Exam2studyguide.docx

[Abx Pharmacotherapeutics] - Antibiotics - Cell wall inhibitors (ex. PCN, cephalosporins, carbapenems) - Protein synthesis inhibitors (ex. AGs, tetracyclines, macrolides, linezolid, mupirocin) - Antifolate drugs - Fluoroquinolones - Common Bacterial Infectio...

[Abx Pharmacotherapeutics] - Antibiotics - Cell wall inhibitors (ex. PCN, cephalosporins, carbapenems) - Protein synthesis inhibitors (ex. AGs, tetracyclines, macrolides, linezolid, mupirocin) - Antifolate drugs - Fluoroquinolones - Common Bacterial Infections - Bacterial conjunctivitis - Trachoma - Otitis media/externa - Strep pharyngitis - Peritonsillar abscess - PNA - Cellulitis - Impetigo - RMSF/Lyme disease - Diverticulitis - H.Pylori infection - C.diff - STDs - UTIs - Bacterial conjunctivitis - Inflammation of conjunctiva from infection - Self-limited, will usually resolve in 5-7 days - Presentation: - Conjunctival erythema, eyelid edema, mucopurulent d/c crusting - Trachoma - Highly contagious ocular infection caused by Chlamydia Trachomatis - Presentation: - Roughening of inner surface of eye, corneal breakdown, eye d/c, light sensitivity - Treatments: - Azithromycin single dose - Sulfacetamide ophthalmic solution - Tetracycline ophthalmic solution/ointment - Otitis Externa - Results from combo of heat and retained moisture with desquamation and maceration of epithelium of canal - Etiology: - P. aeruginosa - S. Pneumo - Presentation: - Ear d/c, pain with palpation of tragus/pinna, ear canal edema and discomfort - Treatment: - Topical otic abx +/- topical steroids - Neomycin/polymyxin/hydrocortisone otic suspension \[Cortisporin\] - Ciprofloxacin/dexamethasone otic suspension \[Ciprodex\] - Strep Throat - Pharyngeal infections caused by GAS aka S.pyrogenes - Presentation: - Sore throat, fever, chills, purulent tonsillar exudate, cervical LAD - Treatments: - PCN V - 1G cephalosporin \[cephalexin\] if PCN allergy - Clindamycin if allergic to PCN and cephalosporins 2/2 resistance to macrocodes - Peritonsillar abscess - Aka quinsy, complication of tonsillitis - Consists of collection of pus in peritonsillar space; considered an ENT emergency!! - Etiology: - Oral flora including anaerobes, GAS - Presentation: - Severe u/l sore throat, dysphagia, dysphonia, referred otalgia, "hot potato voice", LAD, trismus - Treatment: - Surgical I&D and Abx - Clindamycin or metronidazole and benzathine PCN G - Impetigo - Superficial skin infection seen in young children - Etiology: - S.aureus - S.pyogenes - Presentation: - Red popular lesions that evolve to pustules, honeycomb-like crusting affecting facial areas - Treatment: - Mupirocin topical \[Bactroban\] - Dicloxacillin or cephalexin if extensive - Cellulitis - Bacterial infection of skin; bacteria enter through cuts, scratches, burns, incisions, catheters, etc - Etiology: - MRSA - MSSA - P.multocida (cat/dog bites) - Eikenella cordoned (human bites) - P. Aeuginosa (penetrating injury) - Presentation: - Localized pain, erythema, swelling, heat - Treatment: - Amoxicillin/Clavulante \[Augmentin\] for animal bites - Dicloxacillin or Oxacillin MSSA - Clindamycin, vancomycin, or linezolid \[Zyvox\] for MRSA - Rocky Mountain Spotted Fever - Tick/mite-born illness - Transmitted by American dog ticks (Dermacentor Variabilis) an Rocky Mountain wood tick (D. andersoni) - Etiology: - R. Rickettsii - Presentation: - Evolving macular rash; rarely CNS involvement, hypovolemia, HoTN, renal failure - Treatment: - Doxycycline - Chloramphenicol if allergic (or pregnant?) - Lyme disease - Spirochetal infection transmitted by ticks (Ixodes scapularis) - Etiology: - Borrelia burgdorferi - Presentation: - ECM (Stage 1), non-specific sx like HA, MSK pain, near deficits (stage 2), arthritis (stage 3) - Treatment: - Doxycycline - Amoxicillin, cefuroxime, or erythromycin are alternative agents - CAP PNA - Infection of lung parenchyma - Etiology: - S.Pneumo - H. influenzae - S. aureus - K. pneumoniae - P. aeruginosa - Atypicals like - M. pneumoniae - C. pnuemoniae - Legionella spp. - Presentation: - Fever, chills, cough, sweats, pleuritic CP, and dyspnea - Treatment - Clarithromycin \[Biaxin\] - Azithromycin \[Zithromax\] - Doxycycline if previously healthy and no abx in past 3 months - Diverticulitis - Digestive disease in which pouches form within the bowel wall - Etiology - Enterobacteriaceae - P. Aeruginosa - Bacteroides spp. - Enterococci - Presentations - LLQ pain, tenderness, fever, elevated WBC count - Treatment: - Ciprofloxacin \[Cipro\] - Plus metronidazole \[Flagyl\] - Alternative agents include TMP/SMX \[Bactrim\] and amoxicillin/clavulanate \[Augmentin\] - C.Diff Colitis - Diarrheal illness - Most commonly acquired in the hospital - All abx has risk of CDI - Etiology - C.diff - Presentation: - Malodorous diarrhea with up to 20 BMs/day - Treatment: - Metronidazole \[Flagyl\] for mild-moderate disease - Vancomycin for severe disease - Urethritis - Commonly caused by N.gonorrhea or C.trachomatis - Presentation: - Mucopurulent urethral d/c - Must treat while symptoms are present - Treatment: - For Gonorrhea single dose of ceftriaxone IM plus azithromycin single dose PO - For Chlamydia azithromycin single dose PO, doxycycline PO x 7 days - Syphilis - Spirochetal infection caused by T.pallidum - Presentation - Painless chancre (1^st^ degree), skin/mucous membrane rash (2^nd^ degree), symptomless (latent), neurologic/cardiovascular sx (3^rd^ degree) - Treatment - Benzathine PCN G single dose - Tetracycline or doxycycline for 2 weeks if PCN allergy - UTIs - Term encompasses cystitis, pyelonephritis, prostatitis, and asymptomatic bacteriuria - Uncomplicated UTI refers to acute disease in non-pregnant outpatient women without abnormalities or instrumentation; complicated UTIs refers to all other UTIs - Eitiology - E.coli (75-90%) - S. saprophyticus - Klebsiella spp. - Proteus spp. - Citrobacter spp - Presentation - Dysuria, freq/urgency (cystitis), fever, LBP, CVAT, N/V (pyelo), dysuria, frequent chills, prostatic/perennial pain (prostatitis) - Uncomplicated cystitis in females: - TMP/SMX \[Bactrim\] if resistance \AST) - Atypical lymphocytosis common 2/2 stimulation from viral antigens - Jaundice, increased bilirubin (conjugated and unconjugated), increased urobilinogenuira - HAV serology - HAV IgM active infection - HAV IgG protective antibody, recovery or previous vaccination - HCV serology - HCV RNA test using PCR is the gold standard - Can detect virus early, even 1-2 weeks after infections - Detects levels of viral RNA in the blood - If decreases, you know the patient is recovering - If it stays the same, most likely chronic HCV - Acute Infections - HBsAG is positive \[HepB surface antigen\] - Total anti-HBc is positive \[hepB total core antigen\] - IgM anti-Hbc is positive \[hepB IgM always positive in acute infections\] - Anti-HBs are negative \[surface antibodies not present\] - Anti-HBv NRTIs - Adefovir \[Hepsera\] - Entecavir \[Baraclude\] - Telbivudine \[Tyzeka\] - Ribavirin \[Virazole\] - Discovered in 1972, guanosine analog used to stop viral RNA synthesis (some effects on DNA viruses too) - Used for severe RSV infections, HCV, hemorrhagic fevers, and some other viral infections - Interacts with some antiretroviral medications (anemia with AZT, mitochondrial toxicity with didanosine) - Contraindicated in pregnancy - Pegylated Interferon - PEG-IFN has 3 different forms - Pegylated interferon-alpha-2a - Pegylated interferon-alpha-2b - Pegylated interferon-beta-1a - Interferons - Proteins released in the body in response to viral infections - Thru complex pathways, elicits an immune response - Pegylated interferons - Given via injection - Used to treat HBV, HCV, and MS - Many side effects ranging from HA, rigors, dizziness, N/V/D, neutropenia, weakness, arthralgia, fever - Warnings for marrow suppression (aplastic anemia), CNS depression, allergic rxn (SJS), hemorrhagic colitis, neuropsychiatric disorders (BBW), pancreatitis, pulmonary effects - New Anti-HCV drugs - Sofosbuvir (Sovaldi) - Sofosbuvir/Ledipasvir (Harvoni) - Ombitasvir/Paritaprevir/Ritonavir + dasabuvir (Viekira Pak) - Sofosbuvir \[Sovaldi\] - Anti-HCV RNA polymerase inhibitor - Approved by FDA in December 2013 - High cure rate, fewer adverse effects, and shorter duration of treatment - Super expensive (\$84 to 168k for course of treatment) - Ledipasvir - Combination with sofosbuvir called Harvoni was approved by FDA in December 2014 - Inhibitor of HCV NSSA protein which is involved in viral replication - Well tolerated with minimal side effects - Also super expensive (\$1,125 per pill so \>\$90k for 12 week course) - Elbasvir + Grazoprevir (Zepatier) - Approved in the US in 2016 - Once a day combo pill used to treat genotypes 1 or 4 in treatment-naïve or treatment-experienced pt - Sometimes used in pts with concomitant HIV, late-stage kidney disease - Hepatitis C Treatment - Drugs that inhibit serine protease and cleavage of HCV polyprotein - Grazoprevir - Paritaprevir - Simeprevir - Drugs that inhibit activator of HCV RNA polymerase - Daclatasvir - Elbasvir - Ledipasvir - Ombitasvir - Velpatasvir - Drugs that inhibit HCV RNA directed RNA polymerase - Dasabuvir - Sofosbuvir - Hepatitis B Treatment - Drugs that inhibit formation of DNA copy of viral RNA - Entecavir - Tenofovir - Others - For RSV and HepC - Drugs that inhibit guanosine triphosphate and nucleic acid synthesis - Ribavirin - For Hep B and C, condylomata acuminata - Drugs that activate JAK-STAT signaling pathway and T-cells - Peginterferon alfa - Interferon alfa - Treating HAV - Maintain appropriate nutrition/hydration - Watch personal hygiene to prevent spread - No antiviral medications indicated because spontaneous resolution in almost all patients - Post-exposure ppx to people within 2 weeks of exposure for people not vaccinated - Hep A vaccine to people between 1-40 years old - Immunoglobulin to people \40 years old - Treating HCV - Treatment with antiviral medications is recommended for all people with proven chronic HV not at high risk of dying from other causes - Initial treatment guideline depends on genotype of HCV identified - Effectiveness - Sofosbuvir \[Sovaldi\] with ribavirin and interferon is 90% effective in those with genotypes 1, 4, 5, or 6 - Sofosbuvir with just ribavirin is 70-95% effective in types 2 and 3 but has a ton of adverse reactions - Treatments with ledipasvir (combo with sofosbuvir is Harvoni) for genotype 1 are 93-99% effective but super expensive - Ribavirin and peg interferon is 60-90% effective for type 6 - First line agents for treating HBV - Entecavir \[Baraclude\] - Tenofovir \[Viread\] - Peg interferon - Other Drugs used to treat HBV - Lamivudine \[3TC\] - Adefovir \[Hepsera\] - Telbivudine \[Tyzeka\] [Antifungal Drugs] - Classifications - Polyene abx (ex. Amphotericin B) - Azole derivatives (ex. Clotrimazole, fluconazole aka Diflucan) - Allylamine drugs (ex. Terbinafine aka Lamisil) - Echinocandin drugs (ex. Caspofungin) - Other antifungal agents - Fungal Infections are divided into 3 main groups - 1\. Systemic mycoses - Soft-tissue infections - UTIs - PNA - Meningitis - Septicemia - 2\. Subcutaneous mycoses - Sporotrichosis - 3\. Superficial mycoses - Infections of nails, skin, and mucous membranes caused by dermatophytes or yeasts - Superficial dermatophyte infections - Causative agents - Epidermophyton - Microsporum - Trichophyton spp. - Many different terms are used to describe infection - Typically manifest as rash with pruritus and erythema - Ringworm presents as annular, scaly rash with clear center - Terms for dermatophyte infections - Onychomycosis, tinea unguium dermatophyte infection of nails - Tinea pedis athlete's foot - Tinea corporis ringworm of the body - Tinea cruris jock itch - Tinea capitis - Tinea barbae - Seborrheic dermatitis - Superficial yeast infections - Causative agents are Candida spp. Usually C. albicans - Present as oral candidiasis (thrush), vulvovaginal candidiasis, or candidal infections of axilla, groin, and gluteal folds (diaper rash) - Less common causes are M. furor and M. ovalis - M. furfur causes tinea versicolor (also called pityriasis versicolor) - Both yeasts cause seborrheic dermatitis - Subcutaneous mycoses - Often caused by puncture wounds contaminated with soil fungi - Examples include chromomycosis, pseudallescheriasis, and sporotrichosis - Systemic mycosis - Chronic and indolent - Ex. Balstomycosis, coccidiodomycosis and histoplasmosis - Invasive and life-threatening - Ex. Aspergillosis, candididasis, cryptococcosis and mucormycosis - Blastomycosis - Fungal infection of humans and other animals (dogs/cats) caused by Blastomyces dermatitidis - Endemic to North America - Clinical sx similar to histoplasmosis - Flu-like illness, acute illness resembling bacterial PNA, chronic illness mimicking TB/lung cancer, fast progressive disease like ARDS, skin lesion, bony lytic lesions - Coccidioidomycosis - Aka valley fever, California fever and San Joaquin valley fever - Fungal disease caused by Coccidioides immitis or Coccidioides posadasii - Endemic in certain parts of AZ, CA, NV, NM, TX, UT, and norther Mexico - 60% asymptomatic, 40% have varied symptoms - Classic triad "desert rheumatism" of fever, joint pain, erythema nodosum - Histoplasmosis - Aka "cave disease", "splunker's lung", and "ohio valley disease" - Fungal infection caused by histoplasma capsulatum - Found in soil, often associated with decaying bat guano or bird droppings - Primarily affects lungs, called disseminated when other organs affected - Can be fatal if left untreated - Aspergillosis - Wide variety of diesaes caused by fungi from genus aspergillus - Majority of cases in people with underlying TB or COPD but with otherwise healthy immune systems - Most commonly occurs in form of chronic pulmonary aspergillosis, aspergilloma, or allergic bronchopulmonary aspergillosis - Cryptococcosis - Potentially fatal fungal disease caused by cryptococcus neoformans and cryptococcus gattii - Acquired by inhalation of infectious material form environment, found worldwide in soil - Defining opportunistic infection for AIDS (but also seen with lymphomas, sarcoid, liver cirrhosis, and pt on long-term steroid therapy) - Mucormycosis - Any fungal infection caused by fungi in the order or Mucorales - Characterized by hyphae growing in and around blood vessels, potentially life-threatening in diabetic or severely immunocompromised - Treating fungal infections - Amphotericin B is typically used to treat severe mycoses - Azoles are used for less severe infections - Newer agents (ex. Voriconazole and caspofungin) can be used to treat invasive candida and aspergillus infections - Flucytosine is usually given with amphotericin B to treat systemic cryptoccus or candida infections - Polyene Abx - Amphotericin B \[Amphotec\] - Natamycin - Nystatin - Polyene Abx Kinetics - Amphotericin B is not absorbed from the gut - Available for topical and parenteral use - Dosage and route of parenteral treatment depends on site and severity of infection - Low concentration in CSF because it doesn't penetrated BBB well - Metabolized by liver, excreted in urine - Biphasic ½ life, initial ½ life of 24 hours, terminal ½ life of 15 days - Polyene Abx Adverse effects - Causes some degree of renal toxicity in 80% of people who receive it - Toxicity reduces GFR and contributes to hypo-K and hypo-Mg, accumulation of creatinine and urea in the blood (azotemia) - Lipid formulations cause less renal toxicity and should be used in people with renal impairment and those who are intolerant of traditional formulation - Nystatin - Active against candida spp. - Topical formulations including cream, ointment, and powders for mucocutaneous candidiasis - PO tablets and suspensions for intestinal candidiasis - Vaginal tablets for vulvovaginal candidiasis - Azole derivatives - Most are well absorbed from the gut with exception of posaconazole - Absorption of ketoconazole, itraconazole, and posaconazole require gastric acid, so acid-reducing drugs should not be given concurrently - Widely distributed to tissues and body fluids, but only fluconazole achieves significant concentration in CSF - Undergo hepatic biotrans, compounds are excreted in urine and feces - Diazole compounds - Clotrimazole \[Lotrimin\] topical - Econazole topical - Ketoconazole \[Nizoral\] PO/topical; 8hr ½ life; biliary/fecal elim. - Triazole Compounds - Fluconazole \[Diflucan\] PO/IV; 35hr ½ life; renal elim. - Itraconazole \[Sporanox\] PO; 60hr ½ life; renal/biliary/fecal elim. - Posaconazole \[Noxafil\] PO; 28hr ½ life; fecal elim. - Voriconazole \[Vfend\] PO/IV; dose dependent ½ life; renal elim. - Adverse effects - Usually well tolerated but systemic administration can cause skin rash, elevated LFTs, hepatic injury, hematopoietic toxicity, or GI distress (N/V/D) - Inhibit CYP3A4 so concurrent use with other drugs can cause interactions - Chronic use of fluconazole in high doses showed increased risk of birth defects - Itraconazole and fluconazole - Particularly useful in the treatment of blastomycosis and histoplasmosis and is widely used to treat onychomycosis - Fluconazole penetrates CSF, used to prevent cryptococcal meningitis in patients with AIDS, also used for follow up after pt with cryptococcal meningitis finish amphotericin B - Also used to treat mucocutaneous and disseminated candidiasis, also candidal UTIs and vaginal candidiasis - Ketoconazole \[Nizoral\] - Available in PO and topical formulations including shampoo - PO formulation is less widely used than itraconazole or fluconazole because it has a greater potential for drug interactions - Doesn't penetrate CSF and has lower activity against other fungi - Topical formations are useful for treating seborrheic dermatitis and tinea infections - Caspofungin \[Cancidas\] - First echinocandin drug to be approved in the US - Excellent activity against Candida spp., good coverage of aspergillus spp. - Covers candida strains that are resistant to azole compounds - Very effective in treating esophageal, oropharyngeal, and invasive candidiasis - Other antifungals - Flucytosine - Griseofulvin - Ciclopirox - Tolnaftate - Griseofulvin - Fungistatic antibiotic derived from penicillium Griseofulvum - Active against many dermatophytes but not against candida or other fungi - Standard treatment for tinea capitis - Kinetics - Lipophilic drug, not very soluble in water so absorption is increased when taken with a high-fat meal - Drug gets deposited in keratin precursor cells of the skin, hair, and nails - Infected cells are exfoliated and replaced by non-infected tissue - Metabolized in the liver, excreted in urine [Anti Viral] - Antibacterial and antifungal drugs have little to no effect on viral infections - Compounds have been developed to treat some viral infections (ex. HIV, influenza, and hepatitis) - Work in a variety of ways (ex. Prevent replication of viral nucleic acid, inhibit entry, uncoating, or release of virus) - Influenza - One of the most common causes of infectious disease related deaths - Vaccines are primary means of prevention - Neuraminidase inhibitors are useful for ppx. During outbreaks, can shorten duration of illness in infected persons and prevent complications - Neuraminidase Inhibitors - These drugs inhibit the enzyme neuraminidase in influenza A and B viruses - Neuraminidase Catalyzes reactions that promote viral spreading and infection - Enables release of virons from surface of infected cells - Inactivates RT mucous that would prevent spreading of the virons - Drugs reduce complications including OM and PNA, drug therapy should be started as early as possible for any patient with confirmed or suspected influenza who is hospitalized, has severe illness, or is at higher risk of complications - Most beneficial in reducing symptom severity and duration of illness if given \