Pharm Exam 2 Review Guide PDF

Pharm Exam 2 Review Guide (40-50 Questions) 1. For your monoclonal antibodies I want you to identify their mechanism of action and their shared adverse effects. Biologics (Monoclonal Antibodies Drugs Notes...

Pharm Exam 2 Review Guide (40-50 Questions) 1. For your monoclonal antibodies I want you to identify their mechanism of action and their shared adverse effects. Biologics (Monoclonal Antibodies Drugs Notes Adverse Effects Omalizumab (Xolair) MOA: Recombinant anti-IgE antibody → decreased inflammatory mediator release BLACK BOX WARNING → Anaphylaxis (rare) - Inhibits the binding of IgE on the surface of mast cells ↳Has occurred up to 12 months post 1st dose G omalizumab IgE mart - Moderate or severe allergic asthma not controlled with ICS - Dosing based on weight and IgE levels - Injection site reactions: including flu-like symptoms (e.g., myalgias) & pain at site of injection cellv - Increased risk of infections (fungal & helminth) F Dupilumab (Dupixent) MOA: Interleukin-4 antagonist → decreased inflammatory mediator release - Anaphylaxis (does not have a Black Box warning) E 11-4 antagonist - Moderate or severe allergic asthma not controlled with maintenance therapy - Injections site reactions: including flu-like symptoms and injection site pain - Increased risk of infections (herpes & helminths) Benralizumab (Fasenra) - MOA: Recombinant Interleukin-5 Antagonists - Anaphylaxis Mepolizumab (Nucala) Reslizumab (Cinqair) Isagonist - Severe asthma with eosinophilic phenotype - Injection site reactions - Increased risk of infections ROV Palivizumab (Vynagiu) MOA-antibody against epitope in A antigen rite on Fourface protein of extensive , high-risk infant 2. If I have any slides that are like hey we're studying this condition but there are drugs that make this condition worse you should be familiar with those slides. Asthma Cannot use monotherapy LABA → increased risk of death COPD Cannot use monotherapy ICS → increased risk of PNA 3. So what can exacerbate asthma? Does anybody want to throw anything out? What kind of drugs can exacerbate asthma? Aspirin can, propranolol, estrogen has some concerns and I do believe that slide was completely yellow. So although I tell you guys not to memorize a lot of stuff. I think that one's important. Go ahead and memorize that one. Drugs & Asthma - Estrogen replacement therapy during menopause may exacerbate asthma → Outcome absent when estrogen is given in combination with progesterone (mechanism not understood; estrogen decreases may exacerbate asthma during PMS) - Aspirin → Cyclooxygenase-1 (COX-1) inhibition → Inhaled corticosteroids (ICSs) are the primary preventative treatment - Nonselective 𝛃-blocking agents (e.g., propranolol) → These drugs do not precipitate bronchospasm but prevent its reversal 4. I'll give you an acute asthma exacerbation patient. I'll give you the age, I'll give you the weight, I'll tell you the weight dose to prescribe. I'll tell you how to round on it and you tell me what to give. How many milligrams of the steroid to give. 5. On Wednesday we'll look at the different steps one through step five. Identify which medications are on each step and for which patient population they get used. Determine step by using GINA Guidelines screening recommendations - Preferred vs alternative. Now Available = therapy options he emphasized being “unlocked” Note: Symbicort dosing is mostly off-label ICV + LABA Chronic Asthma Step 1 Step 2 Step 3 Step 4 Step 5 ↑ Adults (≥ 12 y/o) Controller: None or Low Dose ICS (Flovent) taken Controller: None or low dose ICS (Flovent) daily Controller: Low dose maintenance Symbicort Controller: Medium dose maintenance Symbicort Controller: Medium/High dose Symbicort whenever reliever is taken (ICS-Formoterol) daily or low dose ICS-LABA daily (ICS-Formoterol) daily or Medium/High dose (ICS-Formoterol) + LAMA daily or Medium/High Reliever: Low dose Symbicort PRN ICS-LABA daily dose ICS-LABA daily Reliever: Low dose Symbicort PRN (ICS-Formoterol) or PRN ICS-SABA or SABA Reliever: Low dose Symbicort PRN (ICS-Formoterol) or PRN ICS-SABA or SABA (ICS-Formoterol) or PRN ICS-SABA or SABA Reliever: Low dose Symbicort PRN Reliever: Low dose Symbicort PRN Now Available: Montelukast (LTRA) therapy for (ICS-Formoterol) or PRN ICS-SABA or SABA (ICS-Formoterol) or PRN ICS-SABA or SABA controller Now Available: Long Acting Beta Agonist (LABA) controller option. MART Therapy Now Available: Add on LAMA (Tiotropium) to Now Available: Option to add on Biologics controller (Anti-IgE, Anti-IL5/5R, Anti-IL4Ra, Anti-TSLP) reliever PRN (rymbicort JABA) , and/or adding low dose OCS (as a last resort) to controller.. Children (6-11 y/o) Controller: Low Dose ICS (Flovent) taken Controller: Daily low dose ICS (Flovent) or LTRA or Controller: Medium Dose ICS (Flovent) or Low Dose Controller: Medium dose ICS-LABA daily or Low Controller: Refer for phenotypic assessment by whenever reliever (SABA) is taken or can consider Low Dose ICS (Flovent) taken whenever reliever is ICS-LABA (Symbicort?) or Low dose ICS + LTRA dose Symbicort for MART or add LAMA or add specialist. Can have higher dose ICS-LABA or add daily low dose ICS taken LTRA. on biologics or add on OCS (last resort) Reliever: PRN SABA (Albuterol) or low dose Reliever: PRN SABA (Albuterol) Reliever: PRN SABA (Albuterol) Symbicort PRN if also being used daily as controller Reliever: PRN SABA (Albuterol) or low dose Reliever: PRN SABA (Albuterol) (this is known as MART) Symbicort PRN (if using MART) Now Available: Montelukast (LTRA) therapy for Now Available: Option to add on Biologics and/or controller Now Available: Long Acting Beta Agonist (LABA) Now Available: Add on LAMA (Tiotropium) to adding low dose OCS (as a last resort) to controller. PRN VABA + IC PRN VABA + daily ICE controller option controller Children (≤ 5 y/o) Controller: None (insufficient evidence for daily Controller: Daily low dose ICS (Flovent) or LTRA* Controller: Double the low dose ICS (Flovent) or Refer to specialist Refer to specialist controller use) or intermittent short course ICS at or intermittent short course ICS at onset of illness ICS+LTRA*. Consider specialist referral Continue controller onset of illness Can add LTRA or increase ICS or add intermittent Reliever: PRN SABA (Albuterol) nebulized solution. Reliever: PRN SABA (Albuterol) nebulized solution. ICS Reliever: PRN SABA (Albuterol) nebulized He said duoneb could be an option during lecture. He said duoneb could be an option during lecture. solution. He said duoneb could be an option during lecture. Now Available: Montelukast (LTRA) therapy for controller (*If >11 months) PRN VABA PRN VABA+ dain  4/5 I dore NO JIMBICORT Sto VTep 2 < 3 Step ~ MART mea. done rumbicort 12 yo DOUBLE DOVE in Symbicort PRN/ rimbicort daily PRN + step 3 Vymbicor PRN/ daily ICU/LABA + VABA mind/high done ICNYLABA"JABAPRN daily ICO + JABA PRN NABA-ICV PRA nukotriene rec. Antagonist tiotropiom (AMA) + Montelenkaut El ↓ + Posteroids , biologic , 6. You'll want to be able to step people up and step people down and to some degree, you'll want to be able to say which category they would be in whether it's intermittent or persistent and then if it's persistent is it mild, moderate, or severe. I'm not crazy about making you guys memorize all that stuff. So I'm still thinking about the best way to present it. If classified as intermittent, the patient will be put into Step 1 treatment. In the case of persistent symptoms/exacerbations, they will be put on step 2-5 depending on severity (mild, moderate or severe). In order to determine step placement, you consider frequency of SABA use, nighttime awakenings, FEV1, FEV1/FVC, and frequency of exacerbations. Using GINA Guidelines screening recommendations, you determine which of the factors is most abnormal (which of the factors is the worst one) and utilize that factor to determine step. GINA Guidelines Screening Recommendations Intermittent (Step 1) Persistent - Mild (Step 2) Persistent - Moderate (Step 3) Persistent - Severe (Steps 4 & 5) Symptoms/SABA (reliever) use ≤ 2 days a week > 2 days a week Daily Throughout the day (multiple times) Nighttime awakenings ≤ 2/month 3-4/month >1/week Nightly (0-4 years old) (0/month) (1-2/month) (3-4/month) (>1/week) FEV1 >80% 60-80% 1 day) 7. There are so many different drugs for asthma and COPD. We're only going to talk about a few and their specific devices and how you should counsel a patient on those. For example, we’ve talked about the MDI albuterol inhalers. What's priming? How often are they cleaned? How long do I wait in between inhalations? Devices MDI albuterol inhalers - Priming: Before first use (or if it’s been more than 7 days since the last use), point the inhaler at the ground and do two puffs to “prime” it - Cleaning: Use warm water to clean only the plastic part of the MDI holder VABA - Wait 15-30 seconds between puffs with a beta2-agonist inhaler Nebulizers - Children < 6 y/o require the use of a face mask as opposed to a mouthpiece for delivery of aerosolized medication Spiriva Respimat & Combivent - Daily use → TOP (turn, open, press) - Multiple dates on the inhaler - 1st date: label from pharmacy “expires in 1 year” LAMA - 2nd date: date on manufacturers box - 3rd date: one that the patient writes on the inhaler Spiriva Handihaler Once-daily dosing in 4 simple steps: 1. Open the handihaler device. Separate only one of the blisters from the blister card, then open the blister. If you accidentally open another blister, the capsule in that blister should not be used. 2. Insert the SPIRIVA capsule and close the mouthpiece firmly against the gray base until you hear a click. LAMA 3. Press the green piercing button once until it is flat against the base, then release. 4. Breathe out completely in one breath and then, with the HANDIHALER in your mouth, breathe in deeply until your lungs are full. You should hear or feel the SPIRIVA capsule vibrate (rattle). Advair Diskus - Breathe all the way out - Breathe in the medicine quickly and deeply through the DISKUS 1TV - 1ABA - Remove the DISKUS from your mouth and hold your breath for 10 seconds - RINSE YOUR MOUTH OUT AFTERWARDS (((v) Trelegy - Steps for use: 1. Open the cover of the inhaler. 2. Breathe out. 3. Inhaler your medicine. Don’t block the vent with your fingers. Remove the inhaler from your mouth and hold your breath for 3 to 4 seconds ICS/LABA/LAMA 4. Breathe out slowly and gently. 5. Close the inhaler. 6. RINSE YOUR MOUTH. 8. Tell me everything about Montelukast. Leukotriene Modifiers MOA: Reduction of production or action of leukotrienes in inflammation and allergy; reduces airway edema and smooth muscle contraction Side Effects: - Headache - GI upset - Psychiatric effects (rare)  INCREDIBLY RARE: idiosyncratic syndrome similar to Churg-Strauss syndrome, with marked circulating eosinophilia, HF, and associated eosinophilic vasculitis, has been reported in a small number of patients Drugs Notes Side Effects / Warnings Montelukast (Singulair) - Leukotriene receptor antagonist (LTRA) - Approved for exercise-induced bronchospasm asthma (EIB asthma) 9. Here's another question where you have to stratify the patient's severity, determine what step to be in, and whether to step up or step down. 10. What are the differences in treatment options available for somebody with acute asthma exacerbation and think about it as mild & moderate versus severe. What objective data would tell you is severe? What drugs can you use if it's severe? Is there any difference between IV versus oral corticosteroids? Determining Course of Care - We will use the objective measures for mild, moderate and severe in this algorithm to determine the course of care for our exams. - Important measures for determine mild/moderate versus severe: methylpredivolone hydrocortisone + dexamethrone V Po in = - Mild or moderate , , → Respiration rate increased → Pulse rate 100-120 bpm PREDNIONE S → O2 saturation (on air) 90-95% → PEF >50% predicted or best NEVERE ACUTE EXACERBATION - Severe RR > 30/ min children 12 mg/kg/day 3-Sdayr max → Respiratory rate >30/minute > - HR) 120 Dpm PEF 50 % best adults 40-60 mg/day → Pulse rate > 120 bpm S-7 dayrdaya → O2 saturation (on air) < 90% O2 rat 65 y0 IMPLE azithromycin 500 Quay I - Azithromycin 500 mg PO once daily (PAE; 5 days of therapy acceptable) COPD - Augmentin 875 mg BID - Doxycycline 100 mg BID Aug. Dont. > 4 exacerbations/yr - Levofloxacin 500 mg once daily COMPLICATED < heart direaus Complicated CB (risk factors: >65 y/o, chronic COPD, >4 exacerbations per year, heart disease, home 02 use, antibiotic use in past 3 months, 87S mg BID homeO2 use corticosteroid use in past month): Aug - Augmentin 875 mg BID Doxy Levoflox in last 3ms antibiotics. - Doxycycline 100 mg BID - Levofloxacin 500 mg once daily INPATIENT ( < CRF FEVI 2 risk factors or FEV1 < 35% predicted) - Levofloxacin 750 mg IV daily (empirically covering P. aeruginosa) Levoflox 750 my 10 daily (P aeruginova). 20. If I ask for prednisone, or if I ask for like a steroid question, I'll give you the equivalence. So you just got to be able to do the math. Just make it proportional. cell wall sell wall 30V rubunit * * D *  to 60mg = s amg mp/smh : 1. n - anxa S Pred MONITOR bronchodilation CYP3A4 1A MOA-inhibit phorphodieter are - , Thophylline ↑ luir w/ inhibitors 1900 max) DOVING 10mg/kg/day ↳ chronic arthma ↓ w/ moring inducers + 21. Tell me about the narrow therapeutic range of theophylline. COPD * NARROW THERAPEUTIC RANGE-5-15 meg/mL NOT EXACERBATION ↳ - reizumr arrhythmiar , Theophylline (Methylxanthine) MOA: - Nausea/vomiting - Non-specifically inhibit phosphodiesterase → bronchodilation - GERD - Inhibit secretion of inflammatory mediators - Nervousness - Tremor Dosing: - Insomnia - 10 mg/kg/day (max 900 mg/day); complicated dosing - HA ***Narrow therapeutic range: 5 - 15 mcg/mL - Tachycardia - Seizures & arrhythmias (if concentration > 15 mcg/mL) Metabolized by CYP1A2 & CYP3A4 - Levels increased by: 1A2 and 3A4 inhibitors (extra risk of seizures & arrhythmias) - Levels decreased by: - Tobacco smoking - CYP3A4 inducers 22. Azithromycin is weird because it's an antibiotic that can be used long-term in COPD. Tell me about that. That's kind of unique, right? Because normally when I think of azithromycin, I'm thinking z-pack, infection, 500 milligrams on day 1, 250 milligrams thereafter. It's got a post-antibiotic effect, so I only need to use it for five days and serum concentrations will persist. There's some unique stuff about azithromycin and COPD. Tell me about it. Macrolides for COPD Drugs Notes Adverse Effects / Warnings Azithromycin - Lower rate of exacerbations and improved quality-of-life scores - No benefit if still smoking - avoid combination - Dosing 250 mg Qday or 250 mg three times weekly; reassess after 12 months 250mg Qday OR 3x/wk - Increased risk of hearing loss for COPD cohort Adverse effects and drug interactions → QT prolongation: - Amiodarone (very serious) - Given the risk of adverse effects with ICS, clinicians may consider by-passing triple inhalation therapy (LAMA/LABA/ICS) for those patients with persistent - Flecainide (all antiarrhythmics) exacerbations and lower blood eosinophil count ( - ↓ replication) Indication Treatment Prophylaxis - 75 mg once - daily x 5 day - Weight based dose for pediatrics BID - 75 mg once daily x 10 days - Weight based dose for pediatrics Ye down - CrCl 30-60 mL/min → 30 mg BID x 5 days - CrCl 30-60 mL/min → 30 mg once daily x 10 days =mL/min → 30 mg once daily x 5 days - CrCl 10-30 - 12 interval - CrCl 10-30 mL/min → 30 mg every other day (QOD) x 10 days 30. Treat acute otitis media. The tricky one about that is like, when do you use high dose Amoxicillin versus when do you use high dose Augmentin? AOM Treatment obvervation or antibiotic - APAP or ibuprofen ↳ 6mo-12 yo mod/revere Observation or antibiotics pain you + 107 2 F. → 6 - 23 months old + nonsevere unilateral AOM → 24 months to 12 years old + nonsevere AOM 6 23 mo BILAT : Antibiotics → 6 months - 12 years old + moderate to severe pain (48hrs) + 102.2℉ → 6 - 23 months old + nonsevere BIL AOM lrt line Amox 80-90 mg/kg/day BID - First line: amoxicillin 80-90 mg/kg/day BID 90 melkg/day anti in lart 30 Aug : days BID - If patient has received amoxicillin in the last 30 days, has concurrent purulent conjunctivitis, or has a history of recurrent infection unresponsive to amoxicillin: Augmentin 90 mg/kg/day BID - If patient has a type II PCN allergy: Cefdinir 14 mg/kg/day type 11 allergy : Cedinir 14 myleglday - If patient has a type I PCN allergy, consider clindamycin monotherapy type I : clindamycin Failure at 48-72 hours - Augmentin 90 mg/kg/day BID - Clindamycin 30-40 mg/kg/day TID +/- Cefdinir 14 mg/kg/day FAILURE : Aud , Clind Duration of Therapy ≥ 6 y/o: 5-7 days if mild to moderate; 10 days if severe 2-5 y/o: 7 days if mild to moderate; 10 days if severe DURATION to 10 dayr , > " S-I day < 2 y/o: 10 days 31. For the upper respiratory infections, I focused a lot on when do you substitute drugs for allergies? If somebody has a penicillin allergy and it's a type 2, such as like a dermatological reaction, you should feel fine writing a cephalosporin. There's only a 10% chance that it could cause an issue. If it’s a type 1, you might need to think about something else even if it's normally avoided. Like there can be instances where you use fluoroquinolones in pediatrics for a type 1 penicillin allergy. DNA gyrave Chisynthesis) He kind of answered his question. 32. There's another pneumonia question. I don't do anything tricky on any of these doses. Every dose I list is a real dose. There's no fake funny doses here. There's another pneumonia question. Pneumonia is tough. And another pneumonia question.  INDUCERY PrPORE & INHIBITORY GPACMAN umoking grape fruit · Ritampin protease inhibitors (HIV) · * - Reference Pneumonia charts. It vonnu wart - azolev + ransplant heart burn OT? · anti veizure * C-cyclosporin + Cimetidine (Phenytoin,Phenobarbitalaazepine( 33. There's a PS PORCS and GPACMAN question every exam. , macrolider (not azithromycin) Strongest Inducers (PS PORCS) Strongest Inhibitors (G PACMAN) · amiodarone/dronedarone Camil Phenytoin Grapefruit * non DHP CCBr (ailtiazem mii) Smoking Protease Inhibitors ↳a channel blocker Phenobarbital Azoles C - cyclosporin & cimetidine Oxcarbazepine Macrolides (not azithromycin) Rifampin (& rifabutin / rifapentine) Amiodarone (& dronedarone) Carbamazepine Non-DHP CCBs (diltiazem and verapamil) St. John’s wort 34. Tell me about RSV updates and what does the American Academy of Pediatrics recommend for treatment? (There's a difference between routine recommendation and alternative therapies that can be used.) Treatment Recommended: AAP-RUV +X antipyretic , antiturive expectorant , is antithromtifloxacin * nebulized valine volution - Nebulized hypertonic saline 35. What do you guys want to treat acute bronchitis with? I've got acute bronchitis. I'm 20 years old. All Not routinely recommended: NOT ROUTINE : Prevention - my labs are fine. I don't have a high fever. Do you want a symptomatic treatment only or do you want to give me an antibiotic? Remember if you got bronchitis, just regular bronchitis, 9 out of 10 times, it's like - Aerosolized 𝛽2-agonists vaX > 60 yo · aerovolized B2 agonist Abryro/AreXVy a viral infection, just symptomatic treatment. Now if they have chronic bronchitis, yeah, you're going to - Systemically administered corticosteroids · systemic cortico vteroid use an antibiotic. But that's going to be like a COPD thing. - Ribavirin (synthetic nucleotide) · Ribavirin (synthetic nucleotide Palivizumab Supportive care, no antibiotics. Prevention: 36. You got to tell me how to treat pharyngitis. - Abrysvo (vaccine) for adults > 60 y/o, pregnant patients 32-36 weeks: 0.5 mL IM - Arexvy (vaccine) for adults > 60 y/o: 0.5 mL IM Pharyngitis(Synagis) - Palivizumab Treatment monoclonal antibody: man-made proteins act like human antibodies, directed against an epitope in the A antigen site on the F surface protein of RSV S *** Expensive 10 days - prior (5 days authorization typically required if azithromycin): 10 dayr (S dayr if azithromycin) Preferred: Amoxicillin Pharyngitir TX : 10 DAY ! Pediatrics → 50 mg/kg/day (max 1,000 mg/day); can divide dose, preferred over PCN due to palatability (PCN) Amox Preferred palatability Adults → 1,000 mg once daily; can divide dose · , Type II PCN allergy: Cephalexin Children-SOmg/kg/day (1 000 , max) Pediatrics → 20 mg/kg/dose BID Adults → 500 mg BID aduitu-1 000 , my daily L Type I PCN allergy: Azithromycin can divide done Pediatrics → 12 mg/kg/day x 5 days Adults → 500 mg daily x 5 days - Type 11- Cephalexin BID Type I PCN allergy or macrolide resistance: Clindamycin Type 1 - Azithromycin SDAT Pediatrics → 7 mg/kg/dose TID z L Adults → 300 mg TID Chronic Carriers: Clindamycin TID macrolida + Clindamycin dose is similar Add rifampin to PCN Amoxil→Augmentin Chronic : cliudimycin done : vimilar add rifampin to PeN amox - and * cell wall  - Hematogenous spread from another infection site - Although aggregate 30-day mortality rates were slightly lower for low-risk patients identified by Etiology Viral infections: the PSI, the clinical relevance of the small differences is unclear. Future comparisons of these - Caused by a variety of viral & bacterial pathogens - Diffuse, interstitial compared with the classic lobar or lobular consolidated prediction rules for guiding the initial site of treatment are needed. infiltrates of bacterial PNA Staphylococcal - Often demonstrate cavitary or necrotizing lesions → Blood cultures, radiography, and non-invasive sputum cultures not routine for outpatient CAP Step 1: CURB-65 Confusion Criteria: - Confusion 20 mad - Uremia (BUN > 20 mg/dL [7.1 mmol/L]) Oremia (BUN) 2 - Respiratory rate ≥ 30 breaths/minute < < out at - Blood pressure (systolic ﹤90 mmHg, diastolic ≤ 60 mmHg) - Age ≥ 65 years Scoring: < 2 → outpatient treatment RR138 breath/min = 2 impatient BP < % O = 2 → inpatient > 2 → inpatient ICU Step 2: CAP or severe CAP? 32 in p + 198 Minor Criteria: - Respiratory rate ≥ 30 breaths/minute - PaO2 / FiO2 ≤ 250 - Multilobar infiltrates 63 + y0 - Confusion/disorientation - Uremia (blood urea nitrogen level) ≥ 20 mg/dL 35 - Leukopenia (WBC count < 4,000 cells/𝜇L) - Thrombocytopenia (platelet count < 100,000/𝜇L) - Hypothermia (core temperature < 36o C) - Hypotension requiring aggressive fluid resuscitation rever CAP PadAiOc : 250 multilobal infiltrator , (3) MINOR-CUR Major Criteria: · (fniation) - Septic shock with need for vasopressors I , - Respiratory failure requiring mechanical ventilation WBT 25%) 500 mg on day 1 and 250 mg on days 2-5 Outpatient CAP w/ chronic heart, lung, kidney or liver disease; DM; EtOH abuse; - Augmentin 875 mg BID + azithromycin 500 mg on day 1 and 250 mg on days 2-5 malignancy; asplenia - Levofloxacin 750 mg qday Inpatient NONsevere CAP w/o RF for MRSA or P. aeruginosa - Ceftriaxone 1-2 grams IV/IM q24 hours + azithromycin 500 mg IV q24 hours - Levaquin 750 mg qday IV q24 hours - Add linezolid 600 mg IV or PO q12 hours OR vancomycin 15-20 mg/kg IV q12 hours & obtain cultures if previous MRSA infection - Switch ceftriaxone to cefepime 1-2 g IV q8-12 hours if previous P. aeruginosa infection - Obtain culture but DO NOT empirically treat for MRSA or P. aeruginosa if hospitalization or IV antibiotics in past 90 days Inpatient severe CAP w/o RF for MRSA or P. aeruginosa - Ceftriaxone 1-2 g IV/IM q24 hours + azithromycin 500 mg qday IV q24 hours - Ceftriaxone 1-2 g IV/IM q24 hours + levofloxacin 750 mg qday IV q24 hours Inpatient severe CAP w/ RF for MRSA - Add linezolid 600 mg IV or PO q12 hours OR vancomycin 15-20 mg/kg IV q12 hours & obtain cultures if previous MRSA infection or hospitalization or IV abx in past 90 days Inpatient severe CAP w/ RF for P. aeruginosa - Switch ceftriaxone to cefepime 1-2 g IV q8-12 hours if previous P. aeruginosa infection or hospitalization or IV abx in past 90 days & obtain cultures HAP HAP (No hospitalization or IV abx in past 90 days / not intubated / no septic shock) HAP (Hospitalization or IV abx in past 90 days, prior MRSA infection, >20% MRSA isolates) HAP (Hospitalization or IV abx in past 90 days, high risk mortality [intubated or septic shock] or structural lung disease [bronchiectasis or cystic fibrosis]) - Piperacillin / tazobactam 4.5 g IV q6 H - Cefepime 2 grams IV q8 hours + vancomycin 15-20 mg/kg IV q12 H OR linezolid 600 mg IV or PO - Cefepime 2 grams IV q8H + amikacin 15-20 mg/kg IV q24H + vancomycin 15-20 mg/kg IV q12 H q12H OR linezolid 600 mg IV or PO q12H - Cefepime 2 grams IV q8 H (better Acinetobacter spp. coverage compared to pip/tazo) - Levofloxacin 750 mg IV daily + vancomycin 15-20 mg/kg IV q12 H OR linezolid 600 mg IV or PO q12 H - Levofloxacin 750 mg IV daily VAP No MDR / MRSA / P. aeruginosa risk factors - Piperacillin / tazobactam 4.5 g IV q6H multidrug resistance MDR Risk Factors: IV antibiotic use within the previous 90 days, septic shock at the time of VAP, ARDS preceding VAP, ≥ 5 days hospitalization prior to occurrence of VAP, acute renal replacement therapy prior to VAP onset - Cefepime 2 grams IV q8H + amikacin 15-20 mg/kg IV q24H + MRSA Risk Factors: >10-20% MRSA isolates or IV antibiotics in past 90 days - Cefepime 2 grams IV q8H + amikacin 15-20 mg/kg IV q24H + ↑ P. aeruginosa Risk Factors: >10% of gram-negative isolates are resistant to an agent being considered for monotherapy, structural lung disease (i.e., bronchiectasis or CF) or IV antibiotics in last 90 days - Cefepime 2 grams IV q8H + amikacin 15-20 mg/kg IV q24H + - Cefepime 2 grams IV q8H vancomycin 15-20 mg/kg IV q12H or linezolid 600 mg IV or PO q12H vancomycin 15-20 mg/kg IV q12H or linezolid 600 mg IV or PO vancomycin 15-20 mg/kg IV q12H or linezolid 600 mg IV or PO q12H q12H - Levofloxacin 750 mg IV daily ↳ W 300 rubunit # Antitussives Medication MOA Adverse Effects Drug-Drug Interactions Contraindications Expectations of Therapy (e.g. formulation, dosing, renal dosing, duration, & others Benzonatate Suppresses cough by topical - Oral mucosa anesthesia - 100 mg to 200 mg tid for patients 10 years and older (Tessalon Perles) anesthetic action on the respiratory may occur if capsules are - No hepatic, renal or geriatric dose adjustments stretch receptors. chewed or dissolved in the mouth Tussionex Opioids - suppress cough in the - Nausea - Additive and synergistic CNS - The FDA in January 2018 recommended against routine use of Hydrocodone 10 mg/ Chlorpheniramine 8 mg/ 5 mL ER medullary center. - Itching depression will occur with codeine/hydrocodone-containing cough/cold products for patients Cetepime vane or linezolid * P. acrug -Leftriaxone antibiotics in last 90 day emperic +x TRIPLE Obtain C +r, no P arrug riVK high · risk morrality · =. lintubation reptic rock) Azithroo Lerotox Cetepime Amikacin , inpt : - ceftriaxone + structural lung direave · revere + Vanc o Linezolid Ibrochiectariv/(F) · Piptazo/Cetepime/Levotion RE VAP MDR , , P aeruginova MRVA. ANTI PLEUDOMONALV - ↳ TRIPLE = Cetepime + amikacin - Vane/Linezolid Piptazo , Cerepime , Cefrazidime , IV antibiotic ure in 90 dayr , reptic shock & time of VAP. ADRS preceding , Isaayr Aztuonam Meropehem Impenem , , Upper Respiratory Infections MDR multidrug revirtance RF · norpitalization Prior , acute renal replacement therapy prior Acute Otitis Media Etiology Pathophysiology Diagnosis (AAP) Signs & Symptoms Treatment Streptococcus pneumoniae - Children more susceptible due to Middle ear effusion with either: - Otalgia (considered to be moderate to severe if pain lasts at least 48 hours) - APAP or ibuprofen - Resistance via penicillin-binding proteins shorter/more horizontal eustachian tube - Moderate to severe bulging of the TM or new onset - Fever (considered to be severe if temperature is 39℃ [102.2℉] or higher. - Middle ear is blocked with fluid otorrhea not due to acute otitis externa Observation or antibiotics Haemophilus influenzae (non-typeable) & - Proliferation of bacteria from nasopharynx - Mild bulging of the TM and onset of ear pain within - Bulging of TM & otorrhea → 6 - 23 months old + nonsevere unilateral AOM Moraxella catarrhalis - Results in bulging and erythematous TM the last 48 hours or intense erythema of the ™ - Following viral URI, nonverbal children will tug, rub, and hold their ears → 24 months to 12 years old + nonsevere AOM - Resistance via 𝛽-lactamases (Augmentin) - Infants will cry, be irritable or have difficulty sleeping. Antibiotics Prevention → 6 months - 12 years old + moderate to severe pain (48hrs) + 102.2℉ Influenza, Haemophilus influenzae and Recurrent AOM criteria: → 6 - 23 months old + nonsevere BIL AOM pneumococcal vaccines. - 3 episodes in 6 months - 4 episodes in one year - First line: amoxicillin 80-90 mg/kg/day BID - Consider T-tubes (reduces risk of hearing loss & language and/or learning disabilities - If patient has received amoxicillin in the last 30 days, has concurrent purulent conjunctivitis, or has a history of recurrent infection unresponsive to amoxicillin: Augmentin 90 mg/kg/day BID - If patient has a type II PCN allergy: Cefdinir 14 mg/kg/day - If patient has a type I PCN allergy, consider clindamycin monotherapy Failure at 48-72 hours - Augmentin 90 mg/kg/day BID - Clindamycin 30-40 mg/kg/day TID +/- Cefdinir 14 mg/kg/day Duration of Therapy ≥ 6 y/o: 5-7 days if mild to moderate; 10 days if severe 2-5 y/o: 7 days if mild to moderate; 10 days if severe < 2 y/o: 10 days Acute Bacterial Rhinosinusitis Etiology Pathophysiology Diagnosis Signs & Symptoms Treatment  2-10% of all upper respiratory - Preceded by a viral URI that causes mucosal - Signs/symptoms not improving after ≥ 10 days - Purulent anterior and posterior nasal discharge - Nasal decongestants and antihistamines are not recommended. infections are bacterial inflammation - Nasal congestion or obstruction - Saline spray for nasal irrigation (0.9% NaCl spray) - Severe signs/symptoms (fever ≥ 102.2℉) for ≥ 3 days at - Facial congestion or fullness - Intranasal corticosteroids are recommended only for patients with a history of allergic rhinitis Streptococcus pneumoniae & - Mucosal secretions become trapped, local defenses are start of infection - Facial pain or pressure (could prolong bacterial infection) Haemophilus influenzae (50-70% impaired, and bacteria from adjacent surfaces begin to - Fever cases) proliferate - Worsening of signs/symptoms for ≥ 3 days starting at - Headache Antibiotic Duration: day 6-8 of initial infection - Ear pain/fullness - Adults → 7 days Moraxella catarrhalis (8-16% - Halitosis - Children → 10 days cases) Risk for antibiotic resistance (will do therapy a couple - Dental pain days longer): - Cough 1st Line - Age 65 - Fatigue Augmentin 45 mg/kg/day BID or Augmentin 875 mg BID - Daycare - Prior antibiotics within the past month High-dose Augmentin (90 mg/kg/day BID or 2000 mg BID): - Prior hospitalization within the past 5 days (a) geographic regions with high endemic rates (10% of greater) of invasive - Comorbidities penicillin-nonsusceptible S. pneumoniae - Immunocompromised (b) severe infection (c) attendance at daycare (d) age less than or greater than 65 years (e) recurrent hospitalization within 5 days (f) antibiotic use within the last month (g) immunocompromised persons