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Infectious Disease > Infectious Disease I > Flashcards

Infectious Disease I Flashcards

1
Q

Common pathogens of the CNS/Meningitis

A

Group B Streptococcus/E Coli (Young)
Haemophilus influenzae
Listeria (Young/Old)
Neisseria meningitidis
Streptococcus pneumonia

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2
Q

Common pathogens of the Mouth

A

Anaerobic GNR (Prevotella)
Peptostreptococcus
Viridans group Streptococci

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3
Q

Common pathogens of the Upper respiratory

A

Haemophilus influenzae
Moraxella catarrhalis
Streptococcus pyogenes
Streptococcus pneumonae

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4
Q

Common pathogens of the endocarditis (Heart)

A

Enterococci
Staphylococcus aureus (including MRSA)
Staphylococcus epidermidis
Streptococci

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5
Q

Common pathogens of the lower respiratory community

A

Atypicals (legionella, Mycoplasma)
Chlamdophilia
Enteric GNR (alcoholics)
Haemophilus influenzae
Streptococcus pneumonia

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6
Q

Common pathogens of the lower respiratory hospital

A

Acinetobacter baumannii
Enteric GNR (ESBL, MDR)
Pseudomonas aeruginosa
Streptococcus pneumonia
Staphylococcus aureus (including MRSA)

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7
Q

Common pathogens of the Skin and Soft Tissue

A

aerobic/anaerobic GNR (in diabetes)
Pasteurella multocida
Staphylococcus aureus
Staphylococcus epidermidis
Streptococcus pyogenes

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8
Q

Common pathogens of the Urinary Tract

A

E-coli
Enterococci
Klebsiella
Proteus
Staphylococcus saprophytic

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9
Q

Common pathogens of the Bone and Joint

A

GNR (only in specific situations)
Staphylococcus aureus
Staphylococcus epidermidis
Streptococci
Neisseria gonorhhea

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10
Q

Gram positive Cocci (appear purple on stain)

Clusters

A

Staphylococcus spp.

including MRSA, MSSA

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11
Q

Gram positive Cocci (appear purple on stain)

Pairs and chains

A

Strep pneumoniae (diplococci)
streptococcus spp.
enterococcus spp.

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12
Q

Gram positive Rods (appear purple on stain)

A

Listeria
monocytogenes
Corynebacterium spp

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13
Q

Gram positive Anaerobes (appear purple on stain)

A

peptosterptococcus
propionibacterium ances
clostridioides

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14
Q

Atypicals (do not stain well)

A

Chlamydia
Legionella
Mycoplasma pneumoniae
Mycobacterium tuberculosis

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15
Q

Gram Negative (appear pink on stain)

Cocci

A

Neisseria

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16
Q

Gram Negative (appear pink on stain)

Rods

Colonize in Gut

A

Proteus mirbillis
E-Coli
Klebsiella spp
Serratia spp.
Enterobacter clocae
Citrobacter spp.

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17
Q

Gram Negative (appear pink on stain)

Rods

Do not colonize in Gut

A

Pseudomonas aeruginosa
Haemophilus influenzae
Providencia spp

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18
Q

Gram Negative (appear pink on stain)

Coccobacilli

A

Acinetobacter bumannii
Bordetella pertussis
Moraxella catarrhalis

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19
Q

Gram Negative (appear pink on stain)

curved or spiral shaped

A

H. Pylori
Campylobacter
Borrelia
Treponema
Leptospira spp.

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20
Q

Gram Negative (appear pink on stain)

Atypicals

A

Bacteriodes fragilis
Prevotella

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21
Q

Antibiogram

A

show susceptibility patterns generally a year

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22
Q

EE_PEAKS

Common resistant pathogens

A 
Enterococcus faecalis (VRE) 
Enterococcus Faecium (VRE)

Pseudomonas aeruginosa
E. Coli (ESBL, CRE)
Acinetobacter baumannii
Klebsiella pneumoniae (ESBL, CRE)
Staph aureus (MRSA)

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23
Q

Intrinsic resistance

A

resistance that is natural to the organism

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24
Q

Selection Pressure

A

resistance occurs when antibiotics kill off susceptible bacteria, leaving behibd more resistant strains to multiply

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25
Q

Acquired resistance

A

bacterial genes are transferred

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26
Q

Enzyme activation

A

enzymes produced by the bacteria break down the antibiotc

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27
Q

BBW warning for clindamycin

A

C-diff

Others can cause but do not have a BBW
highest risk are with broad spectrum;
PCN
Cephalosporins,
quinolones

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28
Q

Antimicrobial sterwardship programs

A

designed to improve patient safety and outcomes, curb resistance, reduce adverse effects and promote cost effectivness

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29
Q

Drugs that target bacterial cell wall

Cell wall inhibitors

A

betalactams:
penicillins
cephalosporins
carbapenems

Monobactam;
aztreonam

vancomycin
dalbavancin
telavancin
oritavancin

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30
Q

Drugs that target bacterial cell membrane

Cell membrane inhibitors

A

Polymixin
Daptomycin
Telavancin
Oritavancin

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31
Q

Drugs that target bacterial protein synthesis

protein synthesis inhibitors

A

50S

Macrolides

Clindamycin

Linezolid

Quiupristin/dalfopristin

30S

Aminoglycosides

Tetracyclines

23S

Tedizolid

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32
Q

Drugs that target bacterial DNA/RNA synthesis

DNa/RNA inhibitors

A

Quinolones

topoisomerase

metronidazole

tinidazole

Rifampin

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33
Q

Drugs that target bacterial folic acid synthesis

folic acid synthesis inhibitors

A

sulfonamides

trimethoprim

dapsone

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34
Q

Hydrophillic agents

A

Betalactams

Aminoglycosides

Glycopeptides

Daptomycin

polymixin

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35
Q

Lipophillic agents

A

Quinolones

macrolides

rifampin

linezolid

tetracyclines

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36
Q

Concentration dependent

CMax:MIC

A

Aminoglycosides

quinolones

daptomycin

GOAL

High peak, low trough

give large doses for long intervals

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37
Q

Exposure dependent

AUC:MIC

A

Vancomycin

macrolides

tetracyclines

polymixins

GOAL

exposure over time

strategy is variable

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38
Q

Time dependent

Time>MIC

A

Beta-lactams

GOAL

Maintain the drug level grater than the mic for most of the dosing interval

strategy is shorter dosing intervals and longer or continuous infusions

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39
Q

Natural Penecillins

A

Penecillin V Potassium (Pen VK)

Penecillin G Benzathine (Bicillin L-A)

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40
Q

Antistaphylococcus penecillin

A

Dicloxacillin

Oxacillin

Nafcillin (Injection)

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41
Q

Aminopenecillins

A

Amoxicillin (Chewable)

Amoxicillin w/ clavulanate (Chewable)

Ampicillin (Injection)

Ampicillin w/ sulbactam (Injection)

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42
Q

Extended spectrum antibiotics

A

Pipercillin/Tazobactam (injection)

prolonged or extended infusions each dose is over 4 hours

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43
Q

Penecillin class safety/side effects/monitoring

A

BBW - Pen G is not for IV use it is IM

Contraindications

Augmentin and unasyn: history of jaundice

Side effects

seizures with accumulation, GI upset, diarrhea, rash (SJS/TEN)

Monitor

Renal function

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44
Q

Penecillin Notes

Antistaphylococcal Penicillins

A

Antistaphylococcal Penicillins

Preferred for MSSA soft tissue, bone and joint, endocarditis and bloodstream infections

No renal dose adjustments

Nafcillin is a vesicant- administration through a central line is preferred; if extravasation occurs, use cold packs and hyaluronidase injections

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45
Q

Penecillin drug interaction

A

Probenecid can increase the levels of betalactams by interfering with renal excretion

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46
Q

All penicillins should be avoided in patients with a beta-lactam allergy

A

Exceptions: treatment of syphilis during pregnancy (all patients) and in HIV patients with poor compliance/follow-up desensitize and treat with penicillin G benzathine

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47
Q

All penicillins increase the risk of seizures if accumulation occurs (e.g., failure to dose adjust in renal dysfunction)

A

All penicillins increase the risk of seizures if accumulation occurs (e.g., failure to dose adjust in renal dysfunction)

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48
Q

A first-line treatment for strep throat and mild nonpurulent skin infections (no abscess)

A

Penicillin VK

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49
Q

First-line treatment for acute otitis media (pediatric dose: 80-90 mg/kg/day)

Drug of choice for infective endocarditis prophylaxis before dental procedures (2 grams PO x 1, 30-60 minutes before procedure)

A

Amoxicillin

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50
Q

First-line treatment for acute otitis media (pediatric dose: 90 mg/kg/day) and for sinus infections (if antibiotics indicated)

Use the lowest dose of clavulanate to diarrhea

A

Amoxicillin/Clavulanate (Augmentin)

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51
Q

Covers MSSA only (no MRSA)

No renal dose adjustment needed

A

Dicloxacillin

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52
Q

■ Drug of choice for syphilis (2.4 million units IM x 1)

■ Not for IV use; can cause death

A

Penicillin G Benzathine (Bicillin L-A)

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53
Q

■ Only penicillin active against Pseudomonas

☐ Extended infusions (4 hours) can be used to maximize T > MIC

A

Piperacillin/Tazobactam (Zosyn)

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54
Q

CEPHALOSPORINS

A

Generally, the Gram-negative spectrum increases with each generation. As a class, they are not active against Enterococcus spp. or atypical organisms.

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55
Q

First generation: CEPHALOSPORINS

A

excellent activity against Gram-positive cocci (e.g., Streptococci and Staphylococci) and p_referred when a cephalosporin is used for MSSA_ infections. They have some activity against the Gram-negative rods Proteus, E. coli and Klebsiella (PEK), but in general, Gram-negative activity is decreased compared to 2nd, 3rd and 4th generation cephalosporins.

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56
Q

CEPHALOSPORINS: Second generation:

A

There are two types.

Drugs such as cefuroxime cover Staphylococci, more resistant strains of S. pneumoniae plus Haemophilus, Neisseria, Proteus, E. coli and Klebsiella (HNPEK).

The second type, cefotetan and cefoxitin, have added coverage of Gram-negative anaerobes (B. fragilis).

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57
Q

CEPHALOSPORINS: Third generation: there are two groups.

A

Group 1: includes ceftriaxone, cefotaxime and oral drugs, which cover resistant Streptococci (S. pneumoniae and viridans group Streptococci), Staphylococci (MSSA), Gram-positive anaerobes (mouth flora) and resistant strains of HNPEK.

Group 2: includes ceftazidime, which lacks Gram-positive activity but covers Pseudomonas.

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58
Q

CEPHALOSPORINS: Fourth generation:

A

only includes cefepime, which has broad Gram-negative activity (HNPEK, CAPES and Pseudomonas), and Gram-positive activity similar to ceftriaxone.

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59
Q

CEPHALOSPORINS: Fifth generation:

A

only includes ceftaroline, which has Gram-negative activity similar to ceftriaxone, but broad Gram positive activity; it is the only beta-lactam that covers MRSA.

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60
Q

Other cephalosporins: Beta-lactamase inhibitor combinations:

A

ceftazidime/avibactam and c_eftolozane/tazobactam_ have a similar spectrum as ceftazidime but with added activity against MDR Pseudomonas and other MDR Gram-negative rods.

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61
Q

1st Generation Cephalosporin

A

CEfazolin (Ancef)

Cephalexin (Keflex) PO 250-500mg Q6-12H

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62
Q

2nd Generation Cephalosporin

A

Cefuroxime (Ceftin)

Cefotetan (Cefotan)

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63
Q

3rd Generation Cephalosporin

A

Group 1

Cefdinir (Omnicef)

CEftriaxone (Rocephin)

Cefotaxime

Group 2

Ceftazidime (Fortaz)

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64
Q

4th Generation Cephalosporin

A

Cefepime

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65
Q

5th Generation Cephalosporin

A

Ceftaroline

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66
Q

CONTRAINDICATIONS (CEFTRIAXONE)

A

Hyperbilirubinemic neonates (causes biliary sludging, kernicterus)

Concurrent use with calcium-containing IV products in neonates ≤28 days old

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67
Q

WARNINGS Cefotetan

A

Cefotetan contains a side chain [N-methylthiotetrazole (NMTT or 1-MTT)] which can ↑ the risk of bleeding and cause a disulfiram-like reaction with alcohol ingestion

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68
Q

Cephalosporin - CLASS EFFECTS ■

A

Due to a small risk of cross-reactivity, do not choose a cephalosporin on the exam if the patient has a penicillin allergy (exception: pediatric patients with acute otitis media) 30 1827

Risk of seizures if accumulation occurs (e.g., failure to dose adjust in renal dysfunction)

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69
Q

1st Generation: Cephalexin (Keflex)

A

■ Common uses: skin infections (MSSA), strep throat

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70
Q

2nd Generation: Cefuroxime (Ceftin)

A

■ Common uses: acute otitis media, community-acquired pneumonia (CAP), sinus infection (if antibiotics indicated)

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71
Q

3rd Generation: Cefdinir (Omnicef)

A

Common uses: CAP, sinus infection (if antibiotics indicated)

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72
Q

1st Generation: Cefazolin (Ancef)

A

Common use: surgical prophylaxis

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73
Q

2nd Generation: Cefotetan (Cefotan) and Cefoxitin

A

■ Anaerobic coverage (B. fragilis)

■ Common use: surgical prophylaxis (colorectal procedures)

Cefotetan can cause a disulfiram-like reaction with alcohol ingestion

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74
Q

3rd Generation: Ceftriaxone and Cefotaxime

A

Common uses: CAP, meningitis, spontaneous bacterial peritonitis, pyelonephritis

Ceftriaxone

No renal dose adjustment

Do not use ceftriaxone in neonates (age 0-28 days)

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75
Q

Ceftazidime (3rd Generation) and Cefepime (4th Generation)

A

Active against Pseudomonas

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76
Q

Ceftolozane/Tazobactam and Ceftazidime/Avibactam

A

Used for MDR Gram-negative organisms (including Pseudomonas)

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77
Q

Ceftaroline

A

Only beta-lactam active against MRSA

Common uses: CAP, skin and soft tissue infections

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78
Q

Carbapenems

A

Very broad spectrum

Reserved for MDR gram negative

Active against Gram negative, Gram Positive including ESBL

NO COVERAGE of atypicals, MRSA, VRE

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79
Q

Ertapenem

A

Is different from other carnbapenems it has NO ACTIVITY against pseudomonas, acinetobacter or enterococcus

STABLE ONLY IN NS

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80
Q

Ertapenam does not cover?

A

Pseudomonas

Acinetobacter

Enterococcus

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81
Q

Meropenam (Merem)

A

Warnings

Do not use in patients with PCN allergy small risk of cross reactivity.

CNS adverse effects, including states of confusion and seizures.

Monitoring

renal functions

Side effects

DRESS

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82
Q

Key features of carbapenems

Class effects

A

All active against ESBL-producing organism and pseudomonas (ertapenem does not cover pseudomonas)

Do not use with penecillin

Seizure risk (with higher doses, failure to dose adjust in renal dysfunction, or use od imipenem/cilistatin)

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83
Q

Key features of carbapenems

What are NOT covered

A

Atypicals

VRE

MRSA

C-Diff

Stenotropomonas

ErtAPenem - (Enterococcus, Acinetobacter, Pseudomonas)

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84
Q

Key features of carbapenems

COMMON uses

A

Polymicrobial infections (Sever diabetic infections)

Empiric therapy when resistant organisms suspected

ESBL- positive infections

Ressitant pseudomonas or acinetobacter infections (Except ertapenem)

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85
Q

Are carbapenems braod or narrow spectrum?

A

Very broad

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86
Q

Key features of carbapenems

mixed with 0.9%

A

All are IV only, Ertapenem MUST be diluted in normal saline (0.9%)

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87
Q

Aztreonam (monobactam) inhibits cell wall synthesis by binding to penecillin binding protein (PBP)

A

Cross reactivity with beta-lactam highly unlikely. Aztreonam is primarily used when a beta lactam allergy is present

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88
Q

Aztreonam covers what bugs?

A

MANY gram negative bacteria, including pseudomonas.

It has NO GRAM-positive or anaerobic avtivity

89
Q

Beta-lactam spectrum of activty

Which beta-lactams cover MRSA?

A

Ceftaroline

90
Q

Beta-lactam spectrum of activty

Which beta-lactams cover MSSA?

A

Oxacillin, Nafcillin

Amox/Clav, Ampicillin/Sulbactam, Piper/Tazo

Cefazolin (1st), Cephalexin (1st)

Cefuroxime (2nd), Cefotetan (2nd), Cefoxitin (2nd)

Cefotaxime (3rd), Ceftriaxone (3rd)

Cefepime (4th)

Ceftaroline (5th)

Ceftazidime/Avibactam, Ceftolozane/Tazobactam

Imipenem/Cilistatin, Meropenam, Doripenam

Ertapenem

91
Q

Aminoglycosides -

Coverage

A

_**Gram-negative, including pseudomonas

Synergy for Gram-positives (staphylococcus/enterococci)**_

92
Q

Aminoglycosides -

Dosing (gentamicin/tobramycin/amikacin)

A

If underweight use TBW, if obese use AdjBW

Traditional (1-2.5 mg/kg IV Q8H) - Peaks and troughs

CrCl >60 Q8

Extended-interval: (4-7 mg/kg IV Q24H) - draw a random level and use nomogram

93
Q

Aminoglycosides use two dosing strategies, whart are they?

A

Traditional: uses lower doses more frequently

Extended interval dosing: less accumulation, less toxicity and decreased cost

94
Q

Aminoglycosides -
Good News

A

Kill Gram-Negatives, synergistic with beta-lactams for gram-positive infections low resistance and cost

95
Q

Aminoglycosides -
Bad News

A

Toxicities: renal damage and ototoxicities

96
Q

Aminoglycosides -
Smart Idea/Dosing

A

Concentration-dependent killing –> give larger doses less frequently (extended-interval dosing) –> allow kidneys to recover

97
Q

Aminoglycoside BBW

A

Nephrotoxicity

Ototoxicity

Neuromuscular blockade

AVOID with neurotoxic/nephrotoxic drugs

98
Q

Aminoglycoside warnings

A

Use caution in renal impariment, also in elderly and those taking other nephrotoxic drugs (amphotericin B, cisplatin, polymixin, cyclosporin, loop diuretics, NSAIDS, radiocontrast dye, tacrolimus and vancomycin)

99
Q

Peaks and Trough

Gentamicin gram positive infection (synergy)

Gentamicin gram negative infection

Tobramycin

Amikacin

A

Gent (GP) - Peak 3-4mcg/mL <> Trough <1mcg/mL

Gent (GN)- Peak 5-10mcg/mL <> Trough < 2mcg/mL

Tobramycin - Peak 5-10mcg/mL <> Trough < 2mcg/mL

Amikacin - - Peak 20-30mcg/mL <> Trough < 5mcg/mL

100
Q

Quinolones -

A

Concentration-dependent killing

101
Q

Quinolones -

Boxed Warnings

A

Tendon inflammation or rupture
peripheral neuropathy
CNS effects (seizures)
Use-last line (only if no alternatives)

102
Q

Quinolones -

Warnings

A

QT prolongation (higher risk with moxi)
Hypo and hyperglycemia
Psychiatric disturbances - delirium, agitation, memory determent
Photosensitivity
Avoid systemic quinolone use in children and in prgnancy/breastfeeding (exception for anthrax)

103
Q

Quinolones -

Interactions

A

Chelation with divalent cations

104
Q

Quinolones -

Respiratory Quinolones

A

Enhanced activity against S. pneumoniae and atypicals

(My Good Lungs)

  • *Moxifloxacin** (IV:PO = 1:1, NOT renally adjusted so do NOT use for UTIs)
  • *G**emifloxacin
  • *L**evofloxacin
105
Q

Quinolones -

Antispeudomonal quinolone

A

Levofloxacin (IV:PO = 1:1)
Ciprofloxacin

Enhanced Gram Negative activity - Including pneumonia

106
Q

Quinolones -

Profile Review Tips

A

Caution in patients with CVD, decreased K/Mg, use of other QT prolongating drugs

Avoid if seizure history or using anti epileptic

Avoid in children

Watch for tendon rupture, neuropathy, CNS/psychiatric side effects

107
Q

Qinolones MOA

A

Inhibit topoisomerase IV and DNA gyrase

108
Q

Quinolones and activity against MRSA?

A

Delafloxacin - ONLY quinolone recommended for MRSA treatment, all others should be avoided due to high rates of resistance.

109
Q

Moxifloxacin spectrum of activity?

A

Enhanced gram positive and anaerobic

110
Q

Ciprofloxacin Brand

A

Cipro

with dexamethasone (Ciprodex)

IV:PO is NOT 1:1

111
Q

Levofloxacin Brand

A

Levaquin

112
Q

Moxifloxacin Brand

A

Avelox

No renal dose adjustments required

Moxifloxacin SHOULD NOT be used for UTI

113
Q

Ciprofloxacin oral suspension counseling points

A

Shake vigorously for 15 seconds. DO NOT put in NG or other feeding tube

114
Q

Quinolone DDI’s

A

Lanthanum (Fosrenol) sevelmer (Renvela) can decrease serum concentrations for oral quinolones seperate administration by at least 2 hours

CIPRO is a STRONG CYP1A2 inhibitor weak inhbitor of 3A4 and P-GP.

Can increase levels of caffeine, theophylline and tizanidine

115
Q

Quinolone common use anf counseling

A

Can very by agent:pneumonias, UTI’s intra-abdominal infections, travelers diarrhea

AVOID sun exposure, separate from cations, monitor BG, watch for tendon rupture, neuropathy, CNS or psychiatric side effects

116
Q

Macrolides -

Agents in Class

A

Azithromycin (Zithromax)
Clarithromycin (Biaxin)
Erythromycin (E.E.S)

117
Q

Macrolides - MOA

Azithromycin (Zithromax)

Clarithromycin (Biaxin)

Erythromycin (EES, Ery-Tab, Erythrocin)

A

Bind to 50s ribosomal sub-unit results in inhibition of RNA-dependent protein synthesis

118
Q

Macrolide spectrum of activity

A

EXCELLENT activity agains Atypicals

LCMM

Legionella

Chlamydia

Mycoplasma

Mycobacterium

Macrolides are treatment options for CAP (Upper & Lower) and certain STI’s (chlamydia & Gonorrhea)

119
Q

Z-Pak vs Tri-Pak

A

Z-Pak:

500mg day 1 and 250 days 2-5

Tri-Pak:

500mg for 3 days

120
Q

Macrolides -

Safety Issues

A

QT prolongation: caution with CVD, decreased K/Mg, use other QT-prolongating drugs

Drug Interactions: clarithromycin/erythromycin contraindicated with simvastatin/lovastatin

Hepatotoxicity

GI Upset

121
Q

Erythromycin and Clarithromycin DDI’s

A

CYP3A4 major substrates and CYP3A4 inhibitors

Caution with warfarin use

122
Q

Macrolides -

Common Uses

A

CAP, strep throat

Azithromycin: COPD exacerbations, chlamydia, gonorrhea, MAC prophylaxis

Clarithromycin: H. pylori

Erythromycin: increase gastric motility (patients with gastroparesis)

123
Q

KEY FEATURES OF MACROLIDES

A

QT Prolongation

Caution with CVD, J- K/Mg and other QT-prolonging drugs (e.g.,

azole antifungals, antipsychotics, methadone, quinolones)

124
Q

KEY FEATURES OF MACROLIDES

Drug Interactions

A

■ Clarithromycin and erythromycin are strong CYP3A4 inhibitors;

lovastatin and simvastatin are contraindicated ( increase risk of muscle toxicity)

125
Q

TETRACYCLINES

A

Doxycycline (Vibramycin)

Minocycline (Minocin, Solodyn)

126
Q

TETRACYCLINES MOA?

A

Inhibit bacterial protein synthesis by reversibly binding to the 30S ribosomal subunit

127
Q

What Gram positive bacteria do macrolides cover?

A

(Staphylococci, Streptococci, Enterococci, Propionibacterium spp.)

128
Q

What Gram-negative bacteria do macrolides cover, including respiratory flora

A

(Haemophilus, Moraxella, atypicals)

129
Q

What other unique pathogens do macrolides cover

A

(e.g., Rickettsiae, Bacillus anthracis. Treponema pallidum and other spirochetes).

130
Q

Which macrolide has broader indications than the other tetracyclines, including respiratory tract infections (e.g., CAP), tickborne/rickettsial diseases, spirochetes and sexually transmitted infections (chlamydia and gonorrhea).

A

Doxycycline

131
Q

Which macrolide is an option for the treatment of mild skin infections caused by CA-MRSA and VRE urinary tract infections.

A

Doxycycline

132
Q

Which macrolide is often preferred for acne.

A

Minocycline

133
Q

Doxycycline brand

A

Vibramycin

134
Q

Minocycline Brand

A

Minocin, Solodyn

135
Q

No renal dose adjustments required for which macrolide?

A

Doxycycline

136
Q

Mactolide warnings

A

Children < 8 years of age, pregnancy and breastfeeding

(suppresses bone growth and skeletal development, and permanently discolors teeth)

Photosensitivity, tissue hyperpigmentation, severe skin reactions (DRESS/SJS/TEN), exfoliative dermatitis

Minocycline: drug-induced lupus erythematosus (DILE)

137
Q

Mactolide NOTES

A

IV:PO ratio is 1:1 (doxycycline, minocycline)

Tablets and capsules should be taken with 8 oz o f water; with doxycycline, sit upright for at least 30 minutes a fter dose to avoid esophageal irritation

138
Q

Key features of tetracyclines

A

Common Uses

  • Doxycycline and minocycline: CA-MRSA skin infections, acne
  • Doxycycline: first-line treatment for Lyme disease. Rocky Mountain Spotted Fever (tickborne illnesses), CAP, COPD exacerbations, sinusitis (if antibiotic indicated), VRE UTI, chlamydia (as monotherapy), gonorrhea (in combination therapy)
  • Tetracycline: used In H. pylori treatment regimens

Do not use in pregnancy, breastfeeding or children < 8 years old

139
Q

Sulfamethoxazole MOA

A

Sulfamethoxazole (SMX) inhibits dihydrofolic acid formation from para-aminobenzoic acid.

Inhibition of the folic acid pathway.

140
Q

Sulfamethoxazole/trimethoprim has activity against?

A

Gram-positive bacteria

Staphylococci (including MRSA and CA-MRSA);

S. pneumoniae and Group A

Gram-negative bacteria (broad)

Haemophilus, Proteus, E. coli, Klebsiella, Enterobacter, Shigella, Salmonella and Stenotrophomonas

141
Q

SMX/TMP is active against what opportunistic pathogens?

A

Nocardia, Pneumocystis, Toxoplasmosis

142
Q

SMX/TMP does not have activity against what pathogens?

A

Pseudomonas, Enterococci, atypicals or anaerobes

143
Q

Sulfamethoxazole/Trimethoprim (Bactrim,Bactrim DS)

A

Dose based on the Trimethoprim component

144
Q

Sulfamethoxazole/Trimethoprim

Single Strength (SS) vs Double Strength (DS)

A

400 mg SMX/80 mg TMP

800 mg SMX/160 mg TMP

SMX:TMP ratio of 5:1

145
Q

SMX/TMP is a moderate-strong

A

CYP2C8 and CYP2C9 inhibitor

146
Q

SMX/TMP

Common Uses

A

CA-MRSA skin infections

UTI

Pneumocystis pneumonia (PCP)

147
Q

5:1 Ratio of SMX/TMP (Dose Based on TMP)

A

■ Single strength (SS) tablet contains 80 mg TMP

■ Double strength (DS) tablet contains 160 mg TMP - usual dose is one tablet BID

148
Q

SMX/TMP use with Warfarin

A

INR increase when used with warfarin. Use alternative antibiotic when possible.

149
Q

Vancomycin is a glycopeptide that inhibits bacterial cell wall synthesis by binding to the D-alanyl-D-alanine cell wall precursor and blocking peptidoglycan polymerization

A

Vancomycin only covers Gram-positive bacteria, including:

  • Staphylococci (MRSA)
  • Streptococci
  • Enterococci (not VRE)
  • C. difficile (using the PO route only)
150
Q

Vancomycin (Vancocin)

A

First-line treatment for moderate-severe systemic MRSA infections

Consider an alternative drug when MRSA MIC > 2 mcg/mL

151
Q

Vanc (Dose based on total body weight)

Systemic infections (IV only) IV: 15-20 mg/kg Q8-12H

A

C. diffKile infections (PO only)

PO: 125 QID x 10 days

152
Q

Vanc Warnings

A

Ototoxicity and nephrotoxicity

PO formulation is used only for C. difficile colitis and enterocolitis, not for systemic infections; IV formulation is not effective fo r C. difficile

153
Q

Vanc monitoring

A

Renal function, drug levels (see below), WBC

AUC/MIC ratio (improved outcomes and less toxicity) or steady state trough (drawn 30 minutes before the 4th or 5th dose)

Serious MRSA infections (e.g., bacteremia, sepsis, endocarditis, pneumonia, osteomyelitis, meningitis): AUC/MIC ratio of 400-600 recommended or goal trough 15-20 mcg/mL

154
Q

Vancomycin can increase the risk of ototoxicity when used with other ototoxic drugs

A

(e.g., aminoglycosides, cisplatin, loop diuretics).

155
Q

The risk of nephrotoxicity is increased when used with othernephrotoxic drugs

A

(e.g., aminoglycosides, amphotericin B, cisplatin, polymyxins, cyclosporine, tacrolimus, loop diuretics, NSAIDs and radiographic contrast dye)

156
Q

Lipoglycopeptides (with the generic name suffix “-vancin”) inhibit bacterial cell wall synthesis by:

Telavancin (Vibativ)

A

l) binding to the D-alanvl-D:alanine portion of the cell wall, blocking polymerization and cross-linking of peptidoglycan
2) disrupting bacterial membrane potential and changing cell permeability (due to the presence of a lipophilic side chain).

157
Q

Telavancin (Vibativ)

A

Approved for complicated skin and soft-tissue infections (SSTI) and hospital-acquired and ventilator-associated pneumonia

158
Q

Telavancin (Vibativ)

A

BBW

  • Fetal risk - obtain pregnancy test prior to starting therapy
  • Nephrotoxicity; Increased mortality with pre-existing moderate-to-severe renal impairment (CrCI < 50 mL/min)
159
Q

Telavancin (Vibativ)

Warnings

A

Can falsely increse coagulation tests (e.g.. aPTT/PT/INR), but does not increase bleeding risk; red man syndrome with rapid IV administration (give over > 60 minutes); QT prolongation

160
Q

Oritavancin (Orbactiv)

&

Dalbavancin (Dalvance)

Contraindications

A

Oritavancin: do not use IV UFH for 120 hours (5 days) after oritavancin administration due to interference (false elevations) with aPTT laboratory results

161
Q

Oritavancin (Orbactiv)

&

Dalbavancin (Dalvance)

A

Can cause falsely increase PT/INR for up to 12 hours and a P IT for up to 120 hours after a dose

162
Q

Daptomycin is a cyclic lipopeptide.

A

It binds to cell membrane components, causing rapid depolarization; this inhibits all intracellular replication processes, including protein synthesis, and causes cell death

163
Q

Daptomycin has concentrationdependent activity against most Gram-positive bacteria, including

A
  • Staphylococci (MRSA) and
  • Enterococci (both species of VRE, E. faecium and E. faecalis)

It has no activity against Gram-negative pathogens.

164
Q

Daptomycin (Cubicin, Cubicin RF)

Warnings

A

Myopathy and rhabdomyolysis

Can falsely increase PT/INR,

165
Q

Daptomycin (Cubicin, Cubicin RF) Side effects

A

Increased CPK, abdominal pain, pruritus, chest pain, edema, hypertension, acute kidney injury

MONITOR

CPK level weekly

166
Q

Cubicin: compatible with NS and LR (no dextrose)

A

Do not use to treat pneumonia; drug is inactivated in the lungs by surfactant

167
Q

Linezolid and tedizolid bind to the 50S subunit of the bacterial ribosome, inhibiting translation and protein synthesis.

A

They have activity against similar pathogens as vancomycin (e.g., MRSA), but also cover VRE (E. faecium and E. faecalis).

168
Q

Linezolid (Zyvox)

No renal dose adjustments required IV:PO ratio is 1:1

A

CONTRAINDICATIONS

Do not use with or within 2 weeks of MAO inhibitors

WARNINGS

Duration-related myelosuppression (thrombocytopenia

When used > 14 days, peripheral and optic neuropathy

When used > 28 days, serotonin syndrome, hypoglycemia

169
Q

Linezolid (Zyvox)

Do not shake linezolid suspension

A
  • decrease platelets
  • decrease Hgb
  • decrease WBC
  • HA,
  • nausea
  • diarrhea
  • Increased LFTs
170
Q

Linezolid/Tedizolid Drug Interactions

A

Linezolid and tedizolid are reversible monoamine oxidase inhibitors. Avoid tyramine-containing foods and serotonergic drugs

171
Q

Tigecycline is a glycylcycline. It binds to the SOS ribosomal subunit inhibiting protein synthesis; structurally, it is related to the tetracyclines

A

Tigecycline has broad-spectrum

Among the Gram-negatives, it has no activity against the “3 P’s”: Pseudomonas, Proteus, Providencia species

172
Q

Tigecycline (Tygacil)

BOXED WARNING

Increased risk of death

A

NOTES

Do not use for bloodstream infections

Reconstituted solution should be yellow/orange: discard if not this color

173
Q

polymyxin class consists of two drugs, colistimethate (sometimes referred to as colistin) and polymyxin B. Colistimethate

A

Due to the risk of toxicities, they are used primarily for MDR Gram-negative pathogens in combination with other antibiotics.

174
Q

Colistimethate(Coly-Mycin M)

Solutions for inhalation must be mixed immediately prior to administration

A

Dose-dependent nephrotoxicity (monitor renal function and electrolytes), neurotoxicity (dizziness, headache, tingling, oral paresthesia, vertigo)

175
Q

Colistimethate is a prodrug that is converted to colistin

A

Colistimethate (Coly-Mycin M) Injection (can be used for inhalation administration)

176
Q

Polymyxin B

Injection

A

BOXED WARNINGS

Nephrotoxicity (dose-dependent)

Neurotoxicity (dizziness, tingling, numbness, paresthesia, vertigo)

Neurotoxicity can result in respiratory paralysis from neuromuscular blockade

177
Q

Chloramphenicol

warnings

A

Gray syndrome with high serum levels - circulatory collapse, cyanosis, acidosis, abdominal distention, myocardial depression, coma and death

178
Q

Clindamycin (Cleocin)

No renal dose adjustments

Topical formulations:

Cleocin-T, Clindasel

A

BBW: C-Diff

Notes:

An induction test (D-test) should be performed on S. aureus that is susceptible to clindamycin but resistant to erythromycin; a flattened zone between the disks (positive D-test) indicates inducible clindamycin resistance and clindamycin should not be used

179
Q

Metronidazole has activity against anaerobes and protozoal infections

A

It is effective for bacterial vaginosis, trichomoniasis, giardiasis, amebiasis, C. difficile (though not preferred) and is used in combination regimens for intra-abdominal infections

180
Q

Metronidazole (Flagyl)

Topical: MetroCream, Metrogel, MetroLotion, Noritate, Rosadan

Vaginal: Nuvessa, Vandazole

A

These antibiotics cause a loss of helical DNA structure and strand breakage resulting in inhibition of protein synthesis

lV:PO ratio is 1:1

181
Q

Metronidazole (Flagyl) Contraindications

A

Pregnancy (1st trimester)

Use of alcohol or propylene glycol-containing products during treatment or within 3 days of treatment discontinuation (disulfiram reaction)

182
Q

Metronidazole (Flagyl)

A

Side effect:

Metallic taste,

183
Q

Secnidazole (Solosec)

A

PO: 2 gram single dose

SOLO = by itself = single dose

SE:

​Vulvovaginal candidiasis, HA, N /D

184
Q

Metronidazole is a weak inhibitor of CYP2C9 and can cause

an increase INR in patients taking warfarin.

A

Metronidazole and tinidazole should not be used with

alcohol

185
Q

Fidaxomicin inhibits RNA polymerase, resulting in inhibition of protein synthesis and cell death.

A

It is used for C. difficile infections.

WARNINGS

Not effective for systemic infections - absorption is minimal

186
Q

Rifaximin inhibits bacterial RNA synthesis by binding to bacterial DNA-dependent RNA polymerase. It is structurally related to rifampin.

A

Not effective for systemic infections (< 1% absorption)

Used off-label for C. difficile infection

187
Q

Fosfomycin Inhibits bacterial cell wall synthesis by inactivating the enzyme pyruval transferase, which is critical in the synthesis of cell walls.

A

It has activity against E. Coli (including ESBLs) and E. faecalis (including VRE).

A single-dose regimen is used for uncomplicated UTI (cystitis only).

188
Q

Fosfomycin (Monurol)

Packet granules = 3 gram per packet

A

Female, uncomplicated UTI 3 grams PO x 1, mixed in 3 -4 oz of cold water

189
Q

Nitrofurantoin is a bacterial cell wall inhibitor. It is used for uncomplicated UTI (cystitis only).

A

It covers E. coli, Klebsiella, Enterobacter, S. aureus and Enterococcus (VRE).

190
Q

Nitrofurantoin

(Macrobid, Macrodantin)

A

Contraindicated: Renal impairment (CrCI < 60 ml/min * )

Warnings: hemolytic anemia (use caution in patients with G6PD deficiency)

SIDE EFFECTS:

Gl upset (take with food), headache, rash, brown urine discoloration (harmless)

191
Q

KEY FEATURES OF NITROFURANTOIN

A
  • Drug of choice for uncomplicated UTI
    • See the ID II chapter for a discussion on use in pregnancy
  • Do not use
    • Contraindicated when CrCI < 60 mL/min Dosing
  • Macrobid is BID
  • Macrodantin is QID
  • Counseling
    • Take with food to prevent nausea, cramping
    • Can discolor the urine (brown)
192
Q

Mupirocin is a topical antimicrobial ointment used to eliminate Staphylococci (MRSA) colonization of the nares

Mupirocin (Bactroban*)

A

Mupirocin (Bactroban*)

Decolonization

1/2 tube in each nostril BID X 5 days

193
Q

Methicillln-sensitive Staphylococcus aureus (MSSA)

A

Dicloxacillin, nafcillin, oxacillin

Cefazolin, cephalexin (and other 1st and 2nd generation cephalosporins)

Amoxiciilin/clavuianate, ampicillin/sulbactam

Doxycycline, minocycline

SMX/TMP

194
Q

Community-associated methicillin resistant Staphylococcus aureus (CA-MRSA) Skin & soft tissue infections (SSTIs)

(CA-MRSA SSTIs)

A

SMX/TMP (Bactrim)

Doxycycline (Vibramycin), minocycline (Minocin)

Clindamycin (Cleocin)

Linezolid (Zyvox)

195
Q

Severe SSTIs requiring IV treatment or hospitalization (cover MRSA and Streptococci)

A
  • Vancomycin (consider using alternative if MIC >2)
  • Linezolid, tedizolid
  • Daptomycin
  • Ceftaroline
  • Telavancin
  • Oritavancin
  • Dalbavancln
  • Quinupristin/Dalfopristin
  • Tigecycline
196
Q

Nosocomial MRSA

A

Vancomycin (consider using alternative if MIC >2)

Linezolid

Daptomycin (not in pneumonia)

Telavancin

197
Q

VRE (E.faecalis)

A
  • Pen G or ampicillin
  • Linezolid
  • Daptomycin
  • Tigecycline
  • Cystitis only: nitrofurantoin, fosfomycin, doxycycline
198
Q

VRE (E.faecium)

A

Daptomycin

Linezolid

Quinupristin/Dalfopristin

Tigecycline

Cystitis only: nitrofurantoin, fosfomycin, doxycycline

199
Q

HNPEK

A
  • H. influenzae.
  • Neisseria gonorrhoeae.
  • Proteus.
  • E. coli.
  • Klebsiella
200
Q

HNPEK

  • H. influenzae.
  • Neisseria gonorrhoeae.
  • Proteus.
  • E. coli.
  • Klebsiella
A
  • Beta-lactam/beta-lactamase inhibitor
  • Amoxicillin (if beta-lactamase negative)
  • Cephalosporins (except 1st generation)
  • Carbapenems
  • SMX/TMP
  • Aminoglycosides
  • Quinolones
201
Q

Atypical Organisms

A

Azithromycin, clarithromycin

Doxycycline, minocycline

Quinolones

202
Q

Pseudomonas aeruginosa

A
  • Piperacillin/tazobactam
  • Cefepime
  • Ceftazidime
  • Ceftazidime/avibactam
  • Ceftolozane/tazobactam
  • Carbapenems (except ertapenem)
  • Ciprofloxacin, levofloxacin
  • Aztreonam
  • Aminoglycosides
  • Colistimethate, polymyxin B
203
Q

Acinetobacter baumannii

A
  • Carbapenems (except ertapenem)
  • Ampiclllln/sulbactam
  • Minocycline
  • Tigecycline
  • Quinolones
  • SMX/TMP
  • Amikacin
  • Colistimethate, polymyxin B
204
Q

Extended-spectrum beta-lactamase producing Gram-negative rods (ESBL GNR) - E. coli, K. pneumoniae, P. mirabilis

A
  • Carbapenems
  • Ceftazidime/avibactam
  • Ceftolozane/tazobactam
  • Aminoglycosides
  • Cystitis only: fosfomycin
205
Q

Carbapenem-resistant Gram-negative rods (CRE)

A
  • Ceftazidime/avibactam
  • Colistimethate, polymyxin B
  • Meropenem/vaborbactam
  • Imipenem/cilastatin/relebactam
206
Q

Bacteroides fragilis

A
  • Metronidazole
  • Beta-lactam/beta-lactamase inhibitor
  • Cefotetan, cefoxitin
  • Carbapenems
  • Tigecycline
  • Others (reduced activity): moxifloxacin
207
Q

C. difficile Infection

A
  • Vancomycin (oral)
  • Fldaxomicin
  • Metronidazole
208
Q

REFRIGERATION REQUIRED AFTER RECONSTITUTION

A
  • Penicillin VK
  • Ampicillin
  • Amoxicillin/Clavulanate (Augmentin)
  • Vancomycin oral (Firvonq)
  • Valganciclovir (Valcyte)*
  • Cephalexin (Keflex)
209
Q

REFRIGERATION RECOMMENDED

A

Amoxicillin - improves taste

210
Q

DO NOT REFRIGERATE

A
  • Cefdinir (formerly Omnicef)
  • Azithromycin
  • Clarithromycin - bittertaste, thickens/gels
  • Acyclovir (Zovirax)*
  • Fluconazole (Diflucan)’
  • Posaconazole (Noxafil)*
  • Voriconazole (Vfend)*
  • Nystatin*
211
Q

STORAGE REQUIREMENTS: IVANTIBIOTICS

Most IV medications are refrigerated; the list below represents a few that are not.

A
  • Metronidazole (Flagyl)
  • Moxifloxacin (Avelox)
  • Sulfamethoxazole/Trimethoprim
  • A cyclovir (Zovirax) - refrigeration causes crystallization
212
Q

Many antibiotics are cleared through the kidneys and require dose adjustments based on renal function. This includes most beta-lactams and quinolones

What are antibiotics that do not require renal adjustment

A
  • Antistaphylococcal penicillins (e.g., dicloxacillin, nafcillin)
  • Ceftriaxone
  • Clindamycin
  • Doxycycline
  • Macrolides (azithromycin and erythromycin only)
  • Metronidazole
  • Moxifloxacin
  • Linezolid
213
Q

Most antibiotics can be taken with food to decrease Gl upset

Exceptions:

A

Take on an empty stomach:

ampiciliin oral capsules and suspension,

ceftibuten suspension,

levofloxacin oral solution,

penicillin VK,

rifampin*, isoniazid*, itraconazole solution’, voriconazole*

214
Q

1:1 IV TO ORAL DOSING

For these drugs, the oral and IV doses are the same.

A

Levofloxacin, moxifloxacin

Doxycycline, minocycline

Linezolid, tedizolid

Metronidazole

Sulfamethoxazole/Trimethoprim

Fluconazole*, isavuconazonium*, posaconazole* (oral tablets and IV), voriconazole*

215
Q

LIGHT PROTECTION DURING ADMINISTRATION

A

Doxycycline

Micafungin*

Pentamidine*

216
Q

DILUENT COMPATIBILITY REQUIREMENTS

Compatible with dextrose only

A

Quinupristin/Dalfopristin

Sulfamethoxazole/Trimethoprim

Amphotericin B* (conventional, Abelcet, Ambisome)

Dalbavancin, oritavancin

Pentamidine*

217
Q

Compatible with saline only - 0.9% NS

A

Ampiciliin

Ampicillin/Sulbactam

Ertapenem

Daptomycin (Cubicin RF - see the daptomycin drug table for reconstitution requirements prior to dilution)

218
Q

Compatible with NS/LR only

A

Caspofungin*

Daptomycin (Cubicin)

Infectious Disease (56 decks)

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