Infectious Disease Flashcards
1
Q
Key Counseling points: Azole antifungals
A
can cause liver damage, QT prolongation (except cresemba), many drug interactions
2
Q
Key Counseling points: Ketoconazole
A
hepatotoxicity has led to liver damage and/or death, possible drug interactions due to high gastric pH (need acidic environment)
3
Q
Key Counseling points: Itraconazole
A
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)
4
Q
Key Counseling points: Posaconazole (Noxafil)
A
tablets - take with food
suspension - take with full meal or oral liquid nutritional supplement
5
Q
Key counseling points: Voriconazole (Vfend)
A
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
6
Q
Key counseling points: nystatin
A
oral suspension - shake well before using
7
Q
Key counseling points: terbinafine
A
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
8
Q
Key counseling points: oseltamivir
A
treatment should begin within 2 days of onset of influenza symptoms, can cause delirium
9
Q
Key counseling points: acyclovir and valacyclovir
A
does not cure herpes infections - use safe practices to lower transmission risk, start treatment within 24 hours of the onset of symptoms
10
Q
Key counseling points: acyclovir
A
drink plenty of fluids, topical cream can cause temporary burning and stinging
11
Q
ZDS <3 LATTE (NRTIs)
A
Zidovudine
Didanosine (NLR)
Stavudine (NLR)
Lamivudine
Abacavir
TDF
TAF
Emtricitabine
12
Q
NRTIs
A
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]
13
Q
All NRTIs
A
lactic acidosis and hepatomegaly with steatosis (fatty liver); boxed warning for didanosine, stavudine, and zidivudine
-common side effects: nausea, diarrhea, headache, increased LFTs
14
Q
NRTIs: HBV and HIV Confection boxed warnings
A
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)
15
Q
Abacavir (Ziagen)
A
-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
16
Q
Emtricitabine (Entrivia)
A
hyperpigmentation of the palms of the hands or soles of the feet
17
Q
Tenofovir Formulations (Higher risk with TDF)
A
-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
18
Q
Zidovudine
A
-hematologic toxicity: neutropenia and anemia (increased MCV is a sign of adherence)
-myopathy
19
Q
Didanosine and stavudine
A
pancreatitis, peripheral neuropathy (can be irreversible)
20
Q
BRED
A
Bictegravir
Raltegravir
Elvitegravir
Dolutegravir
21
Q
BRED Side Effects and Warnings
A
-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)
22
Q
Preferred regimen for HIV
A
2 NRTI and 1 INSTI
23
Q
INSTIs drug interaction with polyvalent cations
A
Take INSTIs 2 hours before or 6 hours after; aluminum, calcium, magnesium and iron-containing products - except for dolutegravir, bictegravir, and raltegravir
24
Q
Polyvalent cations and dolutegravir and bictegravir
A
can be taken with oral calcium or iron if also taken with food
25
Polyvalent cations and raltegravir
dose separations with raltegravir may not be effective; avoid polyvalent cations if possible
26
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
27
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
28
REDDEN
Rilpivirine, Efavirenz, Doravirine, Delavirdine (NLR), Etravirine, Nevirapine
29
All NNRTIs
hepatotoxicity and rash/severe rash, including SJS/TEN
30
Efavirenz
psychiatric symptoms (depression, suicidal thoughts), CNS effects (impaired concentration, abnormal dreams, confusion), generally resolve in 2-4 weeks, increase total cholesterol and TG
31
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)
32
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
33
Rilpivirine and PPIs
DO NOT USE
34
Rilpivirine and H2RAs
take at least 12 hours before or 4 hours after rilpivirine
35
Rilpivirine and antacids
take antacids at least 2 hours before or 4 hours after rilpivirine
36
-navir
protease inhibitor
37
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
38
Atazanavir (Reyataz)
-hyperbilinrubinemia (reversible does not require discontinuation)
-requires acidic gut for absorption
39
Atazanavir and antacids
take atazanavir 2 hours before or 1 hour after
40
Atazanavir and H2RAs
avoid or take atazanavir 2 hours before or 10 hours after
41
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)
42
Darunavir, fosamprenavir, tipranavir
caution with sulfa allergy
43
LPV/r (Kaletra)
oral solution contains 42% alcohol can cause a disulfram reaction if taken with metronidazole
44
Tipranavir
intracranial hemorrhage
45
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
46
PIs and warfarin
not contraindicated but should monitor INR frequently
47
Which HMG-CoA can be used with PIs
rosuvastatin and atorvastatin are preferred
48
Pharmacokinetic boosters
ritonavir (Norvir) and cobicistat (Tybost)
49
which pharmacokinetic booster can be co-formulated
cobicistat
50
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
51
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
52
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
53
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
54
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
55
TDF
CrCl < 50 mL/min: do not start - TDF or TDF containing products (< 70 mL/min for Stribild)
56
TAF
CrCl < 30 mL/min: do not start TAF containing products
57
Stribild
Eltivegravir/ cobicistat/ emtricitabine/ TDF
-take with food
58
Atripla
Efavirenz / emtricitabine/ TDF
-take on an empty stomach
59
Complera
Rilpivirine/ emtricitabine/ TDF
-take with food
60
Genvoya
Elvitegravir/ cobicistat/ emtricitabine/ TAF
-take with food
61
Biktarvy
bictegrvair/ emtricitabine/ TAF
62
Triumeq
Dolutegravir/ abacavir/ lamivudine
63
Dovato
dolutegravir/ lamivudine
64
Odefsey
Rilpivirine/ emtricitabine/ TAF
-take with food
65
Descovy
Emtricitabine/ TAF
-do not use if CrCl < 30 mL/min
66
Truvada
Emtricitabine/ TDF
-do not use if CrCl < 30 mL/min
-do not use if CrCl < 60 mL/min if using for PrEP
67
Diagnosis of aids
CD4 count < 200 cells/mm3 or an AIDs defining illness
68
breastfeeding in HIV + patients
should be avoided
69
combination drugs for HIV+ pregnant patients
Epzicom, Truvada, Cimduo
70
PrEP
-Truvada or Descovy
-IM Inj of Cabotegravir (Apretude) - administered by a healthcare provider monthly for 2 doses then every 2 months
71
Follow-up for PrEP
-truvada and Descovy: 3 months
-Cabotegravir: 1 month after the first injection then every 2 months
72
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
73
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
74
Hydrophilic antibiotics
beta-lactams, aminoglycosides, vancomycin, daptomycin, polymixins
75
Lipophilic antibiotics
quinolones, macrolides, rifampin, linezolid, tetracyclines
76
Natural penicillins
Penicillin V Potassium
Penicillin G
Penicillin G Benzathine
77
Antistaphylococcal Penicillin
Dicloxacillin, Nafcillin, Oxacillin
78
Aminopenicillin
amoxicillin, augmentin, ampicillin, unasyn
79
Extended-spectrum penicillins
zosyn
80
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
81
Penicillin VK
first line treatment for strep throat and mild nonpurulent skin infections (no abscess)
82
Amoxicillin
-first line treatment for AOM
-DOC for infective endocarditis ppx before dental procedures
-used in H. pylori tx
83
Augmentin
-first line treatment for AOM and bacterial sinusitis
-use lowest dose of clavulante to decrease diarrhea
84
Dicloxacillin
-covers MSSA only
-no renal adjustment needed
85
Penicillin G Benzathine
-DOC for syphillis
-Not for IV use; can cause death
86
Nafcillin and Oxacillin
covers MSSA & no renal adjustment required
87
Zosyn
-only penicillin active agent against pseudomonas
-extended infusions (4 hours) can be used to maximize T > MIC
88
1st gen cephalosporin
cefazolin & cephalexin
89
2nd gen cephalosporin
cefuroxime, cefotetan, cefoxitin
90
3rd gen cephalosporin (group 1)
cefdinir, CTX, cefotaxime, cefpodoxime
91
3rd gen cephalosporin (group 2)
ceftazidime - lacks gram positive activity but covers pseudomonas
92
4th gen cephalosporin
cefepime
93
5th gen cephalosporin
ceftaroline
94
Cephalosporin class effect
-do not use in patients with penicillin allergy (except pediatric patients with AOM)
-risk of seizures if accumulation occurs
95
Cephalexin
used in skin infections (MSSA), strep throat
96
Cefuroxime
commonly used in AOM & CAP
97
cefdinir
commonly used in AOM
98
Cefazolin
commonly used in surgical ppx
99
cefotetan and cefoxitin
-anaerobic coverage (B. fragilis)
-commonly used in surgical ppx (GI procedures)
-cefotetan can cause disulfram-like reactions with alcohol ingestion
100
CTX and Cefotaxime
-common uses: CAP, meningitis, SBP, pyleonephritis
-CTX: no renal adjustment, do not use CTX in neonates
101
Ceftazidime and Cefepime
active against pseudomonas
102
Cetolozane/Tazobactam (Zerbaxa) and Ceftazidie/Avibactam (Avycaz)
used for MDR Gram-negative organisms (including pseudomonas)
103
Ceftaroline
-only beta-lactam active against MRSA
-common uses: CAP, skin and soft tissue infections
104
Carbapenem
doripenem, imipenem/cilstatin, meropenem, ertapenem
105
monobactam
aztreonam
106
Class effect of carbapenem
-all active against ESBL-producing organisms
-do not use with penicillin allergy
-seziure risk (highest risk with imipenem)
107
Carbapenems do not cover
atypicals, VRE, MRSA, C. diff, Stenotrophomonas
108
ErtAPenem does not cover
pseudomonas, actinobacter, enterococcous
109
Common uses of carbapenems
polymicrobial infections, empiric therapy when resistance is suspected, ESBL-positive infection, resistant Pseudomonas or acinetobacter (except ertapenem)
110
All carbapenems are IV only
ertapenem must be diluted in normal saline
111
Aztreonam
-gram-negative
-pseudomonas
-no gram + or anaerobic activity`
112
Gentamicin (Gram + infection - synergy)
Peak: 3-4 mcg/mL
Trough: < 1 mcg/mL
113
Gentamicin (gram-negative infection) and tobramycin
Peak: 5-10 mcg/mL
Trough: < 2 mcg/mL
114
amikacin
Peak: 20-30 mcg/mL
Trough: < 5 mcg/mL
115
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
116
Quinolones
ciprofloxacin, levofloxacin, moxifloxacin
117
Respiratory quinolones
levofloxacin, moxifloxacin, gemifloxacin
118
antipseudomonal quinolones
ciprofloxacin, levofloxacin
119
moxifloxacin
only quinolone that is not renally adjusted (do not use in UTIs)
120
IV to PO 1:1
levofloxacin and moxifloxacin
121
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
122
Counseling on quinolones
-avoid sun exposure, separate from polyvalent cations, and monitor blood glucose
-watch for tendon rupture, neuropathy, CNS or psychiatric side effects
123
Macrolides
Azithromycin, clarithromycin, erythromycin
124
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
125
Common Z-pack dosing
two 250 mg tablets PO x1 then 250 mg PO QD x 4 days
126
Macrolides and QT-prolongation
caution with CVD, decrease K/Mg and other QT-prolonging drugs
127
Macrolides and drug interactions
clarithromycin and erythromycin are strong CYP3A4 inhibitors; lovastatin and simvastatin are contraindicated (increased risk of muscle toxicity)
128
Tetracyclines
doxycycline, minocycline
*Do not use in pregnancy, breastfeeding or children < 8 years old*
129
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
130
Sulfonamides
Bactrim
131
common uses of bactrim
CA-MRSA skin infections, UTIs, PJP
132
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
133
bactrim and warfarin
INR increases when used with warfarin - use alternative abx when possible
134
lipoglycopeptides
telavancins, oritavancin, dalbavancin
135
oxazolidinones
linezolid and tedizolid
136
Urinary agents
fosfomycin & nitrofurantoin
137
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
138
MSSA
dicloxacillin, nafcillin, oxacillin, cefazolin, cephalexin (and all other 1st and 2nd gen cephalosporins), augmentin, unasyn, doxycycline, minocycline, bactrim
139
CA-MRSA SSTIs
bactrim, doxycycline, minocycline, clindamycin, linezolid
140
severe SSTIs requiring IV treatment or hospitalization
vancomycin, linezolid, tedizolid, daptomycin, ceftaroline, telavancin, oritavancin, dalbavancin, tigecycline
141
nosocomial MRSA
vancomycin, linezolid, daptomycin (not in pneumonia), telavancin
142
VRE (E. Faecalis)
Pen G or ampicillin, linezolid, daptomycin
-cystitis only: nitrofurantoin, fosfomycin, doxycycline
143
VRE (E. Faecium)
daptomycin, linezolid
-cystitis only: nitrofurantoin, fosfomycin, doxycycline
144
HNPEK
H. Influenzaem Neisseria, Proteus, E. coli, Klebsiella
145
HNPEK commonly used drugs
beta-lactam/beta-lactamase inhibitor*, amoxicillin, cephalosporins (except 1st gen), carbapenem, bactrim, aminoglycosides, quinolones
146
atypical organisms
azithromycin, clarithromycin, doxycycline, minocycline, quinolones
147
pseudomonas aeruginosa
zosyn, cefepime, ceftazidime, Avycaz, Zerbaxa, carbapenem (ertapenem), cirpofloxacin, levofloxacin, aztreonem, aminoglycosides, colistimethane, polymyxin B
148
Acinetobacter
carbapenems*, Unasyn, minocycline, tigecycline, quinolones, bactrim, amikacin, colistimethane, polymyxin B
149
ESBL GNR (E. coli, K. pneumoniae, P. mirabilis)
carbapenems, Avycaz, Zebraxa, aminoglycosides, cystitis only: fosfomycin
150
CRE
Avycaz, colisthimethane, polymyxin B, meropenem/vaborbactam, imipenem/cilstatin/relebactam
151
Bacteroides fragilis
metronidazole, beta-lactam/beta-lactam inhibitor, cefotetan, cefoxitin, carbapenems
152
C. diff
vancomycin, fidaxomicin, metronidazole
153
Drugs that DO NOT require renal adjsutment
antistaphylococcal penicillins, CTX, clindamycin, doxycycline, macrolides, metronidazole, moxifloxacin, linezolid, cholraphenicol, fidaxomicin, rifaximin, rifampin, tedizolid, tigecycline vancomycin PO
154
Storage Requirements: Liquid oral abx - must be refrigerated
Penicillin VK, ampicillin, augmentin, cephalexin, cefuroxime, vancomycin oral, valganciclovir
155
Storage Requirements: Liquid oral abx - refrigerated recommended
ampicillin - improves taste
156
Storage Requirements: Liquid oral abx - DO NOT REFRIGERATE
cefdinir, azithromycin, clarithromycin, doxycycline, ciprofloxacin, levofloxacin, clindamycin, linezolid, bactrim, acyclovir, fluconazole, posaconazole, voriconazole, nystatin
157
Storage Requirements: IV ABX - DO NOT REFRIGERATE
metronidazole, moxifloxacin, bactrim, acyclovir
158
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
159
ABX that has to be taken within one hour of finishing a meal
amoxicillin ER
160
1:1 IV to PO
levofloxacin, moxifloxacin, doxycycline, minocycline, linezolid, tedizolid, metronidazole, bactrim, fluconazole, cresemba, posaconazole, voriconazole
161
light production administration
doxycycline, micafungin, pentamidine
162
compatible with dextrose only
quinupristin/dalfopristin, bactrim, amphotericin B, dalbavancin, oritavancin, pentamidine
163
compatible with saline only
ampicillin, unasyn, ertapenem, daptomycin
164
compatible with NS/LR only
caspofungin, daptomycin (cubicin)
