and breastfeeding?
Avoid
Can be considered in 2nd and 3rd trimester with folic acid to protect against neural tube defects
Which antimalarials can you use in epilepsy?
doxycycline or atovaquone with proguanil
chloroquine and mefloquine contraindicated
How should patients who take anticoagulants take antimalarials?
Travellers taking warfarin should begin prophylaxis 2-3 weeks before departure
INR should be stabilised before, 7 days after starting and after course
What is the treatment for unknown, mixed or uncomplicated falciparum malaria species?
Artemisinin combination therapy:
Artemether with lumefantrine
Quinine 600mg TDS 5-7 days with or followed by oral doxycycline 200mg OD for 7 days OR clarithromycin for 7 days
- Can be given IV if severely ill and can be given IV or orally in pregnant women but give them clarithromycin instead of doxycycline
Malarone (atovaquone with proguanil) - 4 tablets daily for 3 days - avoid in pregnancy
Riamet (artemether with lumefantrine) - 4 tablets initially, followed by 5 further doses of 4 tablets each at 8, 24, 36, 48 and 60 hours - avoid in pregnancy
What is the treatment for non-falciparum malaria?
Chloroquine
If resistant - malarone of riamet
Radical cure: primaquine for 14 days
In pregnancy: chloroquine or primaquine for radical cure
What antibiotics are contraindicated in children?
Tetracyclines ‘cycline’: avoid in under 12 as it deposits in growing bones and teeth
Quinolones ‘floxacin’ : tendon damage more common in children, only used in certain circumstances
Chloramphenicol: can cause grey-baby syndrome
Name 6 vancomycin side effects
Nephrotoxicity
Ototoxicity
Red man syndrome
Skin disorder: steven-johnson syndrome
Blood dyscrasias
Thrombophlebitis
Can tetracyclines be taken with ferrous sulphate?
Do not take ferrous sulphate within 2 hours of a tetracycline
What decreases the absorption of tetracyclines?
Antacids
Iron
Calcium
Zinc
Magnesium
Milk
Which antibiotics cause oesophageal irritation?
DOT
- Doxycycline
- Minocycline
- Tetracycline
Drink plenty of fluids sitting or standing
Which common antibiotic causes cholestatic jaundice?
flucloxacillin - for up to 2 months after stopping treatment
What antibiotics is C.diff most prevalent with?
Clindamycin
Cephalosporin
Fidoxamicin
What are the common side effects of metronidazole?
GI disturbances
Taste disturbances
Oral mucositis
Furred tongue
What are the counselling points for metronidazole?
Take with or after food
Avoid alcohol during treatment and 2 days after - causes disulfiram-like reactions
(hangover-like symptoms)
What is an important ADR of clindamycin?
Associated with Antibiotic-associated colitis (can be fatal with clindamycin) – if diarrhoea develops, stop immediately
> Middle-aged and elderly
women especially after
operations
Which bacteria is most likely to cause a LRTI?
Streptococcus pneumoniae
Which common antibiotics are taken on an empty stomach?
- Ampicillin
- Azithromycin
- Ciprofloxacin
- Levofloxacin
- Flucloxacillin
- Tetracyclines
- Phenoxymethylpenicillin
What increases the bioavailability of itraconazole?
Carbonated drinks
What is the treatment for shingles?
Aciclovir 800mg 5 times a day for 7 days
What are the four main side effects of quinolones?
Seizures – with or w/o previous history
Tendon damage – usually within 48 hours of starting treatment – stop if tendonitis suspected
Arthropathy – avoid in pregnancy and children
QT interval prolongation – especially moxifloxacin
What is the nystatin dose for children?
100,000 units QDS usually for 7 days and continued for 48 hours after lesions have resolved
Which antibiotic colours urine orange/red?
Rifampicin
Which antibiotics can be given during pregnancy?
Penicillins
Cephalosporins
Trimethoprim
What is the treatment for bacterial vaginosis?
metronidazole for 5-7 days
What is the treatment for influenza?
1st line: Oseltamivir given within 48 hours of exposure
2nd line: Zanamivir given within 36 hours of exposure
How does miconazole impact warfarin?
It increases the levels of warfarin
What is the treatment for acute otitis media for a child?
Amoxicillin 500mg TDS for 5 days
How do you take phenoxymethylpenicillin?
On an empty stomach an hour before food or two hours after food
What should the trough value be for gentamicin for endocarditis?
<1mg/L
What is the maximum duration of treatment for endocarditis with gentamicin?
7 days
How is nitrofurantoin taken?
With or just after a meal
What is the treatment for an infected animal bite (tetanus)?
Children over 1 month and adult: co-amoxiclav for 5 days (3 days for prophylaxis)
12-17 years: doxycycline and metronidazole for 5 days (3 for prophylaxis) days
Is trimethaoprim teratoegnic?
It is teratogenic in the first trimester
What factors increase the risk of tendon damage with ciprofloxacin?
corticosteroids and patients over 60
Can Atovaquone with proguanil be used in renal impairment?
Contraindicated in eGFR is less than 30mL/min
What is the safety warning with doxycycline?
Photosensitivity
How would you treat a UTI for a patient with an eGFR of 30ml/min and a penicillin allergy?
Trimethoprim but half the dose after 3 days for eGFR of 15-30 ml/min
If eGFR less than 15 then half the normal dose
Normal dose for lower UTI = 200mg BD for 3 days in women and 7 days for men
How should you use topical miconazole?
twice a day for 10 days after the lesions have healed
What drug should you not give trimethoprim with?
Methotrexate as they are both folate antagonists
What is the treatment for the exacerbation of chronic bronchitis?
Amoxicillin/ ampicillin
Alternatively: tetracyclines
What organism does Tobramycin cover?
pseudomonas
Which antifungal can you use for cushings syndrome?
Ketoconazole - initially 400-600mg daily in 2-3 divided doses, increased to 800-1200mg daily
Maintenance 400-800mg daily in 2-3 divided doses.
Which organism causes chickenpox?
Varicella Zoster
What is the treatment for chlamydia for children and adults over 12?
Doxycycline 100mg BD for 7 days
Azithromycin 1 g orally as a single dose for 1 day, followed by 500 mg orally once daily for 2 days.
What antibiotics are contraindicated in myasthenia gravis?
Aminoglycosides e.g. gentamicin - may impair neuromuscular transmission
What should be done when the peak of gentamicin is high?
Decrease the dose
Multiple daily dose regimens, one hour peak: 5-10mg/L
What should you do when the trough of gentamicin is high?
Increase the dosage interval
Multiple daily dose regimen, pre-dose: <2mg/L
What is the regular dose for phenoxymethylpenicillin in children aged 6-11?
250mg QDS, can be increased to 12.5mg/kg QDS
What is the minimum weight required to take Atovaquone 250mg/Proguanil 100mg?
40kg
What is the treatment for recurrent vaginal candidiasis?
Fluconazole 150mg every third day for a total of 3 doses followed by a 150mg once weekly maintenance dose for 6 months
Which antituberculosis is NOT linked to liver toxicity?
Ethambutol
What is the treatment for meningitis?
Aciclovir IV 700mg TDS
What drug can’t you give penicillins with?
Methotrexate - penicillins reduce the excretion of methotrexate = toxicity
Can you give a patient penicillin if they have a Cefalexin allergy?
Cefalexin’s are beta lactams which has a similar structure to penicillin
If a patient is allergic to Cefalexin - avoid penicillins to as they may react to this due to the similar structure
How do you treat mild diabetic foot infections?
Flucloxacillin 500mg-1g QDS for 7 days
Penicillin allergy
- Clarithromycin 500mg BD 7 days
- Erythromycin 500mg QDS 7 days
- Doxycycline 200 mg on first day, then 100 mg once a day (can be increased to 200 mg daily) for 7 days
How do you treat moderate to severe diabetic foot infections?
Flucloxacillin 1g QDS WITH OR WITHOUT Gentamicin 5 to 7 mg/kg once a day IV AND OR metronidazole 400mg TDS/ 500mg TDS IV
Co-amoxiclav 500/125mg TDS or 1.2 TDS IV WITH OR WITHOUT gentamicin AND OR metronidazole
Ceftriaxone 2g OD IV WITH metronidazole
When are oseltamavir and Zanamivir licensed for use?
Within 48 hours of the first symptom
Post-exposure prophylaxis:
Oseltamivir - within 48 hours of exposure to influenza
Zanamivir - within 36 hours of exposure to influenza
Cna be given unlicensed after this time in severe influenza or immunocompromised patients
How do you treat localised non-bolus impetigo?
1st line: hydrogen peroxide 1% cream BD/TDS for 5 days
2nd line: fusidic acid 2% TDS for 5 days
3rd line: topical mupirocin 2% TDS for 5 days
How do you treat widespread non-bolus impetigo in patients who are systemically unwell ages >18?
Flucloxacillin 500mg QDS for 5 days
Allergy: Clarithromycin 250mg BD for 5 days (in severe infections 500mg)
Pregnant + allergy = erythromycin 250-500mg QDS for 5 days
How do you treat widespread non-bolus impetigo in patients who are systemically unwell ages <18?
1 month - 1 year: 62.5-125mg flucloxacillin QDS for 5 days
2-9 years: 125-250mg flucloxacillin QDS for 5 days
10-17: 250-500mg flucloxacillin QDS for 5 days
What would you add to the treatment if streptococci is suspected in severe impetigo infection?
phenoxymethylpenicillin
allergy: clarithromycin/ erythromycin/ azithromycin for 7 days
How do you treat new onset genital herpes?
Start treatment within 5 days of 1st episode while new lesions are still forming
1st line: Aciclovir 400mg TDS for 5 days OR Valaciclovir 500mg BD for 5 days
2nd line: Aciclovir 200mg 5 times a day for 5 days OR
Famciclovir 250mg TDS for 5 days
If new lesions form while on treatment - extend to 10 days
How do you treat an immunocompromised patient with genital herpes?
Aciclovir 400mg 5 times a day for 7-10 days OR
Valaciclovir 500-100mg BD for 10 days OR
Famciclovir 250-500mg TDS for 10 days
How do you treat episodic treatment (<6 per year) of genital herpes?
Aciclovir 800mg TDS for 2 days OR
Famciclovir 1000mg BD for 1 day OR
Valaciclovir 500mg BD for 3 days
What is the suppressive treatment for genital herpes (>6 episodes per year)?
Aciclovir 400mg BD (TDS if immunocompromised/ breakthrough dose)
Famciclovir 250mg BD (500mg if immunocompromised)
Valaciclovir 500mg OD (BD if immunocompromised)
How do you treat oral herpes in people ages 2-18 years?
Aciclovir 400mg TDS
immunocompromised = double dose
How do you treat oral herpes in 1 month - 2 years?
Aciclovir 100mg 5 times a day for 5 days
How do you treat patients with oral herpes using valaciclovir?
Patients who are 12 and over: 500mg BD for 5 days (10 if new lesions appear)
recurrent episode: 500mg BD for 3-5 days
Herpes labialis: 2000mg BD for 1 day
Immunocompromised: 1000mg BD for 10 days
Which antibiotic can cause black hairy tongue?
Amoxicillin - very rare side effect
What is the treatment for prevention and recurrence of rheumatic fever?
phenoxymethylpenicillin or sulfadiazine
How do you treat prevention of secondary cases of meningococcal meningitis?
1st line: ciprofloxacin or rifampicin or IM ceftriaxone
What is the treatment for antibacterial prophylaxis of pertussis (whopping cough)?
Clarithromycin (or azithromycin or erythromycin)
Within 3 weeks of onset of cough
What is the blind therapy for native valve endocarditis?
1st line: amoxicillin or ampicillin
- consider low-dose gentamicin as add-on
Allergy or meticillin-resistant staphylococcus aureus or if severe sepsis
- Vancomycin + low-dose gentamicin
If severe with risk factors for gram-negative infection
- Vancomycin + meropenem
If prosthetic valve endocarditis (same for non-blind therapy)
- Vancomycin (or flucloxacillin if not allergy) + rifampicin + low-dose gentamicin
How do you treat native valve endocarditis cause by staphylococci?
Flucloxacillin
If penicillin allergic or meticillin resistant staphylococcus aureus
- Vancomycin + rifampicin
Treatment duration: 4 weeks (at least 6 weeks if secondary lung abscess or osteomyelitis also present)
How do you treat endocarditis caused by fully-sensitive streptococci?
Benzylpenicillin
Allergy: vancomycin (or teicoplanin) + low-dose gentamicin
For 4 to 6 weeks (6 weeks if prosthetic valve) - review need for gent after 2 weeks
How do you treat endocarditis cause by less-sensitive streptococci?
Benzylpenicillin + low-dose gentamicin
Allergy or highly resistant: vancomycin + low-dose gentamicin
How do you treat endocarditis caused by enterococci?
Amoxicillin + low-dose gentamicin OR
benzylpenicillin + low-dose gentamicin
If penicillin allergy or penicillin-resistant
- Vancomycin + low-dose gentamicin
If gentamicin resistant
- amoxicillin (add streptomycin for 2 weeks if susceptible)
How do you treat meningitis cause by meningococci?
Benzylpenicillin or cefotaxime (or ceftriaxone)
For 7 days
If history of sensitivity
- chloramphenicol
How do you treat meningitis cause by pneumococci?
Cefotaxime (or ceftriaxone)
(consider adjunctive treatment with dexamethasone before or with first dose to antibacterial but no later than 12 hours after)
If micro-organism penicillin-sensitive
- benzylpenicillin
If micro-organism highly penicillin and cephalosporin sensitive
- add vancomycin
Treatment: 14 days
What is the treatment for otitis externa?
If pseudomonas suspected:
- ciprofloxacin (or aminoglycoside)
No penicillin allergy:
- flucloxacillin
Penicillin allergy or intolerance:
- Clarithromycin (or erythromycin or azithromycin)
How do you treat otitis media?
In a child without a penicillin allergy
- 1st line: amoxicillin
- 2nd line: (worsening symptoms after 2-3 days antibacterial therapy) co-amoxiclav
Penicillin allergy:
- 1st line: clarithromycin or erythromycin
What is the treatment for C.diff infection?
First episode of mild, moderate or severe c.diff:
- 1st line: vancomycin
- 2nd line: fidaxomicin
Further episode of C.diff:
- 1st line for infection within 12 weeks of symptom resolution - fidaxomicin
- 1st line for infection more than 12 weeks of symptom resolution - vancomycin
Life-threatening:
- vancomycin with IV metronidazole
How do you treat bacterial vaginosis?
Oral metronidazole for 5-7 days
OR
Topical metronidazole for 5 days or topical clindamycin for 7 days
How do you treat uncomplicated genital chlamydial infection and non-gonococcal urethritis?
1st line: doxycycline
2nd line: azithromycin
How do you treat sinusitis?
No penicillin allergy:
1st line: non-life threatening symptoms - phenoxymethylpenicillin
- if systemically unwell - co-amoxiclav
2nd line (worsening of symptoms despite 2-3 days of antibacterial):
- non-life threatening symptoms - co-amoxiclav
Penicillin allergy:
1st line: doxycycline or clarithromycin (erythromycin in pregnancy)
Which penicillin is active against beta-lactamase producing bacteria?
Co-amoxiclav
Also good for:
- dental infections with spreading cellulitis
- dental infections not responding to 1st line treatments
If infections due to steptococci become resistant to penicillin, what else are they resistant to?
cephlosporins
What should be considered in an oral infection in penicillin-allergic patients or where a beta-lactamase producing organism is involved?
Macrolides
What is the treatment for acute cough?
1st line: doxycycline
2nd line: amoxicillin, clarithromycin, or erythromycin
Pregnancy choices: amoxicillin or erythromycin
What is the treatment for low severity CAP?
1st line: amoxicillin
Alternative if allergy or atypical pathogen suspected: clarithromycin, doxycycline or erythromcyin
What is the treatment for moderate severity CAP?
1st line: amoxicillin
If atypical pathogen suspected:
Amoxicillin WITH clarithromycin or erythromycin
If penicillin allergy: clarithromycin or doxycycline
What is the treatment for high severity CAP?
Oral or IV
Co-amoxiclav WITH clarithromycin or oral erythromycin
If penicillin allergy: levofloxacin
What is the treatment for HAP if the patient has non-severe symptoms and not at high risk of resistance?
1st line: co-amoxiclav
If penicillin allergy or co-amoxiclav unsuitable:
doxycycline, cefalexin (caution in penicillin allergy), co-trimoxazole, or levofloxacin
What is the treatment for HAP if the patient has severe symptoms or is at high risk of resistance?
IV
1st line: piperacillin with tazobactam, ceftazidime, ceftazidime with avibactam, ceftriaxone, cefuroxime, levofloaxcin or meropenem
If meticillin-resistant staphylococcus aureus confirmed or suspected
- Add vancomycin
How do you treat cellulitis or erysipelas near the nose or eyes?
Oral or IV
Co-amoxiclav
If allergy or unsuitable: clarithromycin with metronidazole
How do you treat cellulitis or erysipelas?
Oral or IV
flucloxacillin
- Child 1 month–1 year: 62.5–125 mg 4 times a day for 5–7 days then review.
- Child 2–9 years:125–250 mg 4 times a day for 5–7 days then review.
- Child 10–17 years: 250–500 mg 4 times a day for 5–7 days then review.
- Adult: 0.5–1 g 4 times a day for 5–7 days then review
If allergy or unsuitable:
clarithromycin, erythromycin, or doxycycline
How do you treat non-severely unwell patients for leg ulcers?
1st line: Flucloxacillin
Allergy/ unsuitable:
doxycycline, clarithromycin, erythromycin
2nd line:
co-amoxiclav
Allergy/ unsuitable:
co-trimoxazole
How do you treat severely unwell patients for leg ulcers?
Oral or iV
1st line: IV flucloxacillin with or without IV gentamicin and or metrondiazole
OR
IV co-amoxiclav with or without IV gentamicin
allergy/unsuitable:
co-trimoxazole with or without gentamicin and or metronidazole
2nd line:
IV piperacillin with tazobactam or IV ceftriaxone with or without metronidazole
What is the prophylactic treatment for human or animal bites?
Oral 1st line: co-amoxiclav
Allergy/unsuitable: doxycycline with metronidazole
IV 1st line: co-amoxiclav
Allergy/unsuitable: cefuroxime, ceftriaxone WITH metronidazole
What is the treatment for secondary bacterial infections of common skin conditions?
Topical 1st line:
Fusidic acid
If unsuitable - offer oral antibacterial
Oral 1st line:
Flucloxacillin
Allergy/unsuitable: clarithromycin or erythromycin
How do you treat mastitis during breast-feeding?
treat if severe, systemically unwell, nipple fissure present, if symptoms do not improve after 24-48 hours of effective milk removal
Continue breast-feeding or expressing milk during treatment
1st line: flucloxacillin for 10-14 days
allergy/unsuitable: erythromycin for 10-14 days
What is the MHRA warning for aminoglycosides?
Increased risk of deafness in patients with mitochondrial mutations - rare cases of ototoxicity
What is the contraindication for aminoglycosides?
Myasthenia gravis - may impair neuromuscular transmission
What are the common side effects of aminoglycosides?
Aphonia (loss of voice)
Appetite decreased
Bronchospasm
Chest discomfort
Cough
Deafness
Diarrhoea
Dizziness
Fever
Headache
RENAL IMPAIRMENT
Skin reactions
Altered taste
Tinnitus
N/V
What is the MHRA warning for gentamicin?
potential for histamine-related adverse drug reactions with some batches
What should the serum concentrations for gentamicin be?
Multiple daily dose reigmen
1 hours after IM/IV (peak): 5-10mg/L
Pre-dose trough : <2mg/L
Multiple daily dose regimen in endocarditis:
Peak: 3-5mg/L
Trough: <1mg/L
Measure after 3 or 4 doses
What kind of bacterials are carbapenems?
Beta-lactam, with broad spectrum of activity
Which other class of antibiotics should you avoid in patients with a penicillin allergy?
Cephalosporins
If not alternative, use the following with caution:
cefixime, cefotaxime, ceftazidime, ceftriaxone, cefuroxime
AVOID:
cefaclor, cefadroxil, cefalexin, cefradine, ceftaroline
What are the common side effects of cephalosporins?
Abdominal pain
Diarrhoea
Dizziness
Eosinophilia
Headache
Leucopenia
N/V
Neutropenia
Pseudomembranous enterocolitis
Skin reactions
Thrombocytopenia (deficiency in platelets - causes bleeding)
Vulvovaginal candidiasis
What is a specific side effect of clindamycin?
Associated with antibiotic-associated colitis
- if c.diff suspected or confirmed: discontinue Abx if appropriate
What needs to be monitored if clindamycin therapy exceeds 10 days?
Liver and renal function
What are the MHRA warnings for erythromycin?
Caution required due to cardiac risks (QT prolongation) and drug interactions with rivaroxaban
- do not give in pt with history of prolonger QT or ventricular arrhythmia or those with electrolyte disturbances
- rivaroxaban: increases risk of bleeding
Increase in infantile hypertrophic pyloric stenosis
- highest in first 14 days after birth
What are the MHRA warnings for quinolones?
Tendon damage within 48 hours of starting treatment; risk increase by:
- history of tendon damage
- ages >60
- concomitant use of corticosteroids
if suspected - stop
Systemic and inhaled fluoroquinolones: small increases risk of aortic aneurysm and dissection
Side effects affecting nervous system and musculoskeletal system
Systemic and inhaled fluoroquinolones: small increases risk of heart valve regurgitation; consider other therapeutic options first in patients at risk
What is the interaction between quinolones and NSAIDs?
Convulsions if they are taken together
What are common side effects of tetracyclines?
Angioedema
Diarrhoea
Headache
Henoch-Schonlein purpura (inflamed vessels)
Hypersensitivity
N/V
Pericarditis
Photosensitivity reactions
Skin reactions
Systemic lupus exacerbated
What is in sprays that helps protect against malaria?
Diethyltoluamide (DEET) - can be used during pregnancy and breastfeeding too but must wash hands and breast tissue before handling the baby
Should be applied AFTER sunscreen - reduces the SPF in the sunscreen = wear SPF30-50
Safe in children over 2 months and adults
How should chloroquine, proguanil, mefloquine, Atovaquone with proguanil and doxycycline be taken?
Chloroquine (310mg) - 1 week before travel
Proguanil - 1 week before travel
Mefloquine - 2-3 weeks before travel
Atovaquone with proguanil - 1-2 days before travel
Doxycycline - 1-2 days
Prophylaxis should be continued for 4 weeks after leaving the area
Apart from Atovaquone with proguanil which needs to be stopped 1 week after leaving
How long would malaria be suspected for after travels?
Any illness within ONE year and especially within 3 months of return might be malaria
How do you treat acute diverticulitis?
For patients who are systemically unwell, immunocompromised or have significant co-morbidities
Suspected or confirmed uncomplicated:
1st line: co-amoxiclav
2nd line: cefalaxin with metronidazole OR
- Trimethoprim with metronidazole OR
- Ciprofloxacin
Suspected or confirmed complicated:
1st line: IV co-amoxiclav or cefuroxime with metrondiazole OR
- Amoxicillin with gentamicin and metronidazole
Allergy: Ciprolofaxin with metronidazole
Why should tetracyclines be avoided in children under 12?
Causes deposition in growing bone and teeth which can lead to staining of the teeth
Can trimethoprim be used in pregnancy?
Avoid in first trimester - teratogenic and folate agonist
When do you take serum-vancomycin measurement?
On the second day of treatment immediately before the second dose
Pre-dose (trough) concentration: 10-20mg/L
What is the HIV treatment in ‘treatment-naive’ patients?
2 nucleoside reverse transcriptase inhibitors (NRTI)
+
1 of the following:
- Integrase inhibitor (INI)
- Non-nucleoside reverse transcriptase inhibitor (NNRTI)
- Boosted protease inhibitor (PI)
What drugs can be chosen from for the NRTI as the backbone part of the HIV treatment?
Option 1: emtricitabine + tenofovir disoproxil OR tenofovir alafenamide
Option 2: abacavir + lamiivudine
Option 3: atazanivir or darunavir + ritonavir OR dolutegravir OR elvitegravir
Which Abx can cause hyperkalaemia?
Trimethorpim
What is the interaction between methotrexate and trimethoprim?
They both antagonise folate - increased risk of haematological adverse effects and bone marrow suppression
What is the one hour ‘peak’ dose concentration be for gentamicin?
5-10mg/L
What should the pre dose ‘trough’ gentamicin concentration be?
<2mg/L
What should the one hour ‘peak’ concentration for gentamicin in endocarditis be?
3-5mg/L
What is the treatment for scarlet fever?
1st line: PenV 250mg QDS for 10 days
2nd line:
Birth to 6 months - clarithromycin for 10 days.
Non-pregnant adults and children aged 6 months to 17 years - azithromycin for 5 days, or clarithromycin for 10 days.
Pregnant or postpartum (within 28 days of childbirth) — erythromycin for 10 days.
What is the MHRA warning for Hydroxychloroquine, chloroquine?
Risk of cardiovascular events when given with macrolides
Psychiatric reactions with chloroquine
How do you treat osteomylitis?
Flucloxacillin (clarithromycin if penicillin allergic)
- consider adding fusidic acid or rifampicin for initial 2 weeks
- duration of treatment: 6 weeks for acute infection
How do you treat an acute exacerbation of COPD?
Duration: 5 day treatment
1st line: amoxicillin, clarithromycin or doxycycline
- if high risk of treatment failure: co-amoxiclav or fluxclox
Which Abx can cause red-man syndrome?
Vancomycin
