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Advanced Pharmacology > Infectious Disease Pt 1 > Flashcards

Infectious Disease Pt 1 Flashcards

1
Q

Classification of Bacteria

  • Gram positive vs. gram negative via Gram ____
    • Microbiological identification system based on _____ structure
    • Differ in structural components, sh____
  • Aerobic vs. anaerobic
    • Differing ____ requirements for survival
  • Gram _____ has a thicker peptidoglycan layer
    • also looks more _____ color under microscope
A
  • Stain
    • cellular
    • shapes
  • Aerobic vs. anaerobic
    • oxygen
  • Positive = thicker
    • ​purple
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2
Q

+Gram Stain

  • Gram negative shape =
    • _______ aeruginosa
  • Gram positive shape =
    • _______ aureus

General rule

  • GPC in clusters =
  • GPC in chains =
A
  • rods
    • Pseudomonas
  • cocci in clusters
    • Staphylococcus
  • staphylococcus species
  • streptococcus species
  • Gram negative = pink and rod like shape*
  • Gram positive = purple and in clusters (cocci- grape like appearance)*
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3
Q

Gram Positive Organisms of Importance

(8)

A
  • Staphylococcus aureus
    • ​Methicillin-susceptible (MSSA)
    • Methicillin resistant (MRSA)
  • Coagulase-negative S**taphylococcus (CoNs)
  • Streptococcus pneumoniae
  • Streptococcus viridans
  • Streptococcus pyogenes (Group A Strep)
  • Streptococcus agalactiae (Group B Strep)
  • Enterococcus faecalis and Enterococcus faecium
  • Clostridium difficule (anaerobic)
  • CoNs - often on skin - potentially a contaminant to blood cultures*
  • Staph aureus never really a contaminant/found on skin so def treat it*
  • Streps are not contaminants*
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4
Q

Gram-Negative Organisms of Importance

(8)

A
  • Escherichia coli (E.coli)
  • Klebsiella pneumoniae
  • Enterobacter cloacae
  • Pseudomonas aeruginosa
  • Acinetobacter baumannii
  • Haemophilus influenzae
  • Mycoplasma pneumoniae
  • Bacteroides fragilis (anaerobic)

Pseudomonas like MRSA is an umbrella term - if a drug covers these, probably will cover others under it

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5
Q

Minimum Inhibitory Concentration (MIC)

What is it?

A

Lowest drug oncentration required to inhibit the growth of an organism at 24 hours (Value determines if sensitive, intermediate, or resistant)

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6
Q

On the Susceptibility Panel, what does it mean when there are all S’s on the right side?

A

The bacteria is PANSENSTIVE - can be treated with all the abx listed

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7
Q

Poll 1

  • Blood cx has come back with preliminary results:
    • Gram-positive cocci (GPC) in clusters on gram-stain
  • Which of the following organisms fits the description?
    • Bacteroides fragilis
    • Staphylococcus aureus
    • Streptococcus pneumoniae
    • Pseudomonas aeruginosa
A

Staphylococcus aureus

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8
Q

Poll 2

Which of the following is considered a gram-positive anaerobic organism?

  • Streptococcus pneumoniae
  • Bacteroides fragilis
  • Clostridium difficile
  • Streptococcus pyogenes
A

Clostridium Difficile

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9
Q

S/S of Infection

A
  • Fever > 38.3 or 100.9F
  • Elevated WBC (leukocytosis)
  • AMS
  • Altered hemodynamics (hypotension, tachycardia)
  • Fatigue
  • N/V
  • Site specific sx (pain, difficulty, breathing, redness, others)
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10
Q

Fever Causes

  • Roughly 75% of fever in hospitalized pts is _____
  • Remaining causes (4)
A
  • pyrogenic
  • malignancy, tissue ischemia, drug-induced, neurogenic

Keep in mind, not all fevers are infectious such as in cancer or seizure pts

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11
Q

Fevers the Good vs. Bad

Pros (4)

Fever > ___/___ C harm outweighs benefit

Cons (3)

A
  • Fevers are designed to be good - mostly the beginning of the fever but if a fever is unaddressed, extended esp > 39/40 can cause lots of bad things*
  • Ie) pediatric febrile seizures (not uncommon in peds)*
  • Ex of taking advantage of some of the pros: doc says hold the tylenol until fever is >39*
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12
Q

Identifying the Source

  1. CNS
  2. Respiratory
  3. CV
  4. GI
  5. Urinary
  6. Integumentary
  7. Skeletal
A

Work by organ system from head to toe

  1. Meningitis
  2. PNA
  3. Endocarditis, Blood infections
  4. Colitis, food borne illness
  5. UTI
  6. Skin infections
  7. Osteomyelitis
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13
Q

Normal Human Flora

  1. Oral (2)
  2. Pulmonary (3)
  3. GI (6)
  4. GU (3)
  5. Integumentary (2)
A
  1. Streptococcus spp, Gram-positive anaerobes
  2. Streptococcus spp, Haemophilus inf, Mycoplasma spp
  3. E. coli, Klebsiella pneumoniae, streptococcus spp, Candida spp, Gram - anaerobes, other gram negatives
  4. Streptococcus spp, E.coli, Candida spp
  5. Streptococcus spp, Staphylococcus spp.
  • After identifying the source - think about whats normally there?-* Translocation of our normal bacteria when we have infections
  • Ex) treating cellulitis on my leg - targeting strep and staph*
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14
Q

Pharmacokinetics (PK)

  • The study of the actions the ____ has on the ____
    • Concerned with concentration/drug availability
  • Incorporates four major body processes
    • ______ - drug into the body
    • ______ - drug into various tissues
    • _______-changing drug into other molecules
    • ______ - removal of drug from body
  • Imp: above processes ___ the same in all patients
    • Genetics: age, comorbities, organ function
A

body has on the drug

4 processes

  • Absorption
  • Distribtuion
  • Metaboism
  • Excretion

NOT

depending on severity of infection/keep in mind PO drugs not fully absorbed compared to IV

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15
Q

Pharmacodynamics (PD)

  • The study of actions the ____ has on the ____
  • E_____ of drug activity
  • Unique in ID- targets bacterial pathogens instead of human receptors/target sites
A
  • drug on the body
  • Efficacy
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16
Q

+Time vs. Concentration Dependent

  • Time dependent
    • Greater bactericidal (killing) activity as:
      • PKPD parameter: __ > ___
    • Example: ___-____ abx
  • Concentration Dependent
    • Greater bactericidial (killing) activity as:
      • PKPD parameter: C__/____ or AUC/MIC
    • Example: _______
A
  • Time Dependent
    • Drug concentrations remain above the MIC
      • ​T > MIC
    • Beta-lactam
  • Concentration Dependent
    • Drug concentrations (Cmax) exceed the MIC
      • ​Cmax/MIC
    • Aminoglycoside
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17
Q

PKPD Parameters

  • Concentration dependent - ____ a day, get to that ____
  • Time dependent - _____ concentration for as long as possible, dosing more ____*
A
  • once, peak

- maintain, frequent

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18
Q

Mechanism of Action Overview

  • Targeting diff parts of the cell
  • Two main classes
    • Intracellular =
    • Extracellular =
A
  • inhibits protein synthesis
  • inhibits cell wall synthesis
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19
Q

+Beta Lactams

(4)

A

Natural Penicillins

Anti-Staphylococcal Penicillins

Amino-Penicillin

Anti-Pseudomonal Penicillins

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20
Q

+Penicillin Evolution

All belong to the ___-____ family

MOA

Increasing spectrum of gram _____ organisms

A

Beta-Lactam

Bind to penicillin binding proteins (PBPs) within the cell wall -> inhibiting cell wall synthesis -> cell lysis -> destruction

negative

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21
Q

+Natural Penicillins

(2)

Discovered in 1928, forever changed medicine

A

Penicillin G

Penicillin V

Prior to discovery of penicillins, we really didn’t have much to treat infections…a slow agonizing death, really reserved for skin infections, doesn’t really cover gram -

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22
Q

+Natural Penicillins

Spectrum

A

Staph aureus (penicillin-susceptible); Streptococcus spp, others

Minimal to NO gram-negative activity

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23
Q

+Natural Penicillins

Indications

A
  • Initially excellent for skin infections
    • Resistance developed over time
  • Drug of choice for: Syphilis
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24
Q

+Natural Penicillins

Routes

  1. Pencillin G
  2. Penicillin V
A
  1. IV, IM as Pen G benzathine
  2. PO - low absoprtion of oral tablet limits its use

Limitiation with Oral beta lactams - poorly absorbed so with serious infections not good enough

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25
Q

+Anti-Staphylococcal Penicillins

(3)

A

Oxacillin

Nafcillin

Dicloxacillin

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26
Q

+Anti-Staphylococcal Penicillins

Spectrum

A

Developed to treat Penicillin-RESISTANT Staph Aureus

  • Originally methicillin-since discontinued (dt hepatotoxicity)

Methicillin-Susceptible Staph Aureus (MSSA)

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27
Q

+Anti-Staphylococcal Penicillins

Indications

Drug of Choice for?

A

Serious MSSA infections (e.g blood stream)

28
Q

+Anti-Staphylococcal Penicillins HF/Dosing

Half life is long or short?

Dosed how frequently?

A

Very short

Every 4 hours (requires frequent dosing) -> not commonly used

29
Q

+Anti-Staphylococcal Penicillins

Clearance

A

Liver = no renal adjustments

Unique - most of the other beta-lactams renally adjusted

30
Q

+Anti-Staphylococcal Penicillins

Routes

A

PO option for dicloxacillin

31
Q

+Amino-Penicillin

(2)

A

Amoxicillin (Amoxil)

Ampicillin

32
Q

+Amino-Penicillin

Developed to provide?

Spectrum

A

Gram negative in addition to gram positive coverage

Streptococcus spp, E.coli, Haemophilus influenzae, Enterococcus faecalis

Not reliable for Staph aureus (often resistant dt beta-lactamase production)

Expanded spectrum to include gram neg, however is a more advanced penicillin that doesn’t work on staph aureus, only these organisms above though -doesn’t really cover hospital infections (Pseudomonas)

33
Q

+Amino Penicillin

Routes

  1. Amoxicillin
  2. Ampicillin
A
  1. PO, used as oral therapy (better bioavailability)
  2. PO and IV, mainly used in IV form (oral with poor bioavailability) compared to PO amoxicillin
34
Q

+Amino-Penicillin Indications

Clinical Use (2)

Not used empirically for?

A

Otitis Media, Acute Pharyngitis

Not used for hospital infections -> Gram-negatives are usually resistant

35
Q

Anti-Pseudomonal Penicillins

(1)

  • Developed to include coverage of _______ (hospital associated, gram-negative organism)
  • Spectrum:
  • Route: only ___ used in hospital combined with _____ for hospital acquired infections (_____)
  • Not used _____ (ie. with tazobactam) due to _______
    • _____-________
A

Piperacillin

  • Pseudomonas aeruginosa
  • Same as Aminopenicillins (+ Pseudomonas)
  • IV, tazobactam, Zosyn
  • alone, resistance
    • Beta-lactamases

Again if a drug can cover pseudomonas, it can probably cover other gram negatives

36
Q

What is Beta-Lactamase?

  • ______ that hydrolyzes the beta-lactam _____ -> antibiotic becomes _____
  • 1,000’s of beta lactamases - classified based on s____/a____ it inactivates
  • ______ beta lactamases vs. _____ beta-lactamases vs. others
A
  • Enzyme, ring, inactive
  • structure/antibiotic
  • simple, expanded

Beta-lactamases are enzymes produced by bacteria that provide multi-resistance to β-lactam antibiotics such as penicillins, cephalosporins, cephamycins, and carbapenems (ertapenem), although carbapenems are relatively resistant to beta-lactamase.

37
Q

+Beta Lactamase Inhibitors

(3)

A

Amoxicillin-_Clavulanate_ (Augmentin)

Ampicillin- Sulbactam (Unasyn)

Piperacillin-_Tazobactam_ (Zosyn)

38
Q

+Beta Lactamase Inhibitors

  • Developed to: _____ the activity of simple _________
  • P_____/e_____ the activity of its ______
  • Routes: Unasyn/Zosyn -___ only, Augmentin - __ only
  • Indication:
    • Also includes ________ activity (with the exception of _____)
  • Augmentin associated with high rates of ___ complaints
A
  • inhibit the activity of simple beta-lactamases
  • Preserve/expand, counterpart
  • IV, PO
  • Used empirically for hospital infections due to their expanded spectrum of activity
    • anaerobic, X c.diff
  • GI
39
Q

Example of Beta-Lactamase Producing Organism

How can you tell if something is producing beta-lactamase?

A

Resistant to Ampicillin vs. Sensitive to Ampicillin-Sulbactam

40
Q

+Penicillin Class AE

(3)

A
  1. Hypersensitivity reactions
    • 10% of US population reports being allergic- Rash most common
  2. Almost all agents are Renally eliminated (require adjustments)
    • ​Notable Exception: Oxacillin and Nafcillin (hepatically eliminated, must monitor LFTs and avoid in elevated LFTs at baseline)
  3. GI intolerances (ie diarrhea)
    • more commonly with oral agents
41
Q

Cephalosporins

  • Inhibits ____-____ synthesis (same as _____ class - ___-____family)
  • MANY DRUGS IN THIS CLASS (will almost always begin with ___/___)
  • Grouped into _______ based on spectrum of activity/characteristics
A
  • cell-wall, penicillin, beta-lactam
  • ceph/cef
  • generations
42
Q

+ First Generation Cephalosporins

(2)

Routes

A

Cephalexin (Keflex) PO

Cefazoline (Acnef) IV

43
Q

+First Generation Cephalosporins Indications

  • _______ to Anti-staphylococccal ______ (e.g. oxacillin/nafcillin/dicloxacillin)
  • Very commonly used for ____ infections and _____ prior to _____
A
  • Alternative, penicillins
  • skin, prophylaxis to surgeries
44
Q

+First Generation Cephalosporins

Spectrum

A

Streptococcus, Staph aureus (MSSA)

NOT MRSA

Minimal gram-negative activity (resistance)

45
Q

+First Generation Cephalosporins

Half Life

Dosing

A

Short half-life

3-4x/day

46
Q

+Third Generation Cephalosporins

(4)

Routes

A

Ceftazidime (Fortaz) IV

Ceftriaxone (Rocephin) IV

Cefpodoxime (Vantin) PO

Cefdinir (Omnicef) PO

Very important class: Extended spectrum beta lactams

47
Q

+Third Generation Cephalosporins Spectrum

  • Developed to further _____ gram-____ spectrum
    • These beta-lactams have an ______ spectrum
    • Spectrum (5)
    • EXCEPTIONS: ______ ONLY one in the group that does ___ cover gram-positive organisms and only one that covers _______ aeruginosa
  • ______ stability against beta-lactamases
A
  • expand, gram-negative
    • Extended
    • Streptococcus spp, MSSA, E.coli, K. penumoniae, Proteus spp
    • Ceftazidime, NOT +, yes Pseudomonas
  • Increased

Ceftaz = TAZMANIAN DEVIL -> covers pseudomonas and doesn’t cover the gramp positive strep and MSSA

48
Q

+Third Generation Cephalosporins

Inactivated by?

A

Extended-spectrum beta lactamases (ESBLs)

ESBLs will inactivate these drugs (very prominent in the Northeast)

49
Q

+Third Generation Cephalosporins PK

Half Life

Dosing Frequency

Elimination

A

Longer half life

Once daily for most infections

Hepatically eliminated = no renal adjustments (unique for cephalosporin class)

Ceftriaxone and Oxacillin class not renally dose adjusted

50
Q

+Third Generation Cephalosporins

Indications

A

Commonly used in hospital and outpatient (community-acquired PNA, UTI, skin, bacteremia, osteomyelitis, CNS infections)

51
Q

Example of an ESBL Producing Organism

A
52
Q

Fourth Generation Cephalosporins

(1) Route

  • Further expanded gram-_____ coverage
  • Spectrum:
  • Reserved for serious ____-associated infections
  • Concern for _____ (including seizure) if not dosed properly
    • Risk highest in e____, ____ impairment
A

Cefepime (Maxipime) IV

  • expanded gram-negative coverage
  • Same as 3rd gen + additional gram negs including Pseudomonas Aeruginosa
  • serious hospital
  • encephalopathy
    • elderly, renal
53
Q

Fifth Generation Cephalosporines

(1) Route

  • _____ the rule
  • Spectrum:
  • “Think Cetriaxone with ____ coverage”
  • Approved for (2)
  • Used off label for b____, endo____ and osteo____ (as salvage therapy)
A

Ceftaroline (Teflaro) IV

  • Breaks
  • Expands gram positive, doesn’t cover pseudomonas but does cover MRSA by binding to PBP-2a
  • MRSA
  • CAP, ABSSSI
  • bacteremia, endocarditis, osteomyelitis
54
Q

+Cephalosporins AE

  • Overall:
  • _____ less commonly seen as compared to penicillin
    • <__% cross reactivity seen in those allergic to penicllins
      • Clinically okay to challenge if pt experienced just a ____
      • Requires allergy testing or avoid use if: H___, S____, A____
  • ______ if not dosed properly (more common with what drug?)
A
  • well tolerated
  • Hypersensitivity
    • <5%
      • Rash
      • Hives, Swelling, Anaphylaxis
  • Seizure (Cefepime)
55
Q

Poll 3

How do beta-lactams exhibit their mechanism of action?

  • Inhibiting cell wall synthesis
  • Mixed martial arts
  • Inhibiting protein synthesis
  • Hydrolyzing the beta lactam ring
A

Inhibiting cell wall synthesis

56
Q

Poll 4

This third generation cephalosporin is the only third generation to have activity against Pseudomonas aeruginosa making it a useful option when treating ventilator associated PNA

  • Cetriaxone
  • Ceftazidime
  • Cefepime
  • Ceftaroline
A

Ceftazidime

57
Q

Poll 5

Which of the following requires hepatic elimination?

  • Cefepime
  • Penicillin
  • Cefazolin
  • Oxacillin
A

Oxacillin

Hepatic adjustment is really just avoiding it

58
Q

Poll 6

People speak highly of me. For example, I am considered an agent who protects my couterpart, similar to a body guard. I am also known to enhance my counterpart’s spectrum of activity. What class of drug am I considered?

  • Cephalosporin
  • Penicillin
  • Beta-Lactamase Inhibitor
  • Beta Lactam

What is an example of a drug in that class? (Beta-Lactamase Inhibitor)

  • Cefepime
  • Sulbactam
  • Oxacillin
  • Piperacillin
A

Beta Lactamase Inhibitor

Sulbactam

59
Q

Poll 6

Which of the following in the class can treat Pseudomonas aeruginosa?

  • Amoxicillin-clavulanate
  • Ampicillin-sulbactam
  • Piperacillin-tazobactam
  • None of the above
A

Piperacillin-tazobactam

60
Q

Poll 6

Which of the following in the class can treat MRSA?

  • Amoxicillin-clavulanate
  • Ampicillin-sulbactam
  • Piperacillin-tazobactam
  • None of the above
A

None of the above

61
Q

Poll 6

Which of the following in the class can treat anaerobic organisms (with the exception of C.diff)

  • Amoxicillin-clavulanate
  • Ampicillin-sulbactam
  • Piperacillin-tazobactam
  • All of the above
A

All of the above

62
Q

+CarbaPENEMs

(4)

Routes

A

Ertapenem (Invanz) IV, IM

Meropenem (Merrem) IV

Imipenem/cilastatin (Primaxin) IV

Doripenem (Doribax) IV

63
Q

+CarbaPENEMs Spectrum

  • _______ beta-lactam class (also inhibits cell wall synthesis)
  • Spectrum:
    • ​______**** does not cover Pseudomonas
A

Broadest

Streptococcus, MSSA, all GNR (including Pseudomonas aeruginosa) and anaerobic gram-negatives

Ertapenem

  • On exam: ERRRRTT does not cover pseudomonas*
  • The only 2 so far that cover gram negative anaerobes - penems and beta lactam combos*
64
Q

+CarbaPENEMS Indications

Drug of choice for ______

Used as ___-line options in gram-negative _____ infections

Stable against many?

A

ESBL’s

last line - gram neg resistant

ESBLs

  • Can use penems for ESBL’s (drug of choice or serious ESBL producing organisms)*
  • ONly gram negative organisms produce ESBL*
65
Q

Poll 7

AB is a 43 M admitted to the hospital with an intra-abdominal infection. He is allergic to penicillin (rash). AB has had several hospital admissions this year including 2 operations. You would like to empirically treat broadly for gram-negatives including Pseudomonas aeruginosa. In addition you would like to cover anaerobic organisms. Which of the following would be a viable option for AB?

  • Ceftazidime
  • Ertapenem
  • Piperacillin-tazobactam
  • Meropenem
A

Meropenem

  • Cef does not cover the anaerobes*
  • Ert does not cover pseudomonas*
  • Penicillin rash - not going to give piperacillin*

Advanced Pharmacology (14 decks)

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