Infectious Disease Flashcards
Key Counseling points: Azole antifungals
can cause liver damage, QT prolongation (except cresemba), many drug interactions
Key Counseling points: Ketoconazole
hepatotoxicity has led to liver damage and/or death, possible drug interactions due to high gastric pH (need acidic environment)
Key Counseling points: Itraconazole
tablets and capsules must be taken with food, solution must be taken on an empty stomach, can cause heart failure, possible drug interactions due to high gastric pH (need acidic environment)
Key Counseling points: Posaconazole (Noxafil)
tablets - take with food
suspension - take with full meal or oral liquid nutritional supplement
Key counseling points: Voriconazole (Vfend)
take on an empty stomach - at least one hour before or one hour after meals, can cause photosensitivity and vision changes, store reconstituted oral suspension at room temperature
Key counseling points: nystatin
oral suspension - shake well before using
Key counseling points: terbinafine
oral - can cause liver damage, can take several months after finishing treatment to see the full benefit of this drug - takes time for new healthy nails to grow and replace the infected ones
Key counseling points: oseltamivir
treatment should begin within 2 days of onset of influenza symptoms, can cause delirium
Key counseling points: acyclovir and valacyclovir
does not cure herpes infections - use safe practices to lower transmission risk, start treatment within 24 hours of the onset of symptoms
Key counseling points: acyclovir
drink plenty of fluids, topical cream can cause temporary burning and stinging
ZDS <3 LATTE (NRTIs)
Zidovudine
Didanosine (NLR)
Stavudine (NLR)
Lamivudine
Abacavir
TDF
TAF
Emtricitabine
NRTIs
competitively inhibit the reverse transcriptase enzyme - preventing the conversion of HIV RNA to HIV DNA in Stage 3 of the HIV Life cycle
[low barrier to resistance]
All NRTIs
lactic acidosis and hepatomegaly with steatosis (fatty liver); boxed warning for didanosine, stavudine, and zidivudine
-common side effects: nausea, diarrhea, headache, increased LFTs
NRTIs: HBV and HIV Confection boxed warnings
severe acute HBV exacerbation can occur if emtricitabine, lamuvidine, or tenofovir-containing products are discontinued (some NRTIs treat HBV). DO NOT USE Epivir-HBV for the treatment of HIV (contains lower dose of lamivudine)
Abacavir (Ziagen)
-boxed warning for HSR
-must be screened for HLA-B*5071 allele before starting
-must carry a card indicating HSR is an emergency
-never re-challenge patients with a history of HSR
-Consider avoid with CVD due to a potential increase risk of MI
Emtricitabine (Entrivia)
hyperpigmentation of the palms of the hands or soles of the feet
Tenofovir Formulations (Higher risk with TDF)
-renal impairment (acute renal failure and Fanconi syndrome)
-decrease dose with renal impairment and avoid other nephrotoxic drugs
-decrease bone mineral density: consider calcium/vitamin D supplementation and DEXA scan
-monitor lipids if switching from TDF to TAF for an improved side effect profile
Zidovudine
-hematologic toxicity: neutropenia and anemia (increased MCV is a sign of adherence)
-myopathy
Didanosine and stavudine
pancreatitis, peripheral neuropathy (can be irreversible)
BRED
Bictegravir
Raltegravir
Elvitegravir
Dolutegravir
BRED Side Effects and Warnings
-Bictagravir and dolutegravir; increase SCr with no effect on GFR
-Raltegravir; increase CPK, myopathy, and rhabdo
-Elvitegravir; proteinuria
-Dolutegravir; HSR, neural tube defects in fetus, increased CPK/myalgia
-All: HA, insomnia, D, weight gain, rare risk of depression and suicidal ideation in patients with pre-existing psychiatric conditions (except bictegravir)
Preferred regimen for HIV
2 NRTI and 1 INSTI
INSTIs drug interaction with polyvalent cations
Take INSTIs 2 hours before or 6 hours after; aluminum, calcium, magnesium and iron-containing products - except for dolutegravir, bictegravir, and raltegravir
Polyvalent cations and dolutegravir and bictegravir
can be taken with oral calcium or iron if also taken with food
Polyvalent cations and raltegravir
dose separations with raltegravir may not be effective; avoid polyvalent cations if possible
INSTIs
block the integrase enzyme, preventing HIV DNA from inserting into the host cell DNA in stage 4 (integration) of the HIV life cycle
-higher barrier to resistance than NRTIs and NNRTIs
NRTIs
non-competitively inhibit the reverse transcriptase enzyme, preventing the conversion of HIV RNA to HIV DNA in stage 3 (reverse transcription) of the HIV life cycles
-lower barrier to resistance than INSTIs or PIs
REDDEN
Rilpivirine, Efavirenz, Doravirine, Delavirdine (NLR), Etravirine, Nevirapine
All NNRTIs
hepatotoxicity and rash/severe rash, including SJS/TEN
Efavirenz
psychiatric symptoms (depression, suicidal thoughts), CNS effects (impaired concentration, abnormal dreams, confusion), generally resolve in 2-4 weeks, increase total cholesterol and TG
Rilpivirine
depression, increased SCr with no effect on GFR, do not use if viral load > 100,000 copies/mL and/or CD4 count < 200 cells/mm3 (higher failure rate), take with a meal and water (DO NOT substitute with a protein drink)
NNRTI drug interactions
all are major CYP3A4 substrates. Rilpivirine and doravirine - do not use with strong CYP3A4 inducers (carbamazepine, oxacarbazepine, phenobarbital, phenytoin, rifampin, rifapentine, St. Johns Wort)
-efavirenz and etravirine are moderate CYP3A4 inducers
-rilpivirine and acid suppressants
Rilpivirine and PPIs
DO NOT USE
Rilpivirine and H2RAs
take at least 12 hours before or 4 hours after rilpivirine
Rilpivirine and antacids
take antacids at least 2 hours before or 4 hours after rilpivirine
-navir
protease inhibitor
PI key features and safety
-metabolic abnormalities (increased LDL/TG & blood glucose, insulin resistance, increased risk of CVD (lowest risk with atazanavir and darunavir & highest with LPV/r)
-hepatic dysfunction (increased LFTs, hepatitis, and/or exacerbation of preexisting hepatic disease)
-HSR
-D/N
Atazanavir (Reyataz)
-hyperbilinrubinemia (reversible does not require discontinuation)
-requires acidic gut for absorption
Atazanavir and antacids
take atazanavir 2 hours before or 1 hour after
Atazanavir and H2RAs
avoid or take atazanavir 2 hours before or 10 hours after
Atazanavir and PPIs
-avoid with unboosted atazanavir
-boosted atazanavir: take boosted at least 12 hours after the PPI (dose should not exceed omeprazole 20 mg or equivalent)
Darunavir, fosamprenavir, tipranavir
caution with sulfa allergy
LPV/r (Kaletra)
oral solution contains 42% alcohol can cause a disulfram reaction if taken with metronidazole
Tipranavir
intracranial hemorrhage
PIs and CYP3A drug interactions
alfuzosin, colchicine, dronedarone, lovastatin and simvastatin, CYP3A4 inducers, anticoagulants/antiplatelets (apixaban, rivaroxaban, edoxaban, ticagrelor), direct acting-antivirals for hepatitis C, some hormonal contraceptives, steroids
PIs and warfarin
not contraindicated but should monitor INR frequently
Which HMG-CoA can be used with PIs
rosuvastatin and atorvastatin are preferred
Pharmacokinetic boosters
ritonavir (Norvir) and cobicistat (Tybost)
which pharmacokinetic booster can be co-formulated
cobicistat
Booster drug interactions
Alfuzosin, tamsulosin
Colchicine (with hepatic or renal impairment),
Lovastatin and simvastatin,
Azole antifungals (especially isavuconazonium, itraconazole, or voriconazole),
Cardiovascular drugs: amiodarone (ritonavir only), dronedarone, eplerenone, ivabradine, ranolazine,
PDE-5 inhibitors used for pulmonary hypertension (tadalafil, sildenafil) (dose reductions required if taking it for erectile dysfunction or BPH),
Many tyrosine kinase inhibitors (nibs),
CYP3A4 inducers
Any NTI drug that is highly dependent on CYP3A4 for clearance
CCR5 Antagonist
Blocks HIV from binding (and subsequently entering) the CD4 cell in virus strains that use CCR5 co-receptor in stage 1 of the HIV life cycle
Attachment Inhibitor
Converted to temsavir (active form) which binds to the gp120 subunit of HIV envelope proteins, inhibiting the interaction between the virus and CD4 host cell in stage 1 of the cell cycle
Post-attachment Inhibitor
Binds to a select domain of CD4 cell receptors in stage 1 (binding/attachment) of the HIV life cycles, blocking entry of the virus into the cell
Fusion Inhibitor
Prevents HIV from fusing to the CD4 cell membrane in stage 2 (fusion) of the HIV life cycle, which prevents virus entry into the cell
TDF
CrCl < 50 mL/min: do not start - TDF or TDF containing products (< 70 mL/min for Stribild)
TAF
CrCl < 30 mL/min: do not start TAF containing products
Stribild
Eltivegravir/ cobicistat/ emtricitabine/ TDF
-take with food
Atripla
Efavirenz / emtricitabine/ TDF
-take on an empty stomach
Complera
Rilpivirine/ emtricitabine/ TDF
-take with food
Genvoya
Elvitegravir/ cobicistat/ emtricitabine/ TAF
-take with food
Biktarvy
bictegrvair/ emtricitabine/ TAF
Triumeq
Dolutegravir/ abacavir/ lamivudine
Dovato
dolutegravir/ lamivudine
Odefsey
Rilpivirine/ emtricitabine/ TAF
-take with food
Descovy
Emtricitabine/ TAF
-do not use if CrCl < 30 mL/min
Truvada
Emtricitabine/ TDF
-do not use if CrCl < 30 mL/min
-do not use if CrCl < 60 mL/min if using for PrEP
Diagnosis of aids
CD4 count < 200 cells/mm3 or an AIDs defining illness
breastfeeding in HIV + patients
should be avoided
combination drugs for HIV+ pregnant patients
Epzicom, Truvada, Cimduo
PrEP
-Truvada or Descovy
-IM Inj of Cabotegravir (Apretude) - administered by a healthcare provider monthly for 2 doses then every 2 months
Follow-up for PrEP
-truvada and Descovy: 3 months
-Cabotegravir: 1 month after the first injection then every 2 months
PEP
-treatment should be started ASAP within 72 hrs of exposure and continued for 28 days
-Truvada, Tivicay or Isentress
-should receive baseline HIV Ab test and follow-up test at 4-6 weeks, 3 months and 6 months after the exposure
Common Resistant Pathogens: Kill Each And Every Strong Pathogen
-Klebsiella pneumoniae (ESBL, CRE)
-E. Coli (ESBL, CRE)
-E. Facalis, E. Faecium (VRE)
-Staph Aureus (MRSA)
-Pseudomonas
Hydrophilic antibiotics
beta-lactams, aminoglycosides, vancomycin, daptomycin, polymixins
Lipophilic antibiotics
quinolones, macrolides, rifampin, linezolid, tetracyclines
Natural penicillins
Penicillin V Potassium
Penicillin G
Penicillin G Benzathine
Antistaphylococcal Penicillin
Dicloxacillin, Nafcillin, Oxacillin
Aminopenicillin
amoxicillin, augmentin, ampicillin, unasyn
Extended-spectrum penicillins
zosyn
Class effects of penicillins
-should be avoided in patients with beta-lactam allergy > except treatment of syphillis during pregnancy or patients with poor compliance
-risk of seizures due to accumulation
Penicillin VK
first line treatment for strep throat and mild nonpurulent skin infections (no abscess)
Amoxicillin
-first line treatment for AOM
-DOC for infective endocarditis ppx before dental procedures
-used in H. pylori tx
Augmentin
-first line treatment for AOM and bacterial sinusitis
-use lowest dose of clavulante to decrease diarrhea
Dicloxacillin
-covers MSSA only
-no renal adjustment needed
Penicillin G Benzathine
-DOC for syphillis
-Not for IV use; can cause death
Nafcillin and Oxacillin
covers MSSA & no renal adjustment required
Zosyn
-only penicillin active agent against pseudomonas
-extended infusions (4 hours) can be used to maximize T > MIC
1st gen cephalosporin
cefazolin & cephalexin
2nd gen cephalosporin
cefuroxime, cefotetan, cefoxitin
3rd gen cephalosporin (group 1)
cefdinir, CTX, cefotaxime, cefpodoxime
3rd gen cephalosporin (group 2)
ceftazidime - lacks gram positive activity but covers pseudomonas
4th gen cephalosporin
cefepime
5th gen cephalosporin
ceftaroline
Cephalosporin class effect
-do not use in patients with penicillin allergy (except pediatric patients with AOM)
-risk of seizures if accumulation occurs
Cephalexin
used in skin infections (MSSA), strep throat
Cefuroxime
commonly used in AOM & CAP
cefdinir
commonly used in AOM
Cefazolin
commonly used in surgical ppx
cefotetan and cefoxitin
-anaerobic coverage (B. fragilis)
-commonly used in surgical ppx (GI procedures)
-cefotetan can cause disulfram-like reactions with alcohol ingestion
CTX and Cefotaxime
-common uses: CAP, meningitis, SBP, pyleonephritis
-CTX: no renal adjustment, do not use CTX in neonates
Ceftazidime and Cefepime
active against pseudomonas
Cetolozane/Tazobactam (Zerbaxa) and Ceftazidie/Avibactam (Avycaz)
used for MDR Gram-negative organisms (including pseudomonas)
Ceftaroline
-only beta-lactam active against MRSA
-common uses: CAP, skin and soft tissue infections
Carbapenem
doripenem, imipenem/cilstatin, meropenem, ertapenem
monobactam
aztreonam
Class effect of carbapenem
-all active against ESBL-producing organisms
-do not use with penicillin allergy
-seziure risk (highest risk with imipenem)
Carbapenems do not cover
atypicals, VRE, MRSA, C. diff, Stenotrophomonas
ErtAPenem does not cover
pseudomonas, actinobacter, enterococcous
Common uses of carbapenems
polymicrobial infections, empiric therapy when resistance is suspected, ESBL-positive infection, resistant Pseudomonas or acinetobacter (except ertapenem)
All carbapenems are IV only
ertapenem must be diluted in normal saline
Aztreonam
-gram-negative
-pseudomonas
-no gram + or anaerobic activity`
Gentamicin (Gram + infection - synergy)
Peak: 3-4 mcg/mL
Trough: < 1 mcg/mL
Gentamicin (gram-negative infection) and tobramycin
Peak: 5-10 mcg/mL
Trough: < 2 mcg/mL
amikacin
Peak: 20-30 mcg/mL
Trough: < 5 mcg/mL
drawing aminoglycoside levels
-draw a trough level right before (or 30 minutes before) 4th dose
-draw peak level 30 minutes after the end of the 30 min infusion for the 4th dose
-extended interval dosing - draw random level per timing on monogram
Quinolones
ciprofloxacin, levofloxacin, moxifloxacin
Respiratory quinolones
levofloxacin, moxifloxacin, gemifloxacin
antipseudomonal quinolones
ciprofloxacin, levofloxacin
moxifloxacin
only quinolone that is not renally adjusted (do not use in UTIs)
IV to PO 1:1
levofloxacin and moxifloxacin
Cautions with quinolones
-caution in those with CVD, decrease K/Mg and with other QT-prolonging drugs
-avoid in patients with seizure hx or if using seizure drugs
-avoid in children
Counseling on quinolones
-avoid sun exposure, separate from polyvalent cations, and monitor blood glucose
-watch for tendon rupture, neuropathy, CNS or psychiatric side effects
Macrolides
Azithromycin, clarithromycin, erythromycin
Common uses for macrolides
-all macrolides: CAP, and as an alternative to a beta-lactam for strep throat
-azithromycin: COPD exacerbation, pertusis, chlamydia, prophylaxis for MAC, severe travelers diarrhea
-clarithromycin: used in H. pylori tx regimens
-Erythromycin increases gastric motility and is used for gastrophoresis
Common Z-pack dosing
two 250 mg tablets PO x1 then 250 mg PO QD x 4 days
Macrolides and QT-prolongation
caution with CVD, decrease K/Mg and other QT-prolonging drugs
Macrolides and drug interactions
clarithromycin and erythromycin are strong CYP3A4 inhibitors; lovastatin and simvastatin are contraindicated (increased risk of muscle toxicity)
Tetracyclines
doxycycline, minocycline
Do not use in pregnancy, breastfeeding or children < 8 years old
Common uses of tetracycline
-doxycycline and minocycline: CA-MRSA skin infections, acne
-Doxycycline: first-line treatment for lyme disease and rocky mountain spotted fever, CAP, COPD exacerbation, bacterial sinusitis, VRE, UTI, Chlamydia
-tetracycline: used in H. pylori treatment regimens
Sulfonamides
Bactrim
common uses of bactrim
CA-MRSA skin infections, UTIs, PJP
Strength of bactrim tablets
-5:1 ratio of bactrim
-SS tablet contains 80 mg TMP
-DS contains 160 mg TMP - usual dose is one tablet BID
bactrim and warfarin
INR increases when used with warfarin - use alternative abx when possible
lipoglycopeptides
telavancins, oritavancin, dalbavancin
oxazolidinones
linezolid and tedizolid
Urinary agents
fosfomycin & nitrofurantoin
Nitrofurantoin
-DOC for uncomplicated UTI
-contraindicated when CrCl < 60 mL/min
-MarcoBID is BID
-Macrodantin is QID
-take with food to prevent nausea and cramping
-can discolor the urine
MSSA
dicloxacillin, nafcillin, oxacillin, cefazolin, cephalexin (and all other 1st and 2nd gen cephalosporins), augmentin, unasyn, doxycycline, minocycline, bactrim
CA-MRSA SSTIs
bactrim, doxycycline, minocycline, clindamycin, linezolid
severe SSTIs requiring IV treatment or hospitalization
vancomycin, linezolid, tedizolid, daptomycin, ceftaroline, telavancin, oritavancin, dalbavancin, tigecycline
nosocomial MRSA
vancomycin, linezolid, daptomycin (not in pneumonia), telavancin
VRE (E. Faecalis)
Pen G or ampicillin, linezolid, daptomycin
-cystitis only: nitrofurantoin, fosfomycin, doxycycline
VRE (E. Faecium)
daptomycin, linezolid
-cystitis only: nitrofurantoin, fosfomycin, doxycycline
HNPEK
H. Influenzaem Neisseria, Proteus, E. coli, Klebsiella
HNPEK commonly used drugs
beta-lactam/beta-lactamase inhibitor*, amoxicillin, cephalosporins (except 1st gen), carbapenem, bactrim, aminoglycosides, quinolones
atypical organisms
azithromycin, clarithromycin, doxycycline, minocycline, quinolones
pseudomonas aeruginosa
zosyn, cefepime, ceftazidime, Avycaz, Zerbaxa, carbapenem (ertapenem), cirpofloxacin, levofloxacin, aztreonem, aminoglycosides, colistimethane, polymyxin B
Acinetobacter
carbapenems*, Unasyn, minocycline, tigecycline, quinolones, bactrim, amikacin, colistimethane, polymyxin B
ESBL GNR (E. coli, K. pneumoniae, P. mirabilis)
carbapenems, Avycaz, Zebraxa, aminoglycosides, cystitis only: fosfomycin
CRE
Avycaz, colisthimethane, polymyxin B, meropenem/vaborbactam, imipenem/cilstatin/relebactam
Bacteroides fragilis
metronidazole, beta-lactam/beta-lactam inhibitor, cefotetan, cefoxitin, carbapenems
C. diff
vancomycin, fidaxomicin, metronidazole
Drugs that DO NOT require renal adjsutment
antistaphylococcal penicillins, CTX, clindamycin, doxycycline, macrolides, metronidazole, moxifloxacin, linezolid, cholraphenicol, fidaxomicin, rifaximin, rifampin, tedizolid, tigecycline vancomycin PO
Storage Requirements: Liquid oral abx - must be refrigerated
Penicillin VK, ampicillin, augmentin, cephalexin, cefuroxime, vancomycin oral, valganciclovir
Storage Requirements: Liquid oral abx - refrigerated recommended
ampicillin - improves taste
Storage Requirements: Liquid oral abx - DO NOT REFRIGERATE
cefdinir, azithromycin, clarithromycin, doxycycline, ciprofloxacin, levofloxacin, clindamycin, linezolid, bactrim, acyclovir, fluconazole, posaconazole, voriconazole, nystatin
Storage Requirements: IV ABX - DO NOT REFRIGERATE
metronidazole, moxifloxacin, bactrim, acyclovir
ABX that must be taken on empty stomach
ampicillin oral capsules and suspension, ceftibuten suspension, levofloxacin oral solution, penicillin VK, rifampin, isoniazid, itraconazole solution, voriconazole
ABX that has to be taken within one hour of finishing a meal
amoxicillin ER
1:1 IV to PO
levofloxacin, moxifloxacin, doxycycline, minocycline, linezolid, tedizolid, metronidazole, bactrim, fluconazole, cresemba, posaconazole, voriconazole
light production administration
doxycycline, micafungin, pentamidine
compatible with dextrose only
quinupristin/dalfopristin, bactrim, amphotericin B, dalbavancin, oritavancin, pentamidine
compatible with saline only
ampicillin, unasyn, ertapenem, daptomycin
compatible with NS/LR only
caspofungin, daptomycin (cubicin)
