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ID Exam 2 > Rx Antibacterials > Flashcards

Rx Antibacterials Flashcards

1
Q

What is antibiotic stewardship?

A
  • Limit inappropriate use (eg. viral URI)
  • Attempt to use more narrow spectrum when possible (eg. antibiotic susceptibility charts)
  • Monitor for adverse outcomes and educate about adverse effects (eg. photosensitization)
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2
Q

Four main subclasses of Cell wall inhibitors depending on the side chains

A

Penicillins- mold from Penicillium
Cephalosporins- mold from Cephalosporium
Monobactams
Carbapenems

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3
Q

Penicillins MOA

A
  • Inhibit transpeptidase, preventing it from forming cross-links in peptidoglycan wall = cell lysis
    “Cell wall inhibitor”- Bactericidal!
  • They do this by binding to Penicillin-Binding Protein (PBP)
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4
Q

Why are Gram negatives typically more resistant to beta-lactam antibiotics?

A

Gram negative bacteria have LPS layer in outer membrane, which protects the peptidoglycan wall from some beta-lactam activity

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5
Q

How are Clavulanic Acid and Tazobactam are beta- lactamase inhibitors?

A

These bacteria have a beta- lactamase enzyme that blocks beta-lactam activity
-Added to some Penicillins to counteract beta-lactamase

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6
Q

Most penicillins are given _____

A

orally

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7
Q

General indications for penicillin

A

Syphilis
Strep pharyngitis
Rheumatic fever
Skin infections - Various
Acute otitis media
Sinusitis
Diphtheria
Hospital acquired infections (ex: Pseudomonas)

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8
Q

These penicillins Have increased ability to cross LPS membrane in Gram negative cells, so more effective with Gram negatives.

A

Ampicillin (IV) and Amoxicillin (PO)

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9
Q

Piperacillin-Tazobactam (Zosyn) is particularly helpful against what?

A

Broad spectrum, “Antipseudomonal,” IV drug

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9
Q

Contraindications of Penicillins

A

Hypersensitivity reaction (rash, hives, anaphylaxis)
Skin testing is available if with Hx of rxn

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10
Q

Side effects with Penicillins

A
  • Hypersensitivity rash
  • Nausea/vomiting
  • Diarrhea
  • Can see likely non-allergic rash in patients with Mononucleosis who are prescribed an aminopenicillin (Amoxicillin).
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11
Q

Penicillin adverse reactions

A

Anaphylactic hypersensitivity reaction

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12
Q

Penicillin Follow up/monitoring

A
  • Excretion is renal- dose adjustment for renal disease eg. seizures
  • Creatinine at baseline; check periodically if long-term use
  • May use during pregnancy, little to no known risk of fetal harm, safe during lactation (compatible with breastfeeding)
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13
Q

T/F MRSA and VRE are resistant to Penicillins

A

T

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14
Q

Black Box Warning for Penicillin

A
  • Pen G benzathine/ procaine - IM injection only, Do not give IV. Cases of cardiorespiratory arrest when inadvertently given IV.
  • Pay attention to the labels
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15
Q

Cephalosporins MOA

A
  • Beta-lactam, like Penicillins.
  • Similar MOA as Penicillins.
  • Broader spectrum then PCN
  • Does not kill MRSA*
  • Emerging resistance due to certain β-lactamases is a concern
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16
Q

First generation cephalosporins

A

Cephalexin (Keflex) oral
Cefazolin (Ancef) IV - popular in Peds

Good for sinus infections, skin conditions

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17
Q

Second generation cephalosporins:

A

Cefoxitin (Mefoxin)
Cefuroxime (Ceftin) Oral
Cefaclor (Ceclor)

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18
Q

Third generation cephalosporins

A

Cefdinir (Omnicef)
Ceftriaxone (Rocephin) - Meningitis
Cefotaxime (Claforan)
Ceftazidime (Fortaz)

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19
Q

Fourth generation cephalosporin

A

Cefepime (Maxipime)- only

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20
Q

Fifth generation cephalosporin

A

Ceftaroline (Teflaro)- *only one that will cover MRSA

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21
Q

Cephalosporins Indications

A

Cellulitis- Cephalexin (Keflex)
Surgical prophylaxis- Cefazolin (Ancef)
Abdominal surgical prophylaxis - Cefoxitin (Mefoxin)
Otitis Media, Sinusitis, Strep throat - Cefuroxime (Ceftin) or Cefdinir (Omnicef)
Pseudomonas infections - Ceftazidime (Fortaz)
Febrile neutropenia, Sepsis - Cefepime (Maxipime)

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22
Q

Cephalosporin Contraindications

A
  • Anaphylactic reaction to Penicillins = “absolute contraindication”
  • Non-anaphylactic reaction to Penicillins = “relative contraindication”
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23
Q

Cephalosporins side effects

A

Stomach ache
Diarrhea
Nausea/vomiting

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24
Q

Cephalosporins Adverse reactions

A

Hematologic: Rare cases of bone marrow suppression
Nephrotoxic: Acute kidney injury
Pseudomembranous Colitis (What organism again?)

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25
Q

Cephalosporins Follow up and monitoring

A
  • Creatinine at baseline, check periodically
    -Older generation cephalosporins associated with bleeding disorders, so consider checking PT if chronically ill patient, anticoagulant use, or using long-term.
  • All can be used during pregnancy with little to no risk (caution with Ceftaroline)
  • Most are either “safe” or “probably safe” during lactation
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26
Q

Cephalosporins PEARLS

A
  • Third generation cephalosporins have good CNS penetration.
  • Common surgery prophylactics: Drug of choice: Ancef
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27
Q

Coverage spectrum of Cephalosporins

A

Gram positive: Very good, esp 1st gen
Gram negative: 3rd gen very good, 2nd gen agents good
MRSA and VRE are resistant

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28
Q

Coverage spectrum of Penicillins

A

Gram positive: Very good
MRSA and VRE are resistant

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29
Q

Carbapenems MOA

A
  • Beta-lactam drug, like Penicillins.
  • Same MOA as Penicillins.
    *Cilastatin- Prevents Imipenem breakdown by renal tubular dipeptidase (an enzyme in the proximal tubule).
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30
Q

Carbapenem names

A

Imipenem-Cilastatin (Primaxin)
Meropenem (Merrem)
Ertapenem (Invanz)

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31
Q

Indication for Carbapenems

A
  • These are IV medications (only in hospital, really)
  • Often reserved for resistant highly drug resistant organisms
    Some bacteria which produce carbapenemases
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32
Q

Sepsis requires which Carbapenem

A

Sepsis - Meropenem

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33
Q

Contraindications of Carbapenems

A

Renal impairment with CrCl < 15
History of seizures

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34
Q

Side Effects of Carbapenems

A

Fever - This can “muddy the water” if you’re treating a patient with an infection

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35
Q

Adverse Reactions of Carbapenems

A

Neurotoxicity (seizures) - Especially Imipenem

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36
Q

Follow Up and Monitoring for Carbapenems

A

Creatinine at baseline; check periodically if long-term use
CBC and LFTs periodically if using long-term
Caution advised during pregnancy;

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37
Q

Considered the “big guns” of antibiotics

A

Carbapenems

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38
Q

Carbapenems coverage spectrum

A

Gram positive: Very good
Gram negative: Very good
Anaerobes: Very good
Pseudomonas: Very good
VRE: Good to poor
MRSA is resistant

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39
Q

Monobactams Mechanism of Action

A

Beta-lactam drug, like Penicillins.
Same MOA as Penicillins

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40
Q

Monobactam drug

A

Aztreonam (Azactam)- only by Inj
Only monobactam on the market

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41
Q

Indication for Monobactams

A
  • Interestingly, inactive against Gram +
  • Effective against aerobic gram negatives, including E coli, Klebsiella, Haemophilus influenzae, N meningitidis, and Pseudomonas aeruginosa. (Good for UTIs)
  • Serious bacterial infection in patients with history of Penicillin anaphylaxis, such as Klebsiella Pneumoniae, Pyelonephritis, Meningitis, and Sepsis (an IV/IM drug)
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42
Q

Contraindications of Monobactams

A
  • Caution if renal or hepatic impairment
  • Caution if history of antibiotic-induced colitis (C.Diff)
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43
Q

Side Effects of Monobactams

A

Nausea/vomiting
Diarrhea
Injection/IV site reaction
ALT or AST elevation
Creatinine elevation

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44
Q

Adverse Reactions of Monobactams

A

Anaphylaxis
Seizures
Pseudomembranous colitis (Clostridium difficile)
Hepatitis
Thrombocytopenia
Neutropenia
Toxic epidermal necrolysis

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45
Q

Follow Up and Monitoring with Monobactams

A

Creatinine at baseline; check periodically if renal impairment
LFTs periodically
May use during pregnancy; No human data available but no risk based on high-dose animal studies
Safe during lactation

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46
Q

PEARLS for Monobactams

A

Aztreonam is another “big gun.” Because of side effects and seriousness of adverse reactions, not often used.
Penetrates the CNS very well

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47
Q

Vancomycin MOA

A
  • Inhibits cell wall synthesis by attaching to the end of the peptidoglycan precursor units, thus preventing peptidoglycan construction.
  • Bactericidal.
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48
Q

____ is considered a “Glycopeptide” Antibiotic

A

Vancomycin

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49
Q

Vancomycin Indications

A

Severe Gram positive infections (IV)
Sepsis (IV)
MRSA infections (IV)- some are resistant
Clostridium difficile (pseudomembranous colitis)

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50
Q

Contraindications for Vancomycin

A

Black Box Warning
Hypersensitivity to corn, as some IV formulations use dextrose

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51
Q

Side Effects of Vancomycin

A

Flushing with fast IV administration.
Triggers histamine release which can drop BP
Called “Red Man Syndrome”
Hypotension, as described above.
Nausea/vomiting
Rash

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52
Q

“Red Man Syndrome” is a side effect found with _____

A

Vancomycin

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53
Q

Adverse Reactions for Vancomycin

A
  • Nephrotoxicity (6-7%)- May see increasing Creatinine.
  • Neutropenia- Could be detrimental if severe infection.
  • Ototoxicity- Rare
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54
Q

Follow Up and Monitoring for Vancomycin

A

Pregnancy test - See Black Box
Creatinine at baseline, then periodically (even daily if the patient is in the hospital-peak and trough levels).
Check WBC if prolonged use.
Check serum drug level periodically to avoid toxicity.
Normal is 10-20 mcg/mL (>20 at trough is toxic)
Trough = Serum level checked just before next dose
Pregnancy- See Black Box
Probably safe during lactation

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55
Q

Black Box Warning for Vancomycin

A

fetal malformations

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56
Q

PEARLS of Vancomycin

A

Administer slowly to avoid drop in BP and flushing. Remember the kidneys!

57
Q

Coverage Spectra of Vancomycin

A

Gram positive: Very good
Gram negative: Resistant
Anaerobes: Resistant
Pseudomonas: Resistant
VRE: Resistant
MRSA: Very good

58
Q

Bacitracin MOA

Basket

A
  • Inhibits cell wall formation by interfering with the lipid carrier that transfers the peptidoglycan subunits to the growing cell wall.
  • Effective against Gram positives.
  • Bactericidal.
  • Usually found in OTC combo ointments
59
Q

Usually found in OTC combo ointments

A

Bacitracin (Neiosporin, Polysporin)

60
Q

Indication for Bacitracin

A
  • Superficial skin infections (Topical)
    Scrapes, lacerations, surgical incision prophylaxis
  • Bacterial conjunctivitis (Ophthal)
61
Q

Side Effects of Bacitracin

A

Highly nephrotoxic, so only used topically.
No major adverse reactions reported with topical.

62
Q

Follow Up and Monitoring with Bacitracin

A
  • May use during pregnancy, risk of harm is not expected.
  • Probably safe during lactation, although limited data.
  • Very minimal systemic absorption.
  • No routine monitoring recommended.
63
Q

Mechanism of Action for Polymixin B

A

Disrupts Lipopolysaccharide and outer cell membrane, causing cell lysis of Gram negatives.
Bactericidal.

64
Q

Three drugs involved in Neosporin

A

Neomycin, Bacitracin and Polymixin B

65
Q

Indications for Polymixin B

A

Superficial skin infections (Topical)
Bacterial conjunctivitis (Ophthalmic)

66
Q

Side effects of Polymixin B

A

Contact dermatitis

67
Q

Adverse Reactions of Polymixin B

A

Highly nephrotoxic and neurotoxic, so really only used topically.
Black Box- An IM/IV form is available, but used as last resort in bacterial meningitis (severely toxic drug). No major adverse reactions reported with topical.

68
Q

Follow Up and Monitoring with Polymixin B

A
  • Caution advised during pregnancy, inadequate data
  • Probably safe during lactation, although limited data.
  • Very minimal systemic absorption.
  • No routine monitoring recommended.
69
Q

Aminoglycosides

A

Streptomycin
Amikacin
Gentamicin (Garamycin)
Tobramycin (Tobrex)
Neomycin (in Neosporin and Cortisporin)
Plazomicin (Zemdri)

70
Q

Aminoglycosides MOA

A
  • Protein synthesis inhibitors.
  • Irreversibly bind the 30S subunit of the ribosome, thereby halting protein synthesis.
  • May also poke holes in outer membrane, explaining their bactericidal activity.
71
Q

Indications for Aminoglycosides

A
  • Aerobic Gram negative infections
  • Triple Antibiotic (Neosporin)
  • Bacterial conjunctivitis (Gentamicin and Tobramycin ophthalmics)
72
Q

Contraindications for AMinoglycosides

A

Renal dysfunction of any kind
Caution if vestibular or auditory dysfunction

73
Q

Aminoglycosides Adverse reactions

A

Ototoxicity
Nephrotoxicity
Neuromuscular Paralysis

74
Q

Aminoglycosides BBWs

A

-Nephrotoxicity
-Ototoxicity
-Neuromuscular dysfunction, leading to paralysis.
- Fetal harm, and advised against during pregnancy

75
Q

Follow Up and Monitoring for Aminoglycosides

A

Must monitor trough serum levels regularly!
Must monitor Creatinine regularly
Audiometry testing periodically
Avoid use during pregnancy, risk of ototoxicity and nephrotoxicity based on human studies.

76
Q

PEARLS for Aminoglycosides

A

Can cause deafness!
Can cause kidney failure!

77
Q

Coverage Spectra for Aminoglycosides

A

Gram positive: Depends
Gram negative: Very good
Anaerobes: Ineffective
MRSA and VRE: Resistant
Pseudomonas: Depends
TB: Good with Streptomycin

78
Q

Tetracyclines MOA

A

Reversibly latch on to part of the 30S subunit, and inhibit protein synthesis.
Tetracycline presence weakens ribosome and tRNA interaction.
Bacteriostatic (slows growth…not a killer)

79
Q

Indication for Tetracyclines

A

Gram-positive and gram-negative
Acne vulgaris (Tetracycline and Minocycline)
Syphilis (Tetracycline or Doxycycline)
If Penicillin allergy
Various bacterial infections (Doxycycline)

80
Q

Tetracyclines

A

Doxycycline (Vibramycin)
Minocycline (Minocin)
Tetracycline (Sumycin)
Newer
Tigecycline
Omadacycline
Eravacycline

81
Q

Tetracyclines Contraindications

A

Pregnancy, lactation, and for use in children under 8 YOA.
Binds calcium and causes permanent mottling of teeth (tooth discoloration

82
Q

Side Effects of Tetracyclines

A

Significant nausea/vomiting/diarrhea
Tooth discoloration, permanent
Photosensitivity - Skin becomes more sensitive to ultraviolet rays

83
Q

Follow Up and Monitoring for Tetracyclines

A

Most excretion is in urine, so check baseline Creatinine.
Some excretion in biliary system
Contraindicated in pregnancy!
Unsafe in lactation

84
Q

PEARLS for Tetracycline

A

Decreased PO absorption if taken with dairy or antacids, as binds to calcium.

85
Q

Macrolides MOA

A
  • Inhibit protein synthesis by binding to part of the 50S subunit and blocking transfer of new amino acids onto the growing chain.
  • Bacteriostatic.
  • Erythromycin also binds GI receptors that increase GI motility.
86
Q

Macrolides

A

ACE

Erythromycin (E-mycin, E-tab)
Clarithromycin (Biaxin)
Azithromycin (Zithromax)

87
Q

Macrolides indications

A

Community-acquired pneumonia (Azithro is alternative)
Chlamydia and Gonorrhea urethritis
GI motility enhancement (Erythromycin)

88
Q

Contraindications for Macrolides

A

QT prolongation or history of.
History of macrolide induced liver complications.

89
Q

Side Effects for Macrolides

A

Significant nausea, vomiting, or diarrhea.
Especially Erythromycin
Transient hearing loss

90
Q

Adverse Reactions for Macrolides

A

Acute cholestatic hepatitis (Especially Erythromycin)

91
Q

Follow Up and Monitoring of macrolides

A
  • Azithro PO safe in pregnancy at regular doses. Erythromycin caution advised, and Clarithro can cause miscarriage and birth defects.
  • Check LFTs with Erythromycin
92
Q

PEARLS for Macrolides

A

Azithromycin can be used with pneumonias

93
Q

Chloramphenicol MOA

A

Binds 50S subunit and inhibits protein synthesis

94
Q

Chloramphenicol Indications

A
  • Life-threatening Rickettsial diseases & Meningococcal Meningitis
    Only used as desperate alternative
95
Q

Contraindications of Chloramphenicol

A

Infancy- Can cause “Gray Baby Syndrome”

96
Q

Black Box Warning for Chloramphenicol

A

Blood Dyscrasias-

97
Q

Follow Up and Monitoring for Chloramphenicol

A

Avoid use in pregnancy
Creatinine at baseline. CBC and drug level at least every 2 days

98
Q

Clindamycin (Cleocin) MOA

A

Binds 50S subunit, inhibiting protein synthesis.
Bacteriostatic
Some Gram + (CA-MRSA) and Gram - anaerobes

99
Q

Clindamycin Indication

A

Dental infections

100
Q

Adverse Reactions for Clindamycin

A

Pseudomembranous Colitis (C diff)

101
Q

Black Box Warning for Clindamycin

A

Highly likely to cause life-threatening Clostridium difficile colitis.

102
Q

Clindamycin Follow Up and Monitoring

A

Safe in pregnancy, risk, maybe infant diarrhea with lactation
Check LFTs if concern for liver disease. BUN/CR, CBC if prolonged
Provide patient education about C diff!

103
Q

Most common cause of C diff is _____

A

Clindamycin

104
Q

Coverage Spectra for Clindamycin

A

Gram positive: Good
Aerobic Gram negative: Resistant
MRSA: Poor to good
VRE: Resistant
Pseudomonas: Resistant

105
Q

Linezolid MOA

A

Binds ribosomal 50S subunit, inhibiting protein synthesis
Bacteriostatic

106
Q

Indications for Linezolid

A

MRSA infections (skin, pneumonia, etc.)
VRE infections

107
Q

Contraindications for Linezolid

A

Caution with Serotonin medications (SSRIs, SNRIs)

108
Q

Adverse Reactions of Linezolid

A

Serotonin Syndrome: Too much serotonin activity in brain.
Lactic acidosis: Due to human mitochondrial inhibition?
Peripheral nerve damage: Occurred with lactic acidosis.
Bone marrow suppression

109
Q

Linezolid Follow Up and Monitoring

A

Check CBC weekly while on medication

110
Q

Mupirocin MOA

A

Binds and inhibits tRNA synthetase, inhibits protein synthesis.
Only available as topical ointment prescription (not OTC)
Effective against Gram positives, including MRSA.

111
Q

Indication for Mupirocin

112
Q

Side Effects of Mupirocin

A

Burning/stinging
Pruritus

113
Q

______ (Vitamin B9) is an essential vitamin that is required for survival.

114
Q

____ are “Folate antagonists”

A

Sulfonamides

115
Q

Sulfonamides MOA

A

Sulfadiazine and Sulfamethoxazole (SMX) inhibit first step of Folate synthesis. Bacteriostatic.
Trimethoprim (TMP; not a “sulfa drug”) inhibits the last step of Folate synthesis and is added to SMX to increase antibiotic efficacy.
TMP-SMX is Bactericidal.

116
Q

Sulfonamides

A

Silver Sulfadiazine (Silvadene)
Trimethoprim- Sulfamethoxazole (TMP-SMX), (Bactrim, Septra)

117
Q

Sulfonamides Indications
You’re a surfer

A

Topical application for burn infection prophylaxis (Silver Sulfadiazine)
Pneumocystis jirovecii Pneumonia (PJP) prophylaxis and Tx

118
Q

Side Effects of Sulfonamides

A

Precipitation in urine

119
Q

Adverse Reactions of Sulfonamides

A

Stevens-Johnson Syndrome
Blood Dyscrasias
Kernicterus

120
Q

Follow Up and Monitoring for Sulfonamides

A
  • Check creatinine at baseline and periodically
  • Sulfonamides have been linked with fetal harm and birth defects, so avoid in pregnancy.
121
Q

Fluoroquinolones

A

Ciprofloxacin (Cipro)
Ofloxacin (Floxin)
Levofloxacin (Levaquin)
Moxifloxacin (Avelox)

122
Q

Fluoroquinolones Mechanism of Action

A

Binds to and inhibits the actions of bacterial DNA gyrase
Bactericidal

123
Q

Indications for Fluoroquinolones

A

UTI/pyelonephritis
Pneumonia
Anthrax
Gram negative skin infections (infected surgical wounds)
Bacterial infectious diarrhea
Prostatitis

124
Q

Contraindications of Fluoroquinolones

A

Myasthenia Gravis (can worsen)
QT prolongation

125
Q

Fluoroquinolones Adverse reactions

A
  • Tendon ruptures (especially Achilles)
  • Can displace warfarin from albumin, increasing INR
  • Myasthenia gravis exacerbation
  • QT prolongation with life-threatening arrhythmias
126
Q

Follow Up and Monitoring of Fluoroquinolones

A

Weigh the risks and benefits of use during pregnancy.
Risk of bone/cartilage damage and fetal toxicity and death based on some animal studies

127
Q

Achilles tendon ruptures can occur with _____

A

Fluoroquinolones

128
Q

Mechanism of Action of Metronidazole

A
  • Metronidazole is a prodrug that needs to be reduced by special enzymes that are only present in anaerobic bacteria and protozoa.
  • Once reduced, the products are toxic and destabilize/damage the DNA.
129
Q

Metronidazole Indications

A

Mild C diff (has been dropped as first line)
Intestinal surgery prophylaxis
Amebic liver abscess and Intestinal amebiasis
Giardia (top photo)
Bacterial vaginosis
Trichomonas (bottom photo)
H pylori infection (part of combo therapy)

130
Q

Contraindications of Metronidazole

A

Alcohol use
Pregnancy- 1st Tri possible link to cleft palate. Weigh risk/benefit of use.

131
Q

Black Box Warning of Metronidazole

A

Carcinogenic risk. Tumor growth in rats/mice

132
Q

Side Effects of Metronidazole

A

Intense metallic taste

133
Q

Follow Up and Monitoring for Metronidazole

A
  • Metabolized in liver; excreted in urine and feces
  • Contraindicated during 1st trimester of pregnancy, but otherwise may use safely
134
Q

PEARLS of Metronidazole

A

Metallic taste is very common!
Remind your patients that they cannot drink alcohol

135
Q

Nitrofurantoin MOA

A

The drug likely inactivates bacterial proteins, which then would inhibit metabolism. MOA not fully understood
Bacteriostatic and Bactericidal.

136
Q

Indication for Nitrofurantoin

A

Lower Urinary Tract Infections

137
Q

Contraindications for Nitrofurantoin

A

Avoid in last month of pregnancy and first trimester
Renal failure

138
Q

Adverse Reactions of Nitrofurantoin

A

Hemolytic anemia of newborn if taken in late pregnancy
Pulmonary Fibrosis

139
Q

Follow Up and Monitoring for Nitrofurantoin

A

Contraindicated during weeks 38-42 of pregnancy

140
Q

Penicillins are generally indicated for most bacterial infections that are gram ____

ID Exam 2 (6 decks)

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