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Pharmacy - Year 2 > infections -overview of antibiotics Amira g > Flashcards

infections -overview of antibiotics Amira g Flashcards

1
Q

Gram positive?

A
  • Cytoplasm
  • Plasma membrane
  • Periplasmic space
  • Peptidoglycan
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2
Q

Gram negative?

A
  • Cytoplasm
  • Plasma membrane
  • Periplasmic space
  • Peptidoglycan
  • Outer membrane!!! (lipopolysaccharide and porin)
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3
Q

Examples of gram positive?

A
  • Streptococcus
  • Staphylococcus
  • Clostridium
  • Botulinum
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4
Q

Examples of gram negative

A
  • Cholera
  • Gonorrhoea
  • E. coli
  • Pseudomonas
  • Aeruginosa
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5
Q

Bacterial groups and infection sites - meningitis

A
  • Streptococcus pneumoniae
  • Neisseria meningitidis
  • Haemophilus influenzae
  • Streptococcus agalactiae
  • Listeria monocytogenes
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6
Q

Bacterial groups and infection sites - Otitis media

A
  • Streptococcus pneumoniae
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7
Q

Bacterial groups and infection sites - Pneumonia (cap)

A
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Staphylococcus aureus
    (atypical)
  • Mycoplasma pneumoniae
  • Chlamydia pneumoniae
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8
Q

Bacterial groups and infection sites - Eye infections

A
  • Staphyloccus aureus
  • Neisseria gonorrhoeae
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9
Q

Bacterial groups and infection sites - sinusitis

A
  • Streptococcus pneumoniae
  • Haemophilus influenzae
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10
Q

bacterial groups Upper RTI

A
  • Streptococcus pyogenes
  • Haemophilus influenzae
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11
Q

Bacterial groups and infection sites - gastritis

A
  • Helicobacter pylori
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12
Q

Bacterial groups and infection sites Food poisoning

A
  • Campylobacter jejuni
  • Salmonella
  • Clostridium
  • Shigella
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13
Q

Bacterial groups and infection sites - UTIs

A
  • Escherichia coli
  • Other Enterobacteriaceae
  • Staphylococcus saprophyticus
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14
Q

Bacterial groups and infection sites STIs

A
  • Chlamydia
  • Gonorrhoeae
  • Treponema pallidum
  • Syphilis
  • Bacterial vaginosis
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15
Q

Which bacteria cause which infections?

A
  • Most are caused by bacteria that are part of natural body flora
  • A change in habit for those organisms can result in infection
    Example:
    CAP:
  • Flora in the nasal cavity and the nasopharynx includes mixtures of Gram -ve and gram +ve anaerobes:
  • Strept pneum (G+ve) 40%
  • Haem influ (G-ve) 5-15%
  • Atypical 20%
  • 0-30% cases are viral
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16
Q

Exceptions to prev ex - Clostridium Difficile

A
  • Gram +ve anaerobe
  • Minor part of normal gut flora
    Risk factors
  • Exposure to broad spectrum antibiotics
  • Multiple antibiotic exposures
  • PPI use
  • Co-morbidities
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17
Q

Exceptions to previous example: Pseudomonas Aeruginosa

A
  • Gram -ve bacillus
  • Not part of our natural flora
  • Able to live in various environments
  • Opportunistic pathogen
  • Immunocompromised hosts are susceptible
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18
Q

Mechanism of action of antibiotics
Cell wall synthesis

A
  • Cycloserine
  • Vancomycin
  • Bacitracin
  • Penicillins
  • Cephalosporins
  • Monobactams
  • Carbapenems
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19
Q

Mechanism of action of antibiotics Folic acid metabolism

A
  • Trimethroprim
  • Sulfonamides
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20
Q

Mechanism of action of antibiotics Cytoplasmic membrane structure

A
  • Polymyxins
  • Daptomycin
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21
Q

Mechanism of action of antibiotics DNA gyrase

A
  • Quinolones
  • Novobiocin
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22
Q

Mechanism of action of antibiotics RNA elongation

A
  • Actinomycin
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23
Q

Mechanism of action of antibiotics DNA-directed RNA polymerase

A
  • Rifampin
  • Streptovaricins
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24
Q

Mechanism of action of antibiotics Protein synthesis (50S inhibitors)

A
  • Erythromycin (macrolides)
  • Chloramphenicol
  • Clindamycin
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25
Q

Mechanism of action of antibiotics Protein synthesis (30S inhibitors)

A
  • Tetracyclines
  • Spectinomycin
  • Streptomycin
  • Gentamicin
  • Kanamycin
  • Amikacin
  • Nitrofurans
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26
Q

Mechanism of action of antibiotics Protein synthesis (tRNA)

A
  • Mupirocin
  • Puromycin
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27
Q

Antimicrobial resistance (AMR): definition

A

‘loss of effectiveness of any anti-infective medicine’

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28
Q

Antimicrobial stewardship: definition

A

‘an organisational or healthcare-system-wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness’

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29
Q

Checklist for prescribing antibiotics?

A
  • Ensure the patient record is accurate, in line with NICE. An allergy history should include the drug name, date of reaction, nature of reaction and whether the patient was hospitalised or required intensive care admission
  • Review allergy status as part of Structured Medication Reviews
  • Review allergy status during New Medicine Service reviews
  • Check the patient medication record against the Summary Care Record
  • On admission to hospital, ensure allergy history is reviewed as part of the drug history and medicines reconciliation process
  • GP practice pharmacy teams can run searches to identify any patients with a documented allergy that have since received penicillin
  • Ensure that the records are updated for any patients with a penicillin allergy label that have since successfully received penicillin without an allergic reaction
  • If trained, carry out an allergy history assessment
  • Set up a penicillin allergy de-labelling service or clinic
30
Q

how to Antimicrobial stewardship?

A

start smart then Focus clinical management algorithm

31
Q

Evidence of infection:

A
  • History
  • Signs and symptoms assess
  • Physical examination
  • Lab results
  • Diagnostic test results
  • Medical imagining
32
Q

START SMART

A

Assess:
- Evidence/suspicion of infection
- Patient risk
Investigate
- Cultures
- Lab investigations
- Imaging
- Source control
Prescribe (taking into consideration):
- Urgency
- Guidelines
- Allergy and c/i
- Spectrum
Document:
- Working diagnosis
- Certainty
- Treatment regimen
- Plan (+ review date)

33
Q

Then Focus (within 48-72 hours)

A

Post-prescription review outcome options:
- Cease
- Amend
- Reference
- Extend
- Switch

34
Q

What is the aim of an antibiotic?

A
  • Kill pathogenic bacteria, whilst causing no harm to human tissue
  • The Abx targets the physiology or biochemistry that are unique to bacteria and then:
    1. Bind to target site
    2. Occupy an adequate number of binding sites
    3. Remain at the binding. Site for sufficient time period
    So major determinants for efficacy are concentration of drug and time at the binding sites
35
Q

Types of antibiotics

A
  • Narrow spectrum
  • Bactericidal
  • Broad spectrum
  • Bacteriostatic
36
Q

Mechanisms of resistance?

A
  • Penetration
  • Efflux pump
  • Hydrolysis
  • Mutation of the binding stie
37
Q

Principles of therapy?

A
  • Antibacterial drug choice
  • Antibacterials, considerations before starting therapy
  • Advice to be given to patients and their family and/or carers
  • Antibacterials, considerations during therapy
  • Superinfection
  • Notifiable diseases
  • Sepsis and early management
38
Q

Choice of antibiotic?

A
  1. Patient factors
    - History of allergy
    - Renal/hepatic function
    - Susceptibility to infection
    - Ability to tolerate drugs by mouth
    - Severity of illness
    - Risk of complications
    - Ethnic origin
    - Age
    - Female?
    - Previous antibiotics
    - Previous microbiology results
  2. Likely causative organism
    - Site
    - Likely pathogen
    - Antibacterial sensitivity
  3. Risk of bacterial resistance

Treatment failure:
- Repeated antibacterial courses
- A previous or current culture with resistance bacteria
- At higher risk of developing complications

39
Q

Antibacterials, considerations before starting therapy?

A
  • Viral infections?
  • Samples should be taken for culture
  • Knowledge of prevalent organisms
  • Dose
  • RoA
  • Duration
40
Q

Antibacterials - Considerations during therapy

A
  • Review choice of antibacterial
  • In the absence of culture, review and stop on clinical grounds
  • Review IV antibac within 48 hours
  • Consider stepping down to oral antibacs where possible
41
Q

Selection of app antimicrobials Blood infections; septicaemia

A
  • Boad-spectrum beta-lactams/penicillins
  • Vancomycin
  • Metronidazole
42
Q

Selection of app antimicrobials - Eye infections:

A
  • Chloramphenicol
43
Q

Selection of app antimicrobials Dental infection:

A
  • Amoxicillin
  • Metronidazole
44
Q

Selection of app antimicrobials Cardiovascular: endocarditis:

A
  • Amoxicillin, low-dose gentamicin, vancomycin, flucloxacillin
45
Q

Selection of app antimicrobials Genital system infections

A
  1. Bacterial vaginosis:
    - Oral or topical metronidazole
    - Or topical clindamycin
  2. Chlamydial infection:
    - Azithromycin
    - Or doxycycline
  3. Uncomplicated gonorrhoea
    - Azithromycin + I/M ceftriaxone
46
Q

Selection of app antimicrobials Ear infections:

A
  1. Otitis externa
    - Flucloxacillin
    - Or clarithromycin
    - Or erythromycin
  2. Otitis media
    - Amoxicillin
    - Co-amoxiclav
    - Or clarithromycin/erythromycin
47
Q

Selection of app antimicrobials Gastrointestinal infections:

A
  • Clarithromycin/erythromycin
48
Q

Selection of app antimicrobials H.pylori triple therapy:

A
  • Amoxicillin/clarithromycin/metronidazole/bismuth
  • Tetracycline
  • Levofloxacin
49
Q

Selection of app antimicrobials C.dfficle:

A
  • Vancomycin
  • OR fidaxomicin
50
Q

Selection of app antimicrobial Nose infections:

A
  1. Sinusitis:
    - Phenoxymethylpenicillin, co-amoxiclav.
    - Doxycycline or clarithromycin
51
Q

Selection of app antimicrobial Skin infections

A
  1. Impetigo
    - H peroxide 1% creams
    - Fusidic acid
    - OR mupirocin
  2. Oral 1st line
    - Flucloxacillin
    - If penicillin allergy: clarithromycin or erythromycin in pregnancy
52
Q

Selection of app antimicrobial Cellulitis and erysipelas:

A
  • Oral or IV flucloxacillin
  • If penicillin allergy: clarithromycin, oral erythromycin
53
Q

Selection of app antimicrobial Near eyes or nose:

A
  • Co-amoxiclav
  • OR clarithromycin with metronidazole
54
Q

Selection of app antimicrobial Mastitis during breast-feeding:

A
  • Flucloxacillin
  • OR erythromycin
55
Q

Selection of app antimicrobial Resp system infections - COPD

A
  • Amoxicillin
  • Clarithromycin
  • OR doxycycline
  • If treatment fails: co-amoxiclav, or levofloxacin
56
Q

Selection of app antimicrobial Resp system infections - acute cough

A
  • Doxycycline
  • Amoxicillin
  • Clarithromycin
  • Or erythromycin
57
Q

Selection of app antimicrobial Resp system infections - CAP

A
  • Amoxicillin
  • Clarithromycin
  • Doxycycline
  • Erythromycin
58
Q

Selection of app antimicrobial - UTI pregnant women:

A
  1. Oral 1st line:
    - Nitrofurantoin (avoid at term)
  2. Oral 2nd line:
    - Amoxicillin
    - Or cefalexin
59
Q

Selection of app antimicrobial - UTI non pregnant women:

A
  1. Oral 1st line: (*and men)
    - Nitrofurantoin
    - Or trimethoprim
  2. Oral 2nd line
    - Nitrofurantoin (if not used 1st line)
    - Fosfomycin
    - Pivmecillinam
    - Or amoxicillin
60
Q

Penicillins?

A

Side-effects:
- Hypersensitivty
- Diarrhoea
- Antibiotic-associated colitis
- Encephalopathy
- Thrombocytopenia
Flucloxacillin, Penicillin V
- To be taken on an empty stomach, an hour before food or 2 hours after food
- Maintain adequate hydration
P+BF
- Not known to be harmful
Cautions and c/i
- Hypersensitivity and anaphylaxis (minor rash after 72h not true allergy)
- Maculopapular rashes common with ampicillin and amoxicillin
- Flucloxacillin: hepatic disorder, cholestatic jaundice and hepatitis may occur even up to 2 months after treatment
- Co-amoxiclav contra-indicated in penicillin-associated jaundice or hepatic disfunction

61
Q

Cephalosporins

A
  • Cefalexin
  • Cefradine
  • Cefadroxil
  • Cefaclor
  • Cefuroxime
  • Cefixime – orally active
  • Ceftriaxone
  • Cefotaxime
  • Ceftazidime
  • Ceftaroline
    Cross sensitivity with other beta-lactam antibacterials
  • Patients with history of immediate hypersensitivity to penicillin and other beta-lactams should not receive cephalosporins
    If no suitable alternative is available then:
  • Cefixime, cefotaxime, ceftazidime, ceftriaxone, or cefuroxime can be used in caution
    Side-effects:
  • Antibiotic-associated colitis (mostly with 2nd/3rd gen cephalosporins)
62
Q

Aminoglycosides

A

Gentamicin serum concentration
- 1 hour peak conc:
5-10mg/L
- Pre-dose trough conc
<2mg/L
Cautions and contraindications:
- Auditory disorders (otoxicity)
- Nephrotoxicity
- Muscular weakness
- Dehydration corrected prior to administration
Side-effects
- May impair neuromuscular transmission, irreversible ototoxicity, nephrotoxicity, N+V, antibiotics-associated colitis, peripheral neuropathy
MHRA/CHM advice
- Aminoglycosides (gentamicin, amikacin, tobramycin, and neomycin): increased risk of deafness in patients with mitochondrial mutations
Once-daily dose should be avoided in CrCl <20ml/min
- Dose adjustment: interval between doses must be increased, if renal impairment is severe, the dose itself should be reduced as well

63
Q

Glycopeptides

A
  • Cautions and contraindications:
    Avoid in history of deafness, elderly caution: systemic absorption enhanced in patients with inflammatory disorders of the intestinal mucosa or with C.difficile.
  • Side-effects:
  • Agranulocytosis
  • Neutropenia
  • Nephrotoxicity
  • Ototoxicity
  • Blood disorders
  • Fever
  • Rashes
  • SCAR reaction
  • Photosensitivity
  • ‘Red-man-syndrome’ flushing
  • Thrombophlebitis
  • Tinnitus
    Monitoring: Trough level 1-20mg/L
  • All patients require monitoring of serum vancomycin, more regularly if renally impaired
  • Monitory auditory function, blood counts, urinalysis, hepatic + renal function, monitor leucocyte count
    Interactions:
  • Avoid with ototoxic drugs: ciclosporins, aminoglycosides, loop diuretics
64
Q

Macrolides

A

Side effects
- GI side-effects (mostly with erythromycin)
- Hepatotoxicity
- Rash
- Ototoxicity (with high doses)
- Skin reactions
- Vision issues
Clarithromycin: take with or just after food
Label 5 – don’t take indigestion remedies 2 hours before or after you take this medicine: azithromycin + erythromycin
Azithromycin can be sold to the public for treatment of confirmed asymptomatic chlamydia in those over 16 years of age, and for the treatment of their partners – max 1g dose
Cautions and contra-i:
- Patients with a predisposition to QT interval prolongation. May aggravate myasthenia gravis.
MHRA/CHM warning for erythromycin (2020):
- Patients shouldn’t be given erythromycin with a history of QT interval prolongation or ventricular arrhythmia, or those with electrolyte disturbances
- 2-3-fold increase in the risk of infantile hypertonic pyloric stenosis during infancy – monitor for vomiting or irritability with feeding
A potential drug interaction between rivaroxaban and erythromycin resulting in an increased risk of bleeding.

65
Q

Quinolones?

A

Side-effects:
- Prolongs QT interval
- Seizures
- GI side-effects
- Dizziness
- Headache
- Eye disorders
- Decreased appetite
Patients advised to seek immediate medical attention if they experience a rapid onset of SOB especially when lying down flat in bed, swelling of ankles, feet, or abdomen or new onset heart palpitations
- Avoid administration of dairy products due to reduced exposure. Do not take milk, indigestion remedies, iron or zinc 2 hours before or after taking this medicine
- Discontinue if psychiatric, neurological and hypersensitivity reactions occur
P+BF
- Avoid in pregnancy, caution in breastfeeding
Cautions and contraindications
- CSM: may induce convulsions
- Tendon damage: don’t given if history or taking corticosteroids
- Small risk of aortic aneurysm and heart valve regurgitation
- Caution: exposure to sunlight and UV radiations should be avoided up to 48 hours after treatment stopped. G6PD deficiency, history of epilepsy, myasthenia gravis, psychiatric disorders, children or adolescents

66
Q

Tetracyclines?

A

Side-effects
- N+V, diarrhoea, antibiotic-associated colitis, dysphagia, oesophageal irritation, hepatotoxicity, blood disorders, photosensitivity, hypersensitivity, hepatotoxicity
Tetracyclines shouldn’t be given within 2 hours of calcium, antacids, or iron, which will prevent antibiotic absorption. Tablets should be swallowed whole with plenty of fluid while sitting or standing. Avoid exposure to sunlight or sun lamps.
Cautions and c/i:
- Headache and visual disturbances
- <12 years (deposition to growing bone and teeth, binding to Ca2+ causing staining
- Shouldn’t be given to P or BF women – affects on skeletal development, maternal hepatotoxicity
- Myasthenia gravis, systemic lupus erythematosus

67
Q

Trimethoprim?

A

Cautions and contra/i
- Blood dyscrasias
- Acute prophylaxis, elderly, neonates, those at risk of folate deficiency
- Avoid in 1st-trimester of pregnancy due to antifolate effect
Side-effects:
- Allergic reactions
- Anaphylaxis
- Drug fever
- Electrolyte imbalances
- GI disturbances
- Photosensitivity
- Fungal overgrowth
Monitoring
- Hyperkalaemia, increased creatinine concentration, renal function, plasma-trimethoprim if used for long-term treatment
- Monitor and advise patients to look out for blood dyscrasias symptoms: sore throat, rash, mouth ulcers, bruising, bleeding, purpura, fever
Interactions
- Not to be used with potassium-elevating drugs (aldosterone antagonist, ACEi, ARBs)
- Not to be used with other folate antagonists (methotrexate) or drugs that increase folate metabolism (phenytoin)

68
Q

Nitrofurantoin?

A

Side-effects:
- Pulmonary reactions, nausea and anorexia, hypersensitivity reactions, peripheral neuropathy, blood disorders
Monitoring
- Renal function: avoid if eGFR <45ml/min; may be used in caution if eGFR 30-44ml/min as a short course of 3-7 days to treat lower UTI
- On long-term therapy, monitor liver function and monitor for pulmonary symptoms, especially in the elderly (discontinue if deterioration in lung function)
Cautions and c/i
- Acute porphyrias, G6PD deficiency, infants less than 3 months
- Caution in anaemia, diabetes, e imbalances, folate deficiency, susceptibility to peripheral neuropathy, Vit B deficiency
- Pregnancy: avoid at term – may produce haemolysis
- BF: avoid, small amounts enough to produce haemolysis in G6PD – deficient infants
May harmlessly discolour urine – take with or just after food

69
Q

Clindamycin?

A

Cautions and c/i:
- Shouldn’t be used with existing diarrhoea
- Avoid injections containing benzyl alcohol in neonates
- Avoid in acute prophyrias
Side-effects:
- Antibiotic-associated colitis, GI side-effects, oesophageal disorders, taste disturbances, jaundice, blood disorders, rash, Steven-Johnson syndrome, skin reactions
Monitoring:
- Monitor liver and renal function if treatment exceeds 10 days and in infants
- Not harmful in 2nd and 3d trimester
- Present in breast milk and so child needs to be monitored for side-effects and diarrhoea
Counselling:
- Patients should be advised to discontinue immediately and contact a doctor if diarrhoea develops
- Dalacin 2% cream can damage latex condoms and diaphragms
- Advise patients to take with a full glass of water

70
Q

Metronidazole ?

A

Side-effects:
- GI issues, taste disturbances, furred tongue, oral mucositis, anorexia, vulvovaginal candidiasis, pelvic discomfort
Don’t drink alcohol – disulfiram-like reaction
Take with or just after food, or a meal – swallow whole – full glass of water
P+BF – avoid high-dose regimens, use only if potential benefits outweighs risk
Interactions: metronidazole is an enzyme inhibitor, so may enhance effect of warfarin, and phenytoin
CYP450 inducers can also decrease the function of metronidazole.
Cautions and c/i:
- Clinical and lab monitoring if treatment > 10 days
- Vaginal gel is not licensed for use in children <18 years
With topical use: avoid exposure to strong sunlight or UV light
With vaginal use: avoid intravaginal preparations in young girls who are not sexually active, unless there is no alternative; NOT recommended during menstruation; some systemic absorption may occur with vaginal gel.

71
Q

Linezolid?

A

Side-effects
- Anaemia, constipation, diarrhoea, eosinophilia, headache, nausea, vomiting, taste disturbances, severe optic neuropathy, blood disorders
Avoid consuming large amounts of tyramine-rich foods (mature cheese, salami, marmite, oxxo, Bovril, pickled herring, or any similar meat or yeast extract or fermented soya bean extract and some bears, lagers or wines) and other MAOIs
P+BF: not recommended unless necessary with close monitoring
Cautions and c/i:
- CHM advice: optic neuropathy; if used >28 days.
- Patients advised to report symptoms of visual impairment or new visual symptoms even if not given for long-term
- Blood disorders: thrombocytopenia, anaemia, leucopoenia – is recommended that patients receive a full blood count weekly
Caution:
- Unless close observation and BP monitoring possible, linezolid should be avoided in uncontrolled hypertension, pheochromocytoma, carcinoid tumour, thyrotoxicosis, bipolar depression, schizophrenia or acute confusional states

72
Q

Summary – principles of antibiotic prescribing

A
  • Initiate antibiotics as soon as possible in severe infection.
  • A dose and duration of treatment for adults is usually suggested, but adjust for age, weight and renal function
  • In severe or recurrent cases, consider a larger dose or longer course.
  • Confirm dosing and interaction information
  • Check for allergy
  • Consider lower threshold for antibiotics in patients with multiple morbidities; consider culture and seek advice
  • Suspect neutropenic sepsis if patients having cancer treatment become unexpectedly or seriously unwell. Refer immediately for assessment at their appropriate local hospital
  • Prescribe an antibiotic only when there is likely to be clear clinical benefit
  • Consider a no, or delayed, antibiotic strategy for acute self-limiting upper respiratory tract infections.
  • Use simple generic antibiotics if possible
  • Avoid braod spectrum antibiotics when narrow spectrum antibiotics remain effective, as they increase risk of Clostridium difficile. MRSA and resistant UTIs
  • Avoid widespread use of topical antibiotics
  • Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice can be obtained from your local microbiology team
  • Monitor renal function, and biochemical results as appropriate
  • Monitor response to treatment, safety and adverse reactions
  • Counsel patients on administration and importance of completing the course

Pharmacy - Year 2 (7 decks)

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