Infections Flashcards
1
Q
What is used in guiding selection of antibiotic
A
Kirby-Bauer method
2
Q
What is used to determine lowest conc. of antibiotic that inhibits visible bacterial growth vs conc. that kills >99.9% bacteria
A
Dilution test
3
Q
How do antibiotics that inhibit cell wall synthesis act?
A
- Inhibits synthesis of peptidoglycan
- bind irreversibly to penicillin binding protein
- leads to cell death
4
Q
What class of antibiotics don’t need b-lactamase inhibitors
A
- Monobactams
- Carbapenem
5
Q
General side effects of b-lactactame antibiotics
A
Nausea and diarrhoea
6
Q
Examples of b-lactamase inhibitors
A
Tazobactam
Clavulanic acid
7
Q
What class of drugs interfere with bacteria cell wall
A
‘PCCM’
- penicillin
- cephalosporins
- carbapenems
- monobactams
8
Q
Side effects of fosfomycin
A
Nausea
Diarrhoea
Dizziness
Headache
9
Q
Side effects of cycloserine
A
Neurological and psychological disturbances
10
Q
Side effects of vancomycin
A
- Hypotension
- Flushing (red man syndrome)
- Nephrotoxicity
- Ototoxicity
- Blood disorders
11
Q
What drugs are used in tuberculosis
A
Isaniazid
Ethambutol
12
Q
Side effects of isoniazid
A
Hepatotoxicity
Peripheral neuropathy
(tingling, constipation, numbness, diarrhoea)
13
Q
Side effects of ethambutol
A
Vision loss
14
Q
What drugs are CI in penicillin allergy
A
Cephalosporins
15
Q
Which cephalosporins are excreted by the liver
A
Ceftriaxone
Cefoperadone
the rest are excreted by the kidney
16
Q
What drug interferes with the absorption of penicillin and cephalosporins
A
Probenecid - used in gout and gouty arthritis
17
Q
Side effects of cephalosporins
A
- hypersensitivity
- GI distress - C.Diff & Diarrhoea
- Rare haemolytic anaemia
- Severe bleeding
18
Q
What is used as an alternative to cephalosporin
A
- gram +: Monobactams
- gram -: Macrolides
19
Q
What cephalosporins have disulfiram like action
A
Cefoperazone
Cefotitan
intolerance to alcohol
20
Q
Examples of first gen cephalosporins
A
’cefa’
- Cefazolin
- Cefalexin
- Cefradine
21
Q
Examples of second gen cephalosporins
A
- Cefaclor
- Cefuroxime
- Cefotetan
22
Q
Examples of third gen cephalosporins
A
’ime, one, ten, ir except cefuroxime’
-Ceftriaxone
- Cefotaxime
- Cefixime
23
Q
Does the third gen cephalosporins cross BBB
A
Yes
and cefuroxime
24
Q
What cephalosporin can be used for surgical prophylaxis
A
Cefazoline
long half life
25
What cephalosporin can be used in meningitis
Cefuroxime
*crosses BBB*
26
What cephalosporins are used in resistant infection
Cefuroxime
Cefoxitin
27
Symptoms of infection
- Fever, aches and pains
- Pus, swelling or inflammation
- Drowsiness in children
- Confusion in elderly
- Worsening renal function
28
Clinical markers of infection
- Low blood pressure
- Raised blood glucose (**hyperglycaemia**)
- High ESR, C-receptive protein, temperature, respiratory rate, pulse
29
What are the cell membrane integrity disruptors
Daptomycin
Polymyxins
30
Side effect of daptomycin
Skeletal muscle toxicity
31
Side effect of polymyxins
Nephrotoxicity
Neurotoxicity
32
What type of bacteria do cell wall synthesis inhibitors work on?
Rapidly dividing bacteria
33
Which penicillin is resistant to b-lactamase
Flucloxacillin
34
Route of administration of Pen G and why
*Benzylpenicillin*
**IV / IM**
They are destroyed by gastric acid when given orally
35
What infection are Pen G and Pen V used to treat
Syphilis - *T.pallidum*
Jaw infections
*the ‘cocci’ infections*
- Streptococci (Depot)
- Pneumococci
- Meningococci
36
What type of penicillin are amoxicillin and ampicillin
Broad spectrum b-lactam sensitive
37
Between amoxicillin and ampicillin, which has the least GI side effects
Amoxicillin
38
Does amoxicillin have a food interaction?
No
*ampicillin does*
39
What is the main use of amoxicillin in infections
Lungs: **COPD, pneumonia, bronchiectasis**
40
When is ampicillin used
Listeria (meningitis)
41
When are PipTaz used? *(Extended spectrum penicillin)*
UTIs
Burns
HAP
42
How are penicillins excreted?
*Exception?*
**Renally**
*Except; **Nafcillin & Oxacillin** which is excreted by the liver*
43
What penicillin drugs are excreted by the liver?
Naficillin
Oxacillin
44
Side effects of penicillin
- Hypersensitivity reaction
- GI distress
- Jarisck herxheimer (siphylis)
45
When **shouldn’t** Broad spectrum penicillin (amoxicillin and ampicillin) be given
**Blindly for sore throat** - *glandular fever* (causes rash that can be mistaken for hypersensitivity)
46
How should ampicillin be taken
Before food
47
Main side effect of amoxicillin
**Cholestatic jaundice**- *do not exceed 14 days*
48
Main side effect of Flucloxacillin
Cholestatic jaundice
Hepatitis
49
How should Flucloxacillin be taken
Before food
50
What type of infections are vancomycin used to treat
MRSA
Enterococci
Also C. diff
51
Trough target for vancomycin
10-15 mg/ml
15-20 mg/ml in endocarditis
52
Drugs that target nucleic acid synthesis
- Metronidazole
- Quinolones
- Rifampicin
53
Use of metronidazole
Dental infections
Vaginal trichomoniasis
54
Side effects of metronidazole
- **Taste disturbances**
- **Furred tongue**
- **Oral mucositis**
- GI disturbance
55
Counselling for metronidazole
**Avoid alcohol**
Take with it after food
56
What to do if peak level is high?
Reduce dose
Maintain interval
57
What to do if trough is high but peak is okay
Maintain dose
Increase interval
58
When should patient report illness after visiting a malaria region
Within 1 year
Especially within 3 months of return
59
What is used to treat externa otitis
- **Flucloxacillin**
- Clarithromycin/ azithromycin/ erythromycin - *Pen allergy*
- Ciprofloxacin/ aminoglycoside
60
A woman is one week away from giving birth and has contracted UTI. What is the best treatment and why?
**Cefalexin**
*Trimethoprim - teratogenic*
*Nitrofurantoin - Avoid at term*
61
What age is tetracycline CI
< 12 years
62
What age should quinolones be avoided
**< 18 years**
*Cause disease of the joint - arthropathy*
63
What class of antibiotics should be avoided in renal impairment
- Aminoglycosides (gentamicin, amikacin,etc)
- Glycopeptides (vancomycin)
- Tetracyclines
- Nitrofurantoin
*Nephrotoxicity*
64
What antibiotics should be avoided in Hepatotoxicity
- Tetracycline
- Rifampicin
65
What antibiotics cause cholestatic jaundice
Amoxicillin
Flucloxacillin
66
What antibiotics are contraindicated in pregnancy
‘**C**arrying **M*others **C**annot **T**ake **A**ntibiotics’
- **Clarithromycin**
- **Metronidazole**
- **Chloramphenicol** *(grey-baby syndrome)*
- **Tetracycline** *(affects skeletal development, risk of discolouration of child’s teeth - 2nd/3rd trimester)*
- **Aminoglycosides** *(auditory or vestibular nerve damage - 2nd/3rd trimester)*
67
General antibiotic cautionary and advisory label
Space the doses evenly throughout the day
Keep taking this medicine until the course is finished, unless you are told to stop.
68
Antibiotics associated with C.diff (antibiotics associated colitis) and thrush (Candida) eg. Vaginal thrush
- Clindamycin
- Broad spec penicillin (amoxicillin & ampicillin)
69
What is used to treat infections caused by staphylococcus
Flucloxacillin
70
What is used to treat infections caused by MRSA
**Vancomycin**
Linezolid
71
What is used to treat infections caused by streptococcus
Benzylpenicillin (Pen G)
Phenoxymethylpenicillin (Pen V)
72
What is used to treat infections caused by anaerobic bacteria
Metronidazole
73
What is used to treat infections caused by pseudomonas aeruginosa
Gentamicin
74
What is the causative agent of Community Acquired Pneumonia (CAP)
**Staphylococcus** - Flucloxacillin
75
What is the causative agent of impetigo or cellulitis (skin)
**Staphylococcus** - Flucloxacillin
76
Warning sign of C.diff and what to do
**Diarrhoea**
STOP antibiotic and see a GP
77
When is linezolide used?
As an alternative to vancomycin in MRSA infection
78
Side effect of linezolid
- **Blood disorders** (STOP if bone marrow suppression)
- **Optic neuropathy** especially when used over 28 days. (Report visual symptoms)
79
Linezolid interaction with food
Tyramine (cheese, soya beans)
80
Linezolid drug interactions
**Antidepressants**
SSRIs, TCAs or MAOi
81
Wash out period of linezolid
2 weeks
82
Trimethoprim dose
200mg BD
83
Side effect of trimethoprim
**Blood dyscrasias**: long term use
Hyperkalaemia
84
When is co-trimoxazole used
- **pneumocystis jirovecii pneumonia**
- Leg ulcer - pen allergy
- diabetic foot infection
85
Side effects of co-trimoxazol
- Rashes
- SJS
- Photosensitivity
- Blood dyscrasia (long term use)
- Hyperkalaemia
86
Side effects of chloramphenicol
- Blood dyscrasias
- Grey baby syndrome (avoid in pregnancy)
87
What type of bacteria is metronidazole active against
**Anaerobic bacteria**
Bacterial vaginosis
88
Side effects of metronidazole
- Furred tongue
- Dark urine
- Taste disturbances
- Liver enzyme increase
- Nausea/ vomiting
- GI disturbances (take with or after food)
89
Nature of interaction: Metronidazole and alcohol
Disulfriam-like reaction
*Avoid alcohol during the course for at least 48 hours after*
90
How is metronidazole taken?
With or after food
Avoid alcohol
91
Side effect of nitrofurantoin
- Blood dyscrasias
- Acute pulmonary reactions
- Cholestatic jaundice
- Peripheral neuropathy
92
When should nitrofurantoin be avoided?
- Renal impairment **eGFR <45**
- Infants **< 3 months old**
- Acute porphyria
93
How is nitrofurantoin taken?
With or after food
94
Nitrofurantoin and urine
Yellow / brown
95
Nitrofurantoin dose
IM **tx: 50mg QDS**
IM **Prophylaxis: 50-100mg ON**
MR **Tx: 100mg BD**
96
Examples of aminoglycosides
**Gentamicin**
**Tobramycin** *(via inhaler in cystic fibrosis)*
**Amikacin** *(gentamicin resistant gram - bacilli)*
**Streptomycin** *(tuberculosis)*
97
How are aminoglycosides given?
Parenteral route
*Not absorbed by the gut*
98
How is gentamicin used in blind therapy?
With metronidazole and/or penicillin
99
When to avoid **OD** gentamicin
- Renal impairment **<20ml/min**
- HACEK or gram(+) endocarditis
- Burns cover > 20% of body
100
When to monitor gentamicin
After 3 or 4 doses
After dose change
101
Target plasma levels of gentamicin
**Peak**: 5-10mg/ml *(3-5mg/ml for endocarditis)*
**Trough**: <2mg/ml *(<1mg/ml)*
*sample taken **1 hour** after dose*
102
What do you do to gentamicin dose in renal impairment
Increase intervals
Severe: reduce dose
103
Side effects of gentamicin
Nephrotoxicity
Ototoxicity *(report hearing loss, tinnitus, or vertigo)*
104
Drugs that increase risk of nephrotoxicity with gentamicin
- Ciclosporin
- Tacrolimus
- Vancomycin
105
Aminoglycosides in pregnancy
**Avoid**
Auditory and vestibular damage in 2nd and 3rd trimester
*risk small with gentamicin*
106
Duration of treatment with aminoglycosides
7 days
107
Aminoglycosides with loop diuretics counselling
**Ototoxicity**
Separate by long period as possible
108
When is gentamicin contraindicated
Myasthenia gravis - muscle weakness
109
Electrolyte imbalance of aminoglycosides
Hyp**O** K, Ca and Mg
110
MHRA warning with gentamicin
Histamine related adverse drug reactions
111
Examples of glycoproteins
- Vancomycin
- Teicoplanin
- Telavacin (only in HAP when other antibiotics are unsuitable)
112
How are glycoprotein given
Parenteral rout
*Not by mouth in systemic infections*
113
When is vancomycin used?
- Antibiotic associated colitis
- MRSA infections
114
Target trough concentration of vancomycin
**10-15 mg/ml**
15-20 mg/ml for endocarditis
115
When should vancomycin be stopped?
Tinnitus
*(Ringing sound in ears)*
116
Most common side effect associated with vancomycin
**thrombophlebitis**
*Pain and inflammation at injection site*
117
Examples of tetracycline
- Democycline
- Doxycycline (used in malaria and chlamydia)
- Lymecyline
118
Side effects of tetracycline
**’POST’**
- Photosensitivity
- Oesophageal irritation
- **Severe headaches** (benign intracranial hypertension)
- Tooth discolouration
- **Visual disturbances**
119
When to stop tetracycline
Headache or visual disturbances
120
When are tetracyclines contraindicated
- Children under 12
- Pregnancy and breastfeeding
*Deposits in growing bone and teeth and cause tweety discolouration and dental hypoplasia*
121
Side effect of minocycline
- Irreversible pigmentation
- Greater risk of lupus-erythematosus-like syndrome
- Dizziness and vertigo
122
What two tetracyclines can be used in renal impairment
**’DM’**
Doxycycline
Minocycline
123
Tetracyclines in hepatic impairment
Avoid - hepatotoxicity
124
What tetracyclines cause photosensitivity
‘Double **D**s’
**Doxycycline**
**Democycline**
125
What tetracyclines do you avoid ingestion remedies with
‘**D**ox **L**ike **M**ilk’
Doxycycline
Lymecycline
Minocycline
+ Azithromycin (tabs)
*2 hours before and after*
126
What tetracyclines are avoided with milk
‘**DOT**’
- Democlocycline
- Oxytetracycline
- Tetracycline
127
What tetracyclines need to be swallowed whole and taken standing with a full glass of water
‘**DMT**’
- Doxycycline
- Minocycline
- Tetracycline
*+ clindamycin*
128
When to avoid quinolones
MRSA - Innate resistance
129
When are quinolones used?
Lower RTI
UTIs
130
Examples of quinolones
Ciprofloxacin
Levoflaxacin
Moxifloxacin
Nalidixic acid
131
Main side effect of quinolones
QT prolongation
*Esp. Moxifloxacin (associated with life threatening hepatotoxicity*
132
Side effects of quinolones
- **QT prolongation**
- **Seizures**
- **Tendon damage**
- Heart valve regurgitation
- Aortic aneurysms
133
Quinolones in pregnancy
Avoid - Arthropathy
134
When to discontinue quinolones
- Psychiatric, neurological and hypersensitivity reactions occur
- Tendonitis
135
When should quinolones be avoided
- Pregnancy
- Children / adolescents
136
Drug interaction with quinolones that increase risk of QT prolongation
- SSRI
- quinine
- Amiodarone
- macrolides
- antipsychotic
137
Drug interaction with quinolones that increase risk of seizures
- ciproflaxacin
- theophylline
- **NSAIDs**
138
Main drug interactions with quinolones
- **QT Prolonging drugs** - increased risk of QT prolongation
- **Corticosteroid** - risk of tendonitis or tendon damage
- **Methotrexate** - increase methotrexate levels
- **NSAIDs** - increased risk of seizures
- **Theophylline** - increased theophylline levels
139
Counselling points for quinolones
- **Driving**; can impair performance of skilled task (enhanced by alcohol)
- **Antacid and zinc/iron**; Leave 2 hours before or after taking
140
How is azithromycin taken
OD
Before food/ indigestion remedies: 2 hour gap
141
How is ezithromycin taken
**QDS/BD**
Before indigestion remedies: 2 hour gap
142
How is clarithromycin taken
BD
143
Common side effect of clarithromycin
Taste disturbances
144
When is azithromycin commonly used?
**Chlamydia**
1g STAT - OTC
**Gonorea**
145
Side effects of macrolides
- **GI effect** *(most common with erithromycin)*
- **QT prolongation**
- Hepatotoxicity
- Ototoxicity
146
How to take macrolides
*exception?*
Take with or after food
(Azithromycin before food)
147
What is used in treating H.pylori infections
Macrolides (clarithromycin BD)
148
Nature of interaction between clarithromycin and warfarin
Increased risk of bleeding
149
Nature of interaction between clarithromycin and statin
Increased risk of myopathy
*Stop statin while on clarithromycin - no need to refer*
150
When is benzylpenicillin used?
Meningitis
151
When is phenyl penicillin used?
Respiratory tract infection in children
*eg. Sore throat, tonsillitis*
152
How is Flucloxacillin given?
Before food
153
What type of infection is Flucloxacillin inactive against?
MRSA
154
When are PipTaz used?
Serious infections
- septicaemia
- complicated UTI
- HAP
155
How is stomach bug treated?
Self limiting
So not typically treated
156
How is C.Diff treated
**Vancomycin**
Fedoxamicin
*10 - 14 days*
157
What it contraindicated in diarrhoea related to colitis
**Loperamide** - worsens infection
158
How is endocarditis treated
**Amoxicillin/ ampicillin** + low dose **gentamicin**
*- if pen allergy; low dose **gentamicin** + **vancomycin***
159
Treatment: endocarditis with staphylococci origin or streptococcus
Staph: **Flucloxacillin**
Strept: **Benzylpenicillin**
160
Treatment: community acquired pneumonia
-**Amoxicillin** - 7 days
- Alt. Clarithromycin or doxycycline
161
Treatment: hospital acquired pneumonia
Early onset; **co-amoxiclav**
Alt: Doxycycline, Cefa, co-trimoxazole, levoflaxacin
*tx for **7 days***
162
Treatment: blind tx of meningitis
**Benzylpenicillin** or **Cefotaxime**
Chloramphenicol - pen allergy
163
Treatment: pneumococci meningitis
**Cefotaxime** (+ dexamethasone)
**Benzylpenicillin**
*Cephalosporin + vancomycin - pen allergy*
164
Treatment: meningitis listeria
- **amoxicillin / ampicillin** + **gentamicin**
- Co-trimoxazole - pen allergy
165
Treatment: osteomyelitis (bone infection)
**Flucloxacillin** - *10 - 14 days*
Clindamycin - pen allergy
166
Treatment: septic arthritis
Flucloxacillin *4-6 weeks*
167
Treatment: impetigo (skin)
- **Hydrogen peroxide**
- fuscidic acid
Wide spread: **Flucloxacillin**
***7 days** tx course*
168
Treatment: cellulitis
**Flucloxacillin**
Near eye: **co-amoxiclav**
Clarithromycin + metronidazole
Severe: **Clindamycin**
169
Treatment: leg ulcer
**Flucloxacillin**
Clar/ erythro/ **doxy** - pen allergy
Co-trimoxazole
170
Treatment: animal and human bite
**Co-amoxiclav** - 14 days
Doxycycline + metronidazole - pen allergy
171
Treatment: mastitis during breast feeding
**Flucloxacillin** - 10-14 days
Erythromycin - pen allergy
172
Treatment: dental infection
**Metronidazole** 200mg TDS for 3 days
Alt. Amoxicillin
173
Treatment: bacterial sore throat
Phenoxymethylpenicillin
174
Symptoms of sinusitis
Pain in the hollow of cheekbones
Nasal congestion
175
Treatment: diabetic foot infection
**Flucloxacillin**
- PO 7 days in mild
- IV for >48 hours in severe
Alt - clarithromycin/ **doxycycline**/ erythromycin
176
Treatment: otitis external
- **Flucloxacillin**
- Clarithromycin/ Azithromycin/ erythromycin
177
Treatment: otitis media
- **Amoxicillin**
- Co-amoxiclav (worsening symptoms)
- Clarithromycin/ erythromycin - pen allergy
178
How long does tuberculosis treatment last for?
6 months
*Split into 2 phases*
179
What is involved in first phase of TB treatment and how long does it last
‘**RIPE**’ - 2 months
- Rifampicin
- Isoniazid
- Pyrazinamide
- Ethambutol
180
Pt counselling: Rifampicin
- report signs of **hepatotoxicity**
- colours soft contact lenses
- **urine red/ orange**
181
Pt counselling: Isoniazid
- report signs of **hepatotoxicity**
- peripheral neuropathy (overcome with pyridoxine)
182
Pt counselling: Ethambutol
Report **visual changes**
183
Which TB drug is not hepatotoxic
Ethambutol
184
Side effect of ketoconazoles
Fatal hepatotoxicity
- *not used in fungal infections*
185
Side effect of itraconazol
- heart failure
- hepatotoxicity
*interacts with antacids*
186
Side effect of voriconazole
- Phototoxicity and hepatotoxicity
- Skin cancer (*avoid direct sunlight and sunlamps. Use high factor SPF and carry **alert card***)
187
Side effect of amphoteracin B
Nephrotoxicity
**specify brand**
Used in serious fungal infections and may cause anaphylaxis
188
Treatment: oral thrush
- Nystatin (POM)
- Miconazole (daktarin oral gel) - OTC
189
Treatment: vaginal thrush
- Oral fluconazole (*single dose*)
- topical imidazole (clotrimazole)
190
Treatment: tinea
- miconazole
- clotrimazole
- terbinafine (athlete foot)
191
What is used to treat athletes foot
Terbinafine
192
Treatment: fungal nail infection
Amorolfine
193
Treatment: herpes
Aciclovir
194
Prophylaxis of influenza virus
Oseltamivir
*start with 48 hours of exposure and reduces symptoms by 1 day*
195
Bites prevention
- NETS impregnated with permethrin is most effective
- DEETS 20-50% (applied to the skin eg. Spray or lotion) - *safe and effective in adults and **children > 2 months***
- Apply sunscreen first and use SPF 35-50
196
Doxycycline counselling in malaria
- Take **1-2 days before** entering area and continue for **4 weeks after** leaving
- Protect skin from sunlight
- Do not take indigestion remedies
- Swallow whole with plenty water while sitting or standing
- Take with meals
197
Side effect of mefloquine
- Serious neuropsychiatric reactions - STOP
- Dizziness (care with driving)
198
Length of malaria prophylaxis before travel and exceptions
**1week before**
Exception:
- **Mefloquine **; *2-3 weeks*
- **Malorone & Doxycycline**; *1-2 days*
199
Length of malaria prophylaxis before travel and exceptions
**4 weeks after**
Exception:
- **Malarone**; *1 week after*
200
Long term prophylaxis duration of malaria
- >5 years: chloroquine and proguanil
- 2 years: doxycycline
- 1 year: mefloquine, malarone
201
What is malarone made of
Atovaquone
Proguanil
202
Malaria drugs to avoid in epilepsy
Chloroquine
Mefloquine
203
Malaria drugs to avoid in renal impairment
- proguanil
- malarone and chloroquine (eGFR <30)
204
Choice of malaria drug in renal impairment
Doxycycline
Mefloquine
205
Malaria drugs to avoid in pregnancy
- Mefloquine
- Malarone *(may be given in 2nd/3rd trimester if no other option)*
- Doxycycline - Contraindicated
206
Anti malaria in pregnancy
- Chloroquine
- Proguanil *(give 5mg folic acid)*
207
Anti malaria and warfarin
- Start **2-3 weeks before**
- INR should be stable before departure
- Monitor INR **before**, **after 7 days** of prophylaxis and **after completing course**
- For prolonged stay, check INR frequently
208
What is used to treat falciparum malaria
- Quinine
- Malarone
- Riamet
209
What is used to treat non-falciparum malaria
Chloroquine
210
When is quinine used in malaria treatment
- Only if medical care is not accessible in 24 hours of fever onset
- Give with written instructions that urgent help is required of fever >38 degrees, 7 days or more after arriving in malarious zone
211
Nature of interaction between carbapenems and valproate
Decrease blood concentration of valproate
*higher risk of seizure - Avoid*
212
What is the most effective barrier protection against mosquitoes
Mosquito nets impregnated with permethrin
213
What penicillins should be taken on an empty stomach
*an hour before food or 2 hours after*
- Phenoxymethylpenicillin
- Ampicillin
- Flucloxacillin
214
Sildenafil and doxycycline
Space dose at least 2-3 hours apart
215
Antibiotic safe to take with quetiapine in Pen allergy
Doxycycline
216
What is used to treat conjunctivitis in eye
**Chloramphenicol**
Fusidic acid if pen allergy
217
Scarlet fever
Strawberry tongue
Sand paper rash
*phenoxymethylpenicillin*
218
Thread word tx
Mebendazole
219
Cause of menengitis
Strept pneumonia
220
Chloramphenicol OTC
2+ years
Conjunctivitis
