Pharm Exam 2

Active and Passive Immunity

• Acquired/adaptive immune response is specific, has memory, takes longer, but is more effective.
• Active immunity involves humoral (B cells and antibodies/immunoglobulins) and cell-mediated (T cells) responses.
• Immunoglobulins recognize, bind to, and aid in the destruction of antigens like bacteria and viruses.
• Passive immunity involves the transmission of preformed immunoglobulins, such as antibodies passed from mother to fetus or plasma transplants from a donor to a patient.

Pharmacodynamics of Antivirals (Oseltamivir) and Monitoring

• Antivirals must either block entry into the cell or be active inside host cells to be effective.
• Oseltamivir is a neuraminidase inhibitor active against Influenza A & B.
• Oseltamivir inhibits the neuraminidase viral enzyme, preventing virus release and halting infection propagation.
• Monitor renal function when using Oseltamivir, especially in older and debilitated patients.
• For older patients taking Oseltamivir, evaluate for confusion, hallucinations, and cognitive impairment.
• Oseltamivir should be initiated within 48 hours of symptom onset.
• Oseltamivir is used for both prophylaxis and treatment of Flu A & B.

Antiretroviral Therapy (ART)

• ART is used ONLY for HIV (HIV 1 is human, HIV 2 is animals).
• ART involves using a combination of 3 or more medications from 2 different classes to reduce the amount of HIV (viral load) in the blood.
• ART should be initiated within 14 days of diagnosis.
• ART regimen determination factors:
  • Comorbid conditions
  • Convenience
  • Gender & pretreatment CD4 T cell count (nevirapine)
  • Genotypic drug resistance testing
  • Human leukocyte antigen (HLA) B*5701 testing if considering abacavir
  • Patient adherence potential
  • Potential adverse drug effects
  • Potential drug interactions with other medications
  • Pregnancy potential
• Challenges that healthcare providers face include complex social problems like substance abuse, domestic violence, lack of child care, and unstable living conditions.
• Other challenges include complex medication problems like lack of health insurance, opportunistic infections, mental illness, and chronic pain.
• Financial assistance can be obtained through state AIDS assistance programs or pharmaceutical co-pays.
• Resistance can occur due to poor adherence, drug-food interactions, or abnormal pharmacokinetics.
• Resistance leads to detectable viral RNA levels in plasma.
• Discontinuation or interruption of ART can be caused by concurrent illness, toxicity, surgery, or unavailable medications.
• This leads to HIV viral load rebound, immune decompensation, and clinical progression.

Goals of Antiretroviral Therapy

• Achieve maximum suppression of plasma viral load for as long as possible.
• Delay medication resistance.
• Preserve CD4 T-cell numbers.
• Confer substantial clinical benefits, leading to reduction in morbidity and mortality.

Factors Increasing Antimicrobial Resistance

• Recent use of antibiotics.
• Overuse of broad-spectrum antibiotics.
• Age less than 2 years or greater than 65 years.
• Daycare center attendance.
• Exposure to young children.
• Multiple medical comorbidities.
• Immunosuppression.

Antibiotic Cross Sensitivity and Cross Resistance

• Beta-Lactams & PCNs, Beta-Lactams & Cephalosporins have cross-sensitivity.
• Both drug classes contain a beta-lactam ring, making them vulnerable to beta-lactamase-producing organisms.

PCNs

• Natural PCNs are effective against Streptococcus, some Enterococcus strains, and some non-penicillinase-producing Staphylococcus.
• Aminopenicillins have greater activity against gram-negative bacteria due to their enhanced ability to penetrate the outer membrane.
• Aminopenicillins are used for gram-negative urinary and GI pathogens.
  • Examples: Escherichia coli, Proteus mirabilis, Salmonella, some Shigella species, and Enterococcus faecalis.
• Aminopenicillins are active against the common gram-negative respiratory pathogens Moraxella catarrhalis and H. influenzae type B.
• Combination with beta-lactamase inhibitors broadens their spectrum: clavulanate, sulbactam, tazobactam.

Cephalosporins

• 1st generation cephalosporins are sensitive to gram-positive bacteria like S. aureus and S. epidermis.
• 2nd generation cephalosporins are sensitive to the same bacteria as first-generation, plus Klebsiella and Proteus.
• 3rd generation cephalosporins have broader indications and are effective against gram-positive and gram-negative bacteria but work better against gram-negative bacteria.
• 4th generation cephalosporins have a broader spectrum and are more resistant to beta-lactamase than 3rd generation, primarily working against gram-positive bacteria.
• 5th generation cephalosporins (Ceftaroline) are similar to 3rd generation and active against MRSA.

Strep Throat Antibiotic Therapy (Group A Streptococcus)

• Primary antibiotic therapy includes beta-lactams (PCN V or Amoxicillin) or 1st generation cephalosporins (cephalexin).
• Secondary antibiotic therapy for patients with PCN allergy includes Clindamycin or Azithromycin.

Antibiotic Side Effects: Management

• Monitor illness symptoms (are symptoms improving?).
• Obtain cultures before and after treatment.
• Patient education on antibiotic use.
• Ensure the patient is completing the entire dose.
• Maintain antibiotic course if effective; change if not working or if culture results indicate a different antibiotic.

"Watchful Waiting" and Antibiotics in Children

• "Watchful waiting" involves initial observation (48-72 hours) without antibiotics for low-risk patients (ages 2 and up with non-severe illness).
• Adequate pain management is essential during the observation period.

Low-Risk Patient Criteria

• Older than 2 years of age.
• Mild otalgia.
• Temperature less than 39 degrees Celsius/102.2 F.
• A "safety net prescription" is given; also referred to as "Wait and See Prescription” (WASP).

Otitis Media Antibiotic Choices in Treatment Failure

• Treatment failure is determined at 48-72 hours.
• If initial treatment with amoxicillin or other first-line therapy fails, use Augmentin or Ceftriaxone IM/IV for 3 days.
• If the patient has a PCN allergy, give Clindamycin + 3rd generation cephalosporin.

Tetracyclines

• Tetracyclines are used to treat bacterial infections.
• Doxycycline is the 1st line therapy for C. trachomatis (chlamydia) and Ureaplasma urealyticum.
• Tetracycline and minocycline are also used to treat infections.
• Some H. pylori regimens include tetracycline.
• Tetracyclines are contraindicated in pregnant women (Category D), lactating women, or children aged less than 8 years.
• Use tetracyclines cautiously with patients who have renal or hepatic failure.
• Drug interactions: antacids, zinc products, or magnesium-containing laxatives. Separate by 2 hours.

Urinary Tract Infections (UTIs) Treatments For All Ages

• Treatment guidelines are discussed separately.

CDC and ACIP Vaccine Guidelines

• Vaccine guidelines include schedules for children 0-18 years and adults.
• Includes catch-up schedules.
• Includes guidelines for vaccinating pregnant women.
• Determining the recommended vaccine by age includes assessing the additional medical condition, reviewing vaccine type/frequency/interval/consideration, and reviewing contraindications/precautions.

CDC Recommendations for Specific Vaccines

MMR (Measles, Mumps, Rubella)

• Clinical Use: Prevent measles, mumps, rubella.
• Dose: 0.5mL SQ.
• Contraindications: Neomycin allergy, pregnancy, immunocompromised, febrile (ok to give to egg allergy or lactating patients).
• ADR: Fever 7 to 12 days, drug interaction with IG, oral steroids, chemo.
• Time table: 2 doses – first dose age 12-15 months, second dose 4-6 years or at least 4 weeks post 1st dose.
• One dose may be given to an infant 6-12 months if traveling abroad but it does not count as the 1st dose.

FluMist (Live Attenuated Influenza Vaccine, LAIV)

• Clinical Use: Prevent flu (live modified virus vaccine).
• Dose: Intranasal spray, 0.2mL split between each nare.
• Contraindications: Egg allergy, asthma, immunocompromised, pregnant.
• ADR: Mild ADRs; nasal congestion, headache, sore throat, cough, muscle aches.
• Time Table: Annually to healthy patients aged 2-49 years ASAP in the fall; children 2-8 years need 2 doses the first year.

Hep B

• Clinical Use: Prevent Hep B (stimulated anti-hepatitis B surface antigen antibodies); inactivated virus vaccine.
• Dose: Dependent on brand and age; usually IM but can given SQ.
• Contraindications: Yeast allergy, moderate or severe illness, immunosuppression (give larger dose).
• ADR: Local reaction, fever, malaise.
• Time Table: All ages, 3 doses over 6 months, with specific intervals between doses.
  • 4 weeks between dose 1 and 2.
  • 2 months between dose 2 and 3.
  • 4 months between dose 1 and 3.
• Newborns weighing less than 2,000 g receive 1st dose within 24 hours of birth.

Varicella

• Clinical Use: Prevent chickenpox; live virus vaccine.
• Dose: 0.5mL IM/SQ.
• Contraindications: Neomycin allergy, febrile illness, immunocompromised, high dose oral steroids, pregnancy.
• ADR: Fever, rash, injection site reaction.
• Time Table: 2 doses; first dose 12-15 months.
  • 2nd dose 4 to 6 years.
• Adolescents and adults with no history of vaccine get 2 doses at least 4-8 weeks apart.

Community Acquired Pneumonia (CAP) Pathogens and Therapies

• Most common pathogen: Streptococcus pneumoniae, also most common in nursing homes, pregnant women, and pediatrics.
• Patients with underlying lung disease: Haemophilus influenzae and Moraxella catarrhalis.
• Staph aureus is usually a co-pathogen with H. influenzae.
• Other pathogens include - Mycoplasma pneumoniae and viral pneumonia.
• Expect clinical improvement in 48-72 hours.

Outpatient CAP Treatment for Previously Healthy Patients (No Risk Factors)

• Macrolide (level 1 evidence): Azithromycin, Clarithromycin, or Erythromycin.
• Doxycycline if allergic to macrolides.
• Treatment for a minimum of 5 days.

Outpatient CAP Treatment for Patients with Risk Factors/Comorbidities

• Respiratory fluoroquinolones (moxifloxacin, gemifloxacin, or levofloxacin).
• Beta-lactam PLUS a macrolide (amoxicillin, amoxicillin/clavulanate, or cefpodoxime, cefuroxime, parenteral ceftriaxone followed by oral cefpodoxime).
• Doxycycline may be used as an alternative to the macrolide.
• For adults older than 60 with comorbidities: Ceftriaxone (Rocephin) 1g daily via IM or IV or Levofloxacin 500 mg IV daily.
• May switch to oral therapy once the patient can tolerate oral medications.
• CURB-65 assesses confusion, uremia, RR, BP, 65 or older.

Pregnancy CAP Treatment

• Pregnancy Category B (Macrolides): erythromycin, azithromycin.
• Pregnancy Category C (Macrolides): Clarithromycin.
• If they have comorbidities or use of recent antibiotics: Beta-lactam (PCNs) plus a macrolide.

Pediatrics CAP Treatment

• Under 5 years old (Bacterial PNA): Amoxicillin 80-90 mg/kg/day, Ceftriaxone 50mg/kg/day until able to take oral.
• PCN allergy: clindamycin or a macrolide.
• Infants may have chlamydial pneumonia: Azithromycin 20 mg/kg/day for 3 days OR erythromycin 50mg/kg/day for 14 days.
• Older than 5 years: Azithromycin 10 mg/kg on day 1, then 5 mg/kg on days 2-5, Clarithromycin 15 mg/kg/day in 2 divided doses (max 1g per day) or Erythromycin 40-50 mg/kg/day.

Decongestant Contraindications

• Children under 4.
• Patients on concurrent MAOI therapy.
• Patients with severe HTN or CAD.
• Use with caffeine.
• Refrain from smoking.

Routine Newborn Medication and Medications for Children with ENT Disorders

Newborns

• Ophthalmia neonatorum (broad term).
  • Gonococcal conjunctivitis: requires IM or IV ceftriaxone
  • Prevention: erythromycin ointment within 1 hr of birth (only prevent gonococcal not chlamydial)
• Chlamydial conjunctivitis: requires treatment with systemic erythromycin.

Children

• Bacterial conjunctivitis.
  • Children 3 months through 8 years are most likely to have staphylococcal, streptococcal, or Haemophilus conjunctivitis.
  • Treat: ophthalmic antibiotics (Ex: Bacitracin, "-mycin", fluoroquinolones).
  • Children younger than 6 years are most likely to have H. influenzae (73%).
  • Treat: high dose amoxicillin-clavulanate.
• Blepharitis (eyelash or eyelid inflammation).
  • Treat: scrubbing eyelashes with gentle, no tears shampoo, or Erythromycin ointment.
• Hordeolum (sty).
  • Caused by S. aureus
  • Treat: antibiotic eye drops or ointment.
• Viral conjunctivitis.
  • Usually caused by adenovirus, herpes simplex, or herpes zoster.
  • Treat: ophthalmic antibiotics.
  • If herpes keratitis is suspected → refer to ophthalmologist.

Ear

• Otitis Externa ("swimmers ear") treat with combo products with corticosteroids (hydrocortisone) and antibiotic.
  • Acute: acid or alcohol drops (UNLESS PERFORATED TM) 4 drops for 7-10 days.
  • Prevention: 1-2 drops to dry the ear after swimming.
  • Chronic: treat with mineral oil daily, steroid cream.
  • Malignant OE: rare but lethal caused by pseudomonas aeruginosa; can cause osteomyelitis and meningitis
  • Treat: parenteral antibiotics, an aminoglycoside and carbenicillin for 4-6 weeks, plus surgical debridement.
• Otitis Media: caused by eustachian tube dysfunction.
  • Negative pressure causes reflux of bacteria into middle ear.
  • Pathogens: S. pneumoniae, Nontypable H. influenzae, M. catarrhalis.
  • Treat: wait and see for low risk patients over 2 years old.
  • 1st line: amoxicillin dose at 80-90 mg/kg/day OR combo drug amoxicillin-clavulanate 90 mg/kg/day.
  • PCN allergy: any of the "-cef" (cephalosporins).
  • Treatment failure: Augmentin or ceftriaxone IM/IV.
• Initial observation only for acute otitis media.

Nose

• Viral URI: most common rhinovirus, includes adenovirus, RSV, COVID, enteroviruses.
  • Typically lasts 7-9 days (if runny nose & cough on days 1-4, predictive of VIRAL origin).
• General URI - symptomatic care: fluids, antipyretics, nasal bulb suctioning in infants.
  • Decongestants ONLY in children age 4 and above.
    • Systemic: pseudoephedrine, phenylephrine.
    • Topical: phenylephrine (neosynephrine) or oxymetazoline (Afrin).
    • NO ABX.
• Sinusitis.
  • First choice: amoxicillin (dose at 80-9 mg/kg/day in high-risk children for 10-14 days); 45 mg/kg/day in low risk children.
  • For PCN allergy: cefdinir, cefuroxime, or cefpodoxime.
  • If worse after 72 hours: switch to Augmentin if amoxicillin was first choice; if on Augmentin first, consider cefdinir, cefuroxime, cefpodoxime for children.

Throat

• Pharyngitis (strep throat) respiratory virus is the most common cause.
  • Most common treatment bacterial cause: Group A strep; confirmed by testing.
  • Treat: beta-lactams (PCN/Amoxicillin OR 1st gen cephalosporins like cephalexin).

Ophthalmic Beta Blockers for Glaucoma

• Treated by ophthalmologist.
• Safety: Monitor client for cardiac failure and hypotension; DO NOT abruptly stop; administer as prescribed.
• Contraindications: Bradycardia/Heart Blocks, cardiogenic shock, CHF, ventricular dysfunction, poorly controlled DM, Raynaud’s disease, PVD, Pregnancy Category C, and other BBs.

Influenza Vaccine: IM vs. Transnasal

• Live attenuated Influenza (LAIV/Flumist).
  • Administered intranasally (virus replicates in nasal mucosa).
  • Live modified virus with Influenza A and B strains.
  • Contraindications: egg allergy, asthma, immunocompromised, pregnant.
  • ADR: mild ADRs: nasal congestion, sore throat, cough, muscle aches.
  • Dose: annual to healthy patients aged 2-49 years (0.2mL split between each nare).
  • Children 2-8 years need two doses the first year.
• Inactivated Influenza.
  • Admin via IM.
  • Killed virus with 3 or 4 strains (2 of type A; 1 or 2 of type B).
  • Contraindications: egg allergy, anaphylaxis to flu vaccine, Guillain-Barre syndrome within 6 weeks of flu vaccine, febrile.
  • ADR: local reaction, mild systemic effects.
  • Drug Interactions: immunosuppressants, theophylline, phenytoin, warfarin.
  • Dose: annual to age 6 months and up.
  • Younger than 9 years gets 2 doses first year, and High dose for 65+.
  • FluBlok or Flucelvax for pt with egg allergy.

Attenuated Live Vaccines vs. Inactivated Vaccines

• Be able to identify each group and common ADRs.

Attenuated Live Vaccine

• Live modified form of virus.
• Contraindicated in pregnancy (avoid for 1 months post vaccination) and in the immunocompromised.
• If 2 doses → give both the same day or at least 4 weeks apart.
• Drug Interactions: antiviral drugs, separate IG administration from live vaccine.
  • Live attenuated influenza vaccine (LAIV/Flumist) → mild ADRs; nasal congestion, headache, sore throat, cough muscle aches
  • MMR → fever 7 to 12 days after vaccine, drug interaction with IG, oral steroids, chemo
  • MMRV → fever greater than 102F, febrile seizures (caution pt with hx of neuro or seizures)
  • Oral polio → NOT USED IN USA, rare risk of vaccine associated poliomyelitis
  • Rotavirus→ mild GI upset (d/t oral admin), slight risk of intussusception
  • Varicella → fever, rash, injection site reactions
  • Herpes zoster → drug interaction with antivirals and steroids, for pt older than 60yrs, do not give to neomycin/gelatin allergy
  • Typhoid → for travel to Asia, Africa, caribbean, central or south america
  • Yellow fever → travel to endemic in africa or tropical south america, caution in pt over 60yrs
  • Cholera → (oral admin) drug interaction with antibiotics (do not admin for 14 days); chloroquine
  • BCG → disseminated disease in pt with TB, skin lesions at injection site (normal), may cause false positive PPD test

Inactivated Vaccine

• “Killed virus”.
• May coadmin with their vaccines.
• Ok if off schedule → use catch up schedule .
  • DTaP/Tdap/Td → pain at injection site, low fever, aches, headache; give antipyretic to kids with hx of febrile seizures
  • Haemophilus B Conjugate → injection site pain and redness
  • Inactive Poliovirus → drug interaction with immunosuppressants; contraindicated for allergy to neomycin, streptomycin or polymycin
  • HAV → soreness at injection site
  • HBV → local reaction, fever, malaise
  • HPV → syncope, injection site pain, redness
  • Inactive influenza → local reaction, mild systemic ADRs
  • PPV → local reaction, mild systemic ADRs
  • Meningococcal → local reaction
  • Typhoid→ mild local and systemic reaction
  • Japanese encephalitis → local/systemic reaction, urticaria (rash) and angioedema of face, lips, oropharynx
  • Rabies → mild local/systemic reaction, serum sickness
  • Lyme disease

Fluoroquinolone Indications in Pneumonia Treatment

• CAP pathophysiology: Pneumonia develops when an organism invades the lung parenchyma and the host defenses are depressed. Bacterial pneumonia results when the lung’s primary defense mechanisms are altered by a viral infection or immunological problems Goals in treatment: return to baseline resp status, resolve fever in 2-4 days, resolution of leukocytosis by day 4 of treatment, and return to normal check x ray in 4 weeks
• Patient education: pneumonia might be bacterial, viral, or mycoplasmal. Educate the patient regarding antibiotics prescribed. Educate the patient regarding hydration, smoking cessation, and rest. Symptoms of worsening status should be described. Patients should be told to expect clinical improvement in 48 to 72 hours.

Treatment Options in Children, Low Risk, High Risk Patients, Length of Treatment (Sinusitis)

• For adults: criteria for diagnosing needs 3 symptoms→ purulent rhinorrhea, facial/pressure/pain, nasal obstruction**
• Children have more subtle symptoms due to sinuses not being fully developed; may vomit (bc of mucus).
• Both have puffy eyes and cough that worsens when lying down.
• Amoxicillin is the 1st line treatment.
• Children: 80-90mg/kg/day in high risk; 45mg/kg/day in low risk (10 to 14 days).
• Adults: 500 mg 3 times/day, (5-7 days) or High dose Augmentin (amoxicillin-clavulanate).
• For PCN allergy patients.
• Children: cefdinir, cefuroxime, or cefpodoxime. Adults: doxycycline or respiratory fluoroquinolone (levofloxacin). Sinusitis (worse after 72 hours).
• Switch to Augmentin if amoxicillin was first choice.
• If started on Augmentin.
• Adults consider respiratory fluoroquinolone (Levofloxacin)
• Children: consider Cefdinir, cefuroxime, cefpodoximePatient Education→ Saline drops/spray for secretions; Topical decongestants; Corticosteroids for CHRONIC sinusitis

UTI Treatment Goals

• Specific length of treatment in complicated vs. uncomplicated and 1st & 2nd line antibiotic choices.
• Eradication of the causative organism (primary goal)
• Relief of symptoms
• Prevention of recurrent infection
• Complicated UTI: Symptoms lasting longer than 7 days, fever, shaking/chills/ rigors, flank pain, other comorbidities (DM, immunocompromised, pregnancy).

New FDA-Approved Drug

• Meropenem-vaborbactam (Vabomere).
• Longer treatment required: 5 to 7 days.
• Fluoroquinolones may be used if complicated.
• Uncomplicated UTI: 3 days for adults, 10 days for children.

1st & 2nd Line Antibiotic Choice:

• 1st Line: Nitrofurantoin (Macrobid) – not recommended for children/infants pregnancy, 100 mg BID for 5 days.
• 2nd Line: Cephalexin, cefpodoxime, cefixime (cephalosporins), and beta lactams (Amoxicillin); need gram-negative coverage.
• Ex: nitrofurantoin, cephalosporins, PCNs, fluoroquinolones, and TMP/SMZ.
• Note: TMP/SMZ (bactrim), Amoxicillin, and fluoroquinolones are no longer 1st line due to growing resistance.

Peds Treatment

• Febrile UTI treated aggressively with IV ceftriaxone until afebrile; 10 days.
• Culture after treatment; diagnosed with catheterized specimen.
• Radiology workup may be needed after treatment; consider anatomy problem (vesicoureteral reflux).
• Pregnancy or Children.
• 1st Line: Beta-Lactams (Amoxicillin-Clavulanate).
• 2nd Line: Cephalosporins (Cephalexin, Ceftriaxone).
• Dependent on culture: TMP/SMZ, Macrolides, and Fluoroquinolones.

Patient Education for All Medications in Readings/Modules: Respiratory

• Beta 2 Receptor Agonists (asthma, bronchitis, COPD).
  • MDI: use return demonstration, use spacer for everyone, check for incorrect inhaler use if the patient says medication is not working.
  • Breath-actuated inhaler requires inspiratory drive to deliver med to lungs.
• Xanthine Derivatives (2nd and 3rd line for asthma; bronchial smooth muscle relaxation).
  • Theophylline and caffeine.
  • Take as prescribed.
  • Discuss s/s of toxicity – N/V, jittery, insomnia, HA, rash, GI pain, restlessness, convulsions, irregular heartbeat.
  • Avoid a large amount of caffeine beverages.
  • Explain that theophylline elimination is influenced by diet.
• Inhaled Anticholinergics (bronchial smooth muscle relaxation, not used for acute bronchospasms).
  • Use as prescribed.
  • Use of inhaler.
  • Rinse mouth after inhaling medication.
• Leukotriene Modifiers (Ex. Montelukast, anti-inflammatory/allergy relief).
  • Do not take if pregnant or nursing.
  • Watch for drug interactions.
  • Watch for neuropsychiatric events & depression.
• Corticosteroids (allergy & asthma); not for emergency use.
  • Administration: if co-administering with bronchodilator, admin bronchodilator first and wait several minutes before using corticosteroid; know how to use MDI (exhale, tilt head back slightly, place in open lips, inhaled while pressing down on inhaler, breath slowly/deeply, hold for 10 seconds, wait 1 minute between puffs), rinse mouth after.
  • ADR: sore mouth or throat (may be a sign of candida), notify provider of ADRs.
• Antihistamines (allergies).
  • Caution while driving.
  • Report any ADR.
  • Do not take any CNS depressants or drink alcohol.
• Antitussives (cough).
  • Do not take for cough caused by smoking, emphysema, or asthma.
  • Do not use if you have excessive respiratory secretions.
  • Do not use if cough is lasting longer than 7 days.
  • Increase fluid intake.
  • Quit smoking.
  • Avoid respiratory irritants.

Bacterial

• Beta-Lactams-PCN- resistance (complete RX), ADRs- anaphylaxis, rash, GI, fungal overgrowth, or c diff colitis
• Beta Lactams- CephalosporinsADRs- allergies, rash, arthralgia, coagulation abnormalities, low blood counts, fever, seizures, renal hepatic failure
• Fluoroquinolones (complicated UTI, pyelonephritis, chronic prostatitis, not first line d/t many risks)
  • ADRs: Black Box warning to avoid when less toxic alternatives are available- tendon rupture, older adults at higher risk- Delayed onset, 120 days to months after administration- GI: pseudomembranous colitis
  • Central nervous system (CNS): sleep disorders, dizziness, acidosis
  • Renal/hepatic failure
  • Cardiovascular: angina, atrial flutter
• increased risk in pregnancy, should be avoided

Lincosamide

• Clindamycin (cleocin)- MRSA, PCN allergic patients, drug resistant strep, dental infectionsDiarrhea Macrolides and Azalides (CAP, chlamydia, pertussis, H. pylori, chronic bronchitis)
  • For altered response to concurrent medications metabolized by CYP3A4 or CY2C9.
  • Hepatic/renal impairment. Hearing loss.
• ADRs- dose-related, GI, N/V, abd pain, cramping, diarrhea.
• Skin- urticaria, bullous eruptions, eczema, Steven-Johnson syndrome Drug interactions strong CYP3A4 inhibitors, so they have lots of drug interactions Fidaxomicin: only used for C-DIFF (not for under 18yrs old), drug interactions rifampin or rifaximin, $$$$ Oxazolidinones: (Linezolid) (MRSA pneumonia, uncomplicated skin infections) ADR: Diarrhea, headache, nausea; myelosuppression has been reported; resolves, administration: well-absorbed orally, does not use CYP450 enzymes; oral less expensive than IV version. Sulfonamides, Trimethoprim, Nitrofurantoin, Fosfomycin (uti and mrsa, alternative for PCN allergy and those older than 2 months): Patient education- finishing course, ADRs: GI: anorexia, n/v, diarrhea, stomatitis; rashes, increased hypersensitivity reactions, photosensitivity; CNS, headache, dizziness, drug interactions & educate on Resistance Tetracyclines (some for h pylori:) food, milk and calcium decreases absorption; don't take while pregnant/breastfeeding, not used for less than 8 yrs old, Glycopeptides (Vancomycin) (gram positive resistant to other meds, oral for CDIFF): administration(poor oral absorption, given IV); ADRs: Ototoxicity (transient or permanent), Nephrotoxicity, "Red Man" syndrome infused too fast; Monitoring – Hearing and renal function Antimicrobaterials (TB): Patient education- Importance of taking medication daily, Reporting of ADRs, INH: peripheral neuropathy, INH, rifampin, and pyrazinamide: hepatotoxicity, Ethambutol: optic neuritis, Streptomycin and capreomycin: ototoxicity, Rifabutin: neutropenia and thrombocytopenia

Viral/Fungal/Protozoa

Antivirals

• Nucleoside analogues (herpes, shingles, chickenpox, bell’s palsy, gingivostomatitis in childrenDrug-started at earliest sign of infection, good hydration, symptoms of renal failure, encephalopathic changes, blood dyscrasias Antibiotics (used to treat Hep C
• Meds daily, side effects, Multi drug interactions, Hep C meds should’nt be used with amiodarone as it lead to bradycardia (Ledsipasvir sofosbuvir Harvoni). Systemic Azoles and Other Antifungals (used to treat yeast/dermatophytes etc.
• all systemic antifungals cause hepatoxicity.*
• *take it with food except voriconazole. Discourage alcohol. educate regarding Liver toxicity.
• Anthelmintics (anti worms,scabies:) Patient education- Albendazole and mebendazole should be taken with a high-fat meal.
• Ivermectin on empty stomach.
• Albendazole should not be taken if pregnant and backup contraception should be used for 1 month after taking
• Metronidazole, Nitazoxanide, and Tinidazole (used for parasitic and bacterial infections like trichomonas, c diff, h pylori:) Administration; metallic taste w/ metronidazole. Avoiding alcohol if taking metronidazole or tinidazole because of disulfiram-like reaction. Concurrent treatment of partner if sexually transmitted infection is present. Avoid metronidazole in first trimester. Signs of leukopenia

Pediatric Dose Calculations

• e.g., Amoxicillin (2 questions). You may use the computer calculator. Amoxicillin first line for sinusitis
• Dose at 80 to 90 mg/kg/day in high-risk children; 45 mg/kg/day in low-risk children.
• If treating AOM with antibiotics, amoxicillin dosed at 80 to 90 mg/kg/day is first choice Amoxicillin first choice, or Amoxicillin/clavulanate 90 mg/kg/day

URI Treatment for Children < 2 yrs

• Nasal bulb suctioning.
• NO DECONGESTANTS**** Avoid cough and cold medicines.
• Symptoms resolve in 7-10 days.
• No abx because its viral; symptomatic care only.

Understand CYP450 Enzymes

• How it affects metabolism of a drug, specific to inducer and ultra-rapid metabolizers specifically related to TB regimen (Rifampin, TB)
• CYP450 enzymes – hepatic metabolism of drugs, used to break down the majority of drugs Inhibitors of CYP450: drugs stay in system longer, increases ADRs or drug interactions. Inducers: metabolize drug too fast, therefore little to no therapeutic effects occur, may need to increase dose. Rifampin is a potent inducer of CYP3A4, thus decrease the effects of drugs that are co-administered with it.
• With repeated administration, the half life of rifampin decreases.

Asthma-Know Your Guidelines

• Diagnose and Management of Treatment of Asthma specific to the first line therapies for each step, table 32-1 including intermittent asthma treatment plan The GINA Guidelines prefer an aggressive approach to gaining quick control (but can do either step up or step down approach)
• Determine the severity of asthma symptoms and use step therapy chart, and start at the recommended step.
• Assess patient’s response every 2-3 months.

Intermittent (less than or equal to 2 days a week)

• Step one therapy. use short-acting beta 2 agonists, as needed, for symptoms.
• Patients have symptoms when exposed to triggers (upper respiratory infections, allergens, chemical inhalants).
• Exercise can be mild intermittent.
• Patients need an annual flu shot. Mild persistent asthma (>2 days/wk but not daily)
• Treat with low-dose inhaled corticosteroid medication daily.
• Low-dose inhaled corticosteroids are the mainstay for patients of all ages.
• Use beta agonists as needed; if using 2 days or more per week, then step up therapy
• Moderate Asthma (daily) Treat with medium-dose inhaled corticosteroids or low-dose inhaled steroids plus long-Acting beta agonists (adults) or medium -dose inhaled steroid, short-acting beta agonists may be used, exacerbations may require oral corticosteroidsSevere persistent asthma (multiple times throughout day) . Step 4 therapyMedium- dose inhaled corticosteroids plus long-acting beta agonist, Step 5 therapy- High-dose inhaled corticosteroids plus long-acting beta agonists, Step 6 therapy- High-dose inhaled corticosteroids plus long-acting beta agonists and oral corticosteroids Requires consultation with asthma specialist-difficulty achieving.maintaining control Consider any adult who require step 4 therapy or child who require step 3 therapy

Management/Monitoring

• Once control is achieved, the patient is seen every 2 to 3 months to determine if a step-up or step-down in therapy is indicated.
• The GINA Guidelines recommend that the dose of inhaled corticosteroids be reduced about 25% to 50% every 2 to 3 months to the lowest possible dose to maintain controlManaging Exacerbations- Treat with oral steroids to regain control- use a short burst; Adults= 40 to 60 mg/day for 5 to 10 days - Children= 1 to 2 mg/kg daily (maximum 50 mg/day) for 3 to 10 days- If not effective, then step up therapy, PEDS – Steps similar but not the same, and some meds are not approved for kids. Long-acting beta agonists (Ex: Salmeterol) NOT used by itself !! Combined with inhaled corticosteroids. Use Aerochamber with mask for infants and young children; spacer for all; home neb is an option. If requiring step 3 therapy → refer to asthma specialist. Steps for children in The GINA guidelines.

LABA/SABA Medication Side Effects

• Cardiac: Tachycardia, palpitations, arrhythmias