Pharm II Lecture 1

-Gram positive cocci in chains =

 

-Gram positive diplococci

 

-Urethral pus Gram _____ doughnut shaped diplococci within WBC = gonococci

Streptococci or Enterococci

 

Pnumonococci

 

-negative

Why is it important to know a PCN pts renal fct?

 

What are these two drugs…oxacillin(IV) and nafcillin(IV)

 

-Can we use these for MRSA?

-They are renally excreted

 

-Penicillinase-resistant penicillins

 

-Nope (MSSA okay though)

-A major SE of extended-spectrum PCN is?

 

-Name specifically which drugs this would be?

-diarrhea.

 

-Ampicillin and amoxicillin-Amoxil

Ticarcillin-Ticar® and piperacillin-Pipracil®

-What is their major SE?

-Antipseudomonal penicillins

-Platelet disfct (thrombocytopenia…and the few that are there don’t stick together well)

What are these?

Ampicillin + sulbactam = Unasyn;
Ticarcillin + clavulanic acid = Timentin;
Piperacillin + tazobactam = Zosyn;
Amoxicillin + clavulanic acid = Augmentin;

;

-What do they help us do?

;

;

Beta-lactamase inhibitors + PCN

;

-Broaden PCN spectrum to include more Gram Neg…(including pseudomonas…but at very high doses)

Which PCN will also kill these bugs?

H. flu, E. coli, Proteus, Salmonella, Shigella,

-Extended Spectrum PCN…Amox and Ampi

What bugs do PCNs generally kill (5 general ones)?
1); Penicillin G ; group A streptococcus, 2); penicillin susceptible pneumococcus and 3); staphylococcus, 4); Neisseria, 5); syphilis (these don’t include broad spectrums or special PCN)

What is MOA of Cephalosporins?

 

-Contraindicated in PCN allergies?

 

-They may potentiate nephrotoxicity if combined with what two drugs?

 

Beta lactam ring and batericidal

 

-PCN allergy may be at increased risk for allergic reaction – relatively contraindicated with history of immediate anaphylaxis with PCN
aminoglycosides and loop diuretics (furosemide)

What are the Broad spectrum GORILLA Abx that are good for resistant bugs…. except MRSA?

 

SE?

Carbapenams

-Toxicity – allergy more common in PCN and ceph allergy, superinfections (bc they are so broad), seizures (older patients with renal dysfunction and neurologic problems by lowering seizure threshold), rapid infusion = N/V

Monobactam – only covers Gm negative organisms… similar to aminoglycoside coverage (NO coverage for GPC (gram positive cocci or anaerobes)
Safe in penicillin allergic patients
IV ONLY

 

 

Aztreonam-Azactam®

-Bactericidal agents – 30S ribosome

 

-What is major SE of these Abx?

 

-Any major problems?

Aminoglycosides

 

-Ototoxicity

 

Resistance (getn>tobra>amikacin)

  active on 30S ribosome,  bacteriostatic
Antimicrobial spectrum of activity = Gram positive, Gram negative, chlamydia, rickettsia, mycoplasma (uncommon infections as RMSF, plague, psittacosis, brucellosis, anthrax)

 

 

Tetracyclins… doxycycline-Vibramycin®, minocycline-Minocin®

WHo doesn’t get Tetracyclins?

;

-Okay for use in blood infections?

;

-Okay for use in acne?

-those under 8 yo (yellow tooth staining

-Pregos (reduced bone growth)

;

-No

;

-Yes, low dose

-work at 50S ribosome, bacteriostatic
Covers: atypicals such as mycoplasma, legionella, chlamydia

-SE?

-Okay for use in Myasthenia Gravis?

-Okay for use in those with PCN allergy?

Macrolides…azithromycin- Zithromax;(IV/PO), clarithromycin-Biaxin;(PO), telithromycin-Ketek;(PO)

-hepatic toxicity, QT prolongation, dizzy,

-no use in myasthenia gravis

YES DRUG OF CHOICE FOR THOSE WITH SSTI and Resp Infections with PCN ALLERGY

Bacteriostatic 50S ribosome, inhibits toxin production.; Use in PCN allergic patients for GPC ; (not enterococci),; staph (community acquired MRSA) and streptococcus, .; Anaerobes above diaphragm– Bacteroides fragilis, Clostridium perfringens and tetani (NOT other Clostridia)

Clindamycins:; Clindamycin(Cleocin;) and Lincomycin
SE of Clindamycin?
ADR ; diarrhea (pseudomembranous colitis ;CDAD), N/V
Glycopeptide, bactericidal blocks cell wall synthesis (peptidoglycan).; Use for GPC coverage in PCN allergic patient.; Covers: S. aureus, MRSA, streptococci, enterococci (but NOT vancomycin resistant = VRE), pneumococcus, Clostridium difficile (oral use when metronidazole fails), corynebacterium

;

;

;

Vancomycin

What are these teh SE for?allergic reactions, phlebitis, oto/nephrotoxicity esp. with aminoglycosides, red man syndrome (not allergic rxn ; flush face, neck, upper trunk, hypotension..NEUTROPENIA

;

-B/c of these how fast do you infuse?

;

Vancomycin

;

-slow infusion 500mg over 30 minutes or longer

-Cyclic lipopeptide, bactericidal by depolarizing the bacterial membrane ; NOT for pneumonia;surfactant keeps it from working.
Antimicrobial spectrum: GPC only, SSTI, bacteremia, right sided endocarditis

;

;

Daptomycin-Cubicin

Why is Linezolid not that great of an Abx?
Expensive…bad ADEs (thrombocytopenia, neutropenia, anemia (bone marrow suppression)…MUST WATCH FOR selective serotonin syndrome with use of SSRI’s…ITS BASICALLY ONLY GOOD FOR KILLING MRSA, but if you can use any other drug…you should

What is the Serotonin Syndrome Triad?

 

-what should we monitor for to have early detection?

-Triad of 1) mental status changes, 2)  autonomic hyperactivity/instability, and 3)  neuromuscular abnormalities

 

-for hyperreflexia, tremor, clonus (greater in lower extremities), tachycardia, diaphoresis, mydriasis, increased bowel sounds/diarrhea

folic acid antagonist inhibits DNA formation in bacteria, bacteriostatic
IV (large volumes) & PO – excretion renal…HUGE VOLUMES GIVEN.
Sulfa drug – ask allergy information SJ Syndrome

 

 

Trimethoprim/sulfamethoxazole:  (Septra® or Bactrim®)

Wide coverage with Bactrim?

 

-What drug should we avoid while one Bactrim?

Yea…Gm +/- (no anaerobes) and PCP prophylaxis & treatment in AIDS, Toxoplasmosis

 

Warfarin (drug interaction that increases bleeding risk)

IV and PO, bactericidal and covers anaerobes such as Bacteroides fragilis
Treat: Giardia lamblia,Trichomonas vaginalis, and anaerobic cocci and bacilli below diaphragm including Bacteroides fragilis, Clostridium difficile, Gardnerella vaginalis
ADR: metallic taste in mouth, disulfiram-like reaction with ethanol (H/A, N/V, chest or abdominal pain)

 

 

Metronidazole

Bactericidal, inhibits DNA gyrase
ADR: tendon inflammation and rupture esp. w/corticosteroids, transplant recipients, and >60yo (stop at first sign of  tendon inflammation/pain), joint damage (do NOT use in children, risk vs benefit in pregnancy), nausea, dizziness, rash, insomnia, diarrhea, allergic reactions, QT prolongation/arrythmias.INHIBITS CAFFEINE EXCRETION

 

 

Fluoroquinolones

Which Gen of Fluoroquinolones covers Psueomonas?

-Which Fluoroquinolone am I?

    – renal, UTI, GNR
    – hepatic, NOT UTI, respiratory infections

       covers  Gm+/- including penicillin resistant 

       Streptococcus pneumoniae (PRSP), anaerobic

       coverage better than levofloxacin, SSTI,

       complicated intraabdominal infection, sinusitis
    – renal, UTI and respiratory infections covers   

       Gm+/- and PRSP, SSTI, sinusitis

-Ciprofloxacin (2nd Gen)

 

-Ciprofloxacin (2nd)

-Moxifloxacin (4th)

-Levofloxacin (3rd)

Urinary Antiseptics:  Nitrofuranation:  don’t use if CrCl is under ___

 

-How do we dose Streptogramins?

 

-What does it cover?

 

-What is its only available ROA?

-60

 

-Dose – 7.5mg/kg every 8 hours (D5W)

 

-Covers VRE (faecium), MRSA, MSSA

 

-IV

Which Antifungal am I? IV only and very broad antifungal spectrum, bactericidal to cell membrane
ADE: fever, chills (“shake and bake”- treat with acetaminophen and diphenhydramine 30 minutes before each dose), malaise, anemia, thrombophlebitis, nephrotoxic (saline load), wastes potassium & magnesium, renal tubular acidosis- RTA

 

-HOW IS IT DOSED?

 

Amphotericin B

 

-Dose: 0.3 to 1.2mg/kg/day

Which Antifungal am I…..Interferes with ergosterol synthesis (cell membrane) cytochrome P450 process (DI posa>vori/itra>fluco)

 

-Which one of these is the “primary antifungal”

 

-What is used for Aspergillus infections?

-Azoles


-Fluconazole


-Itra and Voriazole

What antifungal group am I?  Caspofungin-Cancidas®, micafungin-Mycamine®, anidulafungin-Eraxis®(ethanol as diluent)
Glucan synthase inhibitor (part of cell wall)
Rather nontoxic, hepatically excreted-caspo&mica, anidula -hydrolysis
Covers Candida species esp. C. glabrata & krusei (not covered by fluconazole), but lower MIC for parapsilosis
Drug interactions: caspo>mica>anidula

 

 

Echinocandins

Staphylococci are catalase _____, gram _____

 

-What genus is this? anaerobic spore forming gram + rod

 

-Which Clostridium causes diarrhea (CDAD) and enterocolitis

 

-Which causes gas gangrene?

-positive, positive

 

-Clostridium

 

C. difficile

 

C. perfringens

DOC Gram Positives…

 

-Corynebacterium diphtheriae

Listeria monocytogenes


DOC: penicillin or erythromycin

DOC IV ampicillin

S. aureus is Coagulase _____.

 

-DOC for MRSA?

 

-What staph is Coag negative and causes UTIs?

Positive.

 

-DOC Vancomycin, linezolid, daptomycin

 

S. saprophyticus

What is the main drug for S. pneumoniae?

PCN  (second choices

Cephalosporin 3>2>1 (Rocepherin)
Quinolones (not ciprofloxacin)
Vancomycin)

-DOC for E. faecium

 

-DOC for E. faecalis

-This is a VRE…so linezolid or Synercid®

 

–  penicillin or ampicillin + or – gentamicin or streptomycin

-Gram ______ cocci:
Neisseria gonorrhoeae and Neisseria meningitidis

 

-These are all what kind of Gram negative bacteria….Pseudomonas aeruginosa, Acinetobacter calcoaceticus-baumanii (we are having a lot of resistence problems), Burkholderia cepacia (CF patients), Stenotrophomonas maltophilia

-Negative

 

-Nosocomials

-N. gonorrhaea DOC?

 

-N. Meningitidis DOC?

 

-E. coli DOC?

 

-Ceftriaxone

 

-IV PCN

 

-3rd Gen Cephalosporin (Rocephrin)

Nosocomial Pneumonia is caused by what Serratia SPACE bug?

 

-DOC?

-Serratia marcescens

 

-Double cover (3rd generation cephalosporin, carbapenem, +/- gent, or quinolone )

SPACE BUGS name em’

I found this on a thread site so take with a grain of salt…

Serratia
Pseudomonas
Acinetobacter
Citrobacter
Enterobacter

-Double coverage with what for Pseudomonas aeruginosa
Gentamycin (aminoglycoside) and PCN

-According to our lecturer a fever is anything over what?

;

-;____ neutrophils = increase bacterial and fungal infections

Fever is ;=100.5 F body temperature orally

;

-500

-Sputum is more reliable and indicative of infection if contains ;___ epithelial cells and ;___ PMNs is purulent sputum vs spit

-Urinalysis (UA) ;___ WBC, nitrites, leukoesterase=Infection

-10 epithelials….25 PMN

;

-10

Abx andMetabolic abnormalities: as G6PD deficiency (favism ; www.g6pd.org) ; hemolysis with ____ drugs, nitrofurantoin, naldixic acid, antimalarials, dapsone, and chlorampenicol.
-Sulfa

Age Factors and Abx:

;

Baby ; kernicterus with sulfa drugs and _____, Gray baby syndrome with ________.

;

-Age ;65 have decreased renal function so increased ADE of renally eliminated drugs such as; ___________; _______.

-ceftriaxone (Rocephin)….chloramphenicol (because baby does not have a functioning liver and cannot eliminate teh drug)

;

aminoglycosides ; carbapenems

-What 2 commonly Rxd drugs does RIFAMPIN interact with?

;

-Beta-lactams are ___-dependent

;

-The proper route is _____ for CNS, osteomyelitis, infective endocarditis(IE)

-Birth control and WARFARIN

;

-time

;

-intravenous (IV)

Gonnorhea should DOC?

;

-what should we stay away from to Tx if we can?

;

-Since Chylamydia often coexists…what should we use for co-Tx?

-Cephalosporin

;

-FQ…they are becoming resistent.

;

– azithromycin po 2Gm x1 or doxycycline 100mg bid x7days

What is the difference between early and latent phase syphillis?

;

-How are they detected?

;

;

-Both are asymmtomatic, but early latent phase is infectious (first 4-10 weeks after secondary infection)

;

-Serologic Testing

;

How long does primary syphillis incubate before you get the painless chancre?


-Jarish-Herxheimer reaction ; NOT allergic reaction to penicillin but action of penicillin on ______

-10 to 90 days (mean 3 weeks).

;

-Spirochetes (Treponema pallidum) (RESULTS IN FLU-LIKE SYMPTOMS)

Syphillitic Tx:; VDRL or RPR (quantitative nontreponemal tests) see ______ change in titer considered necessary to show clinically significant difference

-Neurosyphilis examine CSF every ______ until cell count normal

-fourfold (1:16 to 1:4 or 1:8 to 1:32)

-6 months

Chlamydia Tx: No sex for __days following initiation txmt
________(DOC) 1 Gm PO x1 or
_________ (DOC option2) 100mg bid PO x7 days

7

;

-Azithromycin

;

-Doxycycline

HSV-2:; Recurrent: prodrome ~__% tingling, burning, itching prior to lesion appearance

-Trich: Men frequently asymptomatic ; spontaneous cure, greater M;W transmission rate?

-When should males be cultured?

-Women should have PCR or wet mount slide prepared…what might the protozoan look like?

-50

;

-True

;

-First voided urine

;

-Flagellated, pear-shaped.

Tx of Trich?

Metronidazole 2 g orally in a single dose

OR
Tinidazole 2 g orally in a single dose

;

Both: Bitter metallic taste, anorexia, N/V, diarrhea
No ethanol for 24 hrs after metronidazole and 72 hrs for tinidazole

-HPV strands:; __;__ = genital warts (vaginal, anal, urethral meatus, and external genital warts), ___;___ = 70% of cervical cancers

-What does Gardasil protect against?

-6 ; 11

;

-type 16 ; 18

;

-The above four strains (and that’s it)

until 65 yo who has more UTIs (m or f?)

 

-how many UTI’s until you are considered recurrent?

;

-Significant abacteriuria distinguish infection vs contaminant with clean-catch ______ organisms per ml urine

-Females…equal after 65 yo

;

-3 or more a year.

;

-100,000

-E. coli makes up __% of uncomplicated and __% of complicated UTIs

85%,; (uncomplicated S. saprophyticus 5-15%, K. pneumoniae, P. spp., P. aeruginosa, Enterococcus spp…consider S. epidermidis as well (BUT IT CAN BE CONTAMINANT)

;

50% (others include above (as resistant), VRE and Candida)

UTI Tx times:

Uncomplicated cystitis:
;__ to __ days

;Uncomplicated pregnant: __ days
UTI in males
___ days
Acute pyelonephritis
___ days
Prostatitis
__ to __; weeks

Uncomplicated cystitis
;1 to 3 days
;Uncomplicated pregnant 7 days
UTI in males
14 days
Acute pyelonephritis
14 days
Prostatitis
4 to 6 weeks

For uncomplicated Cystitis: Most effective drugs are ______ eliminated

;

-What are 3 major complications with untreated UTI in Pregnancy?

;

-How are they Txd?

-Renally

-Untreated = LBW, prematurity, stillbirth

;

-Amoxicillin/clavulanate (Augmentin😉
Bactrim (TMP/SMZ); (Avoid in the 3rd trimester hyperbilirubinemia)

Cephalexin

Nitrofurantoin

UTI: Which Abx can we absolutely not have?

;

-In Males: what is Acute cystitis often associated with?

;

-Male UTI Tx empirically with?

-NO FQ, tetracyclines in pregnancy

;

-Bladder obstruction (BPH, stones, instrumentation)

;

FQ, SMZ-TMP

How do you Tx Assymptomatic Bacteruria in NON-PREGNANT and ELDERLY PEEPS??

;

-For PYELONEPHRITIS:;; E. coli is most likely pathogen, other gram negatives; DOC?

;

-For PYELONEPHRITIS if your culture comes back Gram Positive…what is most likely culprit?

You don’t Treatment has little effect on natural course of infection

 

FQ or SMZ/TMP for E. coli

 

Enterococcus faecalis  (DOC Ampicillin QID or Augmentin if Beta-lactamase positive.

What seperates moderate/severe from mild pyelonephritis

 

-How to Tx?

-Dehydration, nausea/vomiting
Hypotension/sepsis

 

-Check em in and put em on IV Abx…if afebrile x 24 hours you can do PO and check em out

Sev/Mod Pyelonephritis

single therapy?

 

Double coverage?

Quinolone (14 days…unless Pseudomonas)

 

Extended-spectrum penicillin x 14 days
 (Zosyn®)
(Timentin®)

  PLUS
Aminoglycoside x 3 days
Gentamicin
Tobramycin

-Indwelling urinary catheters
Acquire UTI at rate of __% incidence per day

 

-If you have a Symptomatic UTI related to CATHEDAR insertion…how should you Tx?

 

-Prostatitis DOC?

5%…Traumatic insertions, poor insertion technique

 

-As complicated UTI

 

-TMP-SMX, quinolones(not moxifloxacin as it is not excreted through the ureter)

x

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