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Infections Flashcards

1
Q

Before presiding an antibacterial what 3 things should be considered?

A
  1. Patient
  2. Causative organism
  3. Risk of bacterial resistance
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2
Q

What Patient factor should be considered?

A
  1. Allergy
  2. Renal impairment
  3. Hepatic impairment
  4. Immunocompromised
  5. Ability to tolerate the drug by mouth
  6. Severity of illness
  7. Risk of complications
  8. Ethnic origin
  9. Age
  10. Other medication
  11. Pregnant/breastfeeding or taking oral contraceptives
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3
Q

After how long do you review IV antibacterial therapy

A

48 hours. Consider stepping down to oral antibacterial therapy

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4
Q

What do B-road spec antibiotics cause. In terms of adverse reactions?

A

B-road spectrum antibiotics are most likely to be associated with adverse reactions. Such as:
- fungal infection
- antibiotic associated colitis
- vaginitis
- pruritis ani

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5
Q

What is the early management of sepsis?

A

Anyone identified as being at high risk of severe illness or death due to sepsis need to be given the following:-

  1. Broad spec antibacterial @ max dose (within 1 hour)
  2. Microbiological samples need to be taken without any delay prior to antibiotics, then reassess and change
  3. Identify the source of the infection
  4. Iv fluids
  5. Inotropes
  6. Vasopressors
  7. Oxygen
  8. Check patient parameters: - lactate concentrate - blood pressure.

Monitor no less than every 30 minutes

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6
Q

Antibiotic option - MRSA suspected

A

Vancomycin

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7
Q

Antibiotic option - anaerobic infection

A

Metronidazole

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8
Q

Antibiotic option - streptococcal infection

A
  • phenoxymethylpenicillin (Pen V)
  • Azithromycin/clarithromycin/erythromycin (macrolid)
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9
Q

Antibiotic option - staphylococci

A

Flucloxacillin

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10
Q

Diabetic foot infections

A

Mild
- flucloxacillin
- pen allergy - clarithromycin, doxycycline
- pregnancy - erythromycin

Moderate - severe
Dual antibiotics - oral or IV
- Flucloxacillin +- IV gentamicin, metronidazole
- co-amox +- Iv Gentamicin
- IV ceftriaxone + metronidazole

For penicillin allergy
- co-trimoxazole +/- iv gentamicin
And/or metronidazole.

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11
Q

Otitis externa treatment
- causative agent

A

Usually caused by pseudomonas aeruginosa, staphylococcus aureus.

Pseudomonas - ciprofloxacin (aminoglycoside)

Staphylococcus - Flucloxacillin
Penicillin allergy - clarithromycin or azithromycin
Pregnancy - erythromycin

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12
Q

Which drugs are safe in pregnancy

A
  • Penicillin
  • Macrolid - erythromycin
  • Most cephalosporins not known to be harmful (some are avoid)
  • Gluycopeptide (teicoplanin/vancomycin’s) - benefits > risks
  • clindamycin - not known to be harmful in second and third trimester.

AVOID
1. Aminoglycosides - risk of auditory and vestibular nerve damage in infants when given in 2nd or 3rd trimester
2. Quinolones
3. Co-trimoxazole - trimethoprim is folate antagonist. Avoid in 1st and 3rd trimester (neonatal haemolysis and methaemaglobinaemia).
4. Tetracyclines
5. Chloramphenicol
6. Tetracycline

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13
Q

Treatment of otitis media

A

Commonly seen in children, usually caused by virus, self limiting.
Both virus and bacteria can co-exist

Treatment
1st line. Amoxicillin
2nd line. Co-amoxiclav (worsening symptoms despite 2-3 days of antibacterial treatment)

Penicillin allergy
1st line. Clairthromycin or erythromycin
2nd line. Consult local microbiologist.

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14
Q

Eye infection - conjunctivitis

A
  • chloramphenicol
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15
Q

Treatment in gastrointestinal infections
- gastroenteritis
- campylobacter enteritis
- diverticulitis
- salmonella
- shigellosis
- typhoid fever
- c.diff
- Billary tract infection
- peritonitis
- dialysis associated peritonitis

A

Gastroenteritis - self limiting

Campylobacter enteritis -
macrolid or ciprofloxacin

Diverticulitis
UNCOMPLICATED
- co-amoxiclav
-cefalexin with metronidazole
- trimethoprim with metronidazole
- ciprofloxacin with metronidazole
COMPLICATED - IV
- Co-amoxiclav with metronidazole
- cefuroxime with metronidazole
- amoxicillin with gentamicin + metronidazole
- ciprofloxacin with metronidazole

Salmonella
- ciprofloxacin
- cefotaxime

Shigellosis
- ciprofloxacin
- azithromycin
- amoxicillin if sensitive

Typhoid fever
- cefotaxime or ceftriaxone
- azithromycin
- ciprofloxacin

C-diff
- Vancomycin
- fidaxomycin
Life threatening c-diff - vancomycin + IV Metronidazole.

Biliary tract infection
- ciprofloxacin
- gentamicin
- cephalosporin

Peritonitis
- cephalosporin + metronidazole
- gentamicin + metronidazole
- gentamicin + clindamycin
- piperacillin with tazobactam

Peritoneal dialysis associated peritonitis
- vancomycin + ceftazidine
Added to the dialysis fluid
- vancomycin (added to fluid) + ciprofloxacin by mouth

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16
Q

Treatment of gastroenteritis

A

Self limiting - antibiotics not indicated

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17
Q

Treatment of campylobacter enteritis

A

Self limiting
Treat if immunocompromised or severe infection

  • clarithromycin (azithromycin or erythromycin)
  • ciprofloxacin
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18
Q

Treatment of acute diverticulitis

A

Acute diverticulitis + systematically well. - watchful waiting and no prescribing strategy.

Acute diverticulitis + systemically unwell/immunocompromised or have significant co-morbidities -
Antibacterial prescribing strategy should be offered - oral antibacterial

Suspected or confirmed uncomplicated - ORAL
1st line - co-amoxiclav
2nd line - cefalexin + metronidazole
- trimethoprim + metronidazole
- ciprofloxacin + metronidazole

Suspected or confirmed complicated - IV
1st line - co-amoxiclav or cefuroxime + metronidazole
- amoxicillin + gentamicin + metronidazole
Penicillin allergy
Ciprofloxacin + metronidazole

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19
Q

Treatment for salmonella

A

Only treat severe or invasive infection
Or if there is a high risk of invasive infection because the patient is immunocompromised, has haemoglobinopathy or the child is under 6 months.

Treatment - ciprofloxacin
- Cefotaxime

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20
Q

Treatment of shigellosis

A

Antibacterial not indicated in mild cases
If given
- ciprofloxacin
- azithromycin
- amoxicillin if sensitive

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21
Q

Treatment of typhoid fever

A

Sensitivity needs testing
- cefotaxime or ceftriaxone
- azithromycin
- ciprofloxacin

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22
Q

Treatment of c.diff infection
What happens?
Complications?
Why?
Risk factors?
Treatment?

A

C.diff occurs when the normal guy bacteria is killed. The c.diff bacteria produces toxins which damages the lining of the gut causing DIARRHOEA.

Infection can be mild to life-threatening

Complications include - pseudomembranous colitis, toxic megacolon, colonic perforation, sepsis and death.

Most common in pts who have taken broad-spec antibiotics, multiple or for long periods.
- clidamycin
- cephalosporin
- fluroquinolones
- B-road spectrum penicillin

Risk factors
- acid suppressing drugs
- age over 65
- prolonged hospitalisation
- underlying co-morbidities
- being around those with c.diff
- previous history of c.diff

Treatment
1. Vancomycin
2. Fidaxomycin
Life-threatening - oral vancomycin + IV metronidazole.

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23
Q

Treatment of bacterial vaginosis

A
  • oral metronidazole
    Duration of treatment is 5-7 days
  • topical metronidazole for 5 days
  • topical clindamycin for 7 days
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24
Q

Treatment of Uncomplicated genital chlamydia infection

A

Contact tracing recommended
- 1st line - doxycycline
- erythromycin

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25
Q

Treatment of Gonorrhoea - uncomplicated

A

Obtain cultures
Contact tracing

If less than 14 days since exposure - treat
If more than 14 days since exposure - test and if positive treat

Sex needs to be avoided for 7 days after pts and partners have completed treatment.

1st line: ceftriaxone
- ciprofloxacin if sensitive
- gentamicin plus azithromycin if allergy or contra-indicated.
- cefixime plus azithromycin
- azithromycin if all unable to take

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26
Q

Treatment of pelvic inflammatory disease

A

Contact tracing recommended
- doxycycline + metronidazole + single dose of i/m ceftriaxone
- ofloxacin and metronidazole

Duration of treatment is 14 days

Severely Ill patients - doxycycline + IV Metronidazole + IV ceftriaxone then switch to oral doxycycline + metronidazole

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27
Q

Treatment if syphilis

A

Contact tracing recommended

  • benzathine benzylpenicillin
    Single dose normally
    Pregnancy second dose after a week

Alternatives
- doxycycline
- erythromycin
Duration of treatment is 14 days

If late syphillis after two years
Benzathine benzylpenicillin once weekly for 2 weeks
Doxycycline (alternative) duration is 28 days

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28
Q

Treatment of sinusitis

A

Not to generally treat
Delayed prescription for pts systemically unwell and symptoms present for around 10 days.

1st line - (non- life threatening) phenoxymethylpenicillin
2nd line - worsening symptoms or systemically very unwell - co-amoxiclav

PENICILLIN ALLERGY - clarithromycin or doxycycline
PREGNANCY- erythromycin

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29
Q

Treating oral bacterial infection

A

Dentoalveolar abscess - phenoxymethylpenicillin
- amoxicillin is better absorbed
- co-amoxiclav is active against beta lactamase producing bacteria or if severe dental infection
- metronidazole - anaerobic infections, penicillin allergies, resistance to penicillin.
- cefalexin or cefradine (cephalosporin) used in oral infections. Others offer little advantage.
- doxycycline (effective against oral anaerobes) longer half life than oxytetracycline or tetracycline
- macrolids - useful in penicillin allergies or resistance to penicillin

Clindamycin should not be used routinely

If the oral infection fails to respond to antibiotics within 48 hours, the antibacterial should be changed.

Failure to respond may also be due to incorrect diagnosis, lack of other measures like drainage, poor host resistance, or poor patient compliance.

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30
Q

Treatment for bronchiectasis (non CF) Acute

A
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31
Q

Treatment for COPD

A
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32
Q

Treating an acute cough

A
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33
Q

Treating community acquired pneumonia

A
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34
Q

Treating hospital acquired pneumonia

A
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35
Q

Treatment for impetigo

A

Depends on the type and severity
Non bullous impetigo - most common
Bullous impetigo - not as common

Localised non bullous -
1. topical hydrogen peroxide 1% cream
2. Fusidic acid or mupirocin
3. Flucloxacillin or macrolid

Wide-spread non bullous, systemically well and no high risks of complications
Topical or oral antibacterial
1. Fusidic acid or mupirocin
2. flucloxacillin or macrolid

Non-bullous, unwell or high risk of complication / bullous impetigo
ORAL antibacterial
1. Flucloxacillin or macrolid

NOT TO GIVE BOTH ORAL AND TOPICAL TOGETHER.

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36
Q

Treatment for cellulitis

A
  1. Swab for microbiological testing
  2. Drawing around and monitor can be considered
  3. Manage any underlying conditions
    - diabetes
    - venous insufficiency
    - eczema
    - oedema
  4. Refer patients to hospital if signs and symptoms suggest more serious illness.
    - orbital cellulitis
    - osteomyelitis
    - septic arthiritis
    - necrotising fasciitis
    - sepsis

TREATMENT
1. Oral or Iv - flucloxacillin
2. Clarithromycin/erythromycin/doxycycline

Infection near the eye or nose
3. Co-amoxiclav
4. Clarithromycin + metronidazole

Severe infections
5. Co-amoxiclav
6. Clindamycin
7. Iv cefuroxime
8. IV ceftriaxone

MRSA
+ vancomycin / teicoplanin / Linezolid

If atleast 2 separate episodes in 12 months. Consider prophylactic antibiotic.
Review every 6 months

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37
Q

Treating leg ulcers

A

Takes more than 4-6 weeks to heal.

Signs and symptoms
- redness
- swelling spreading beyond the ulcer
- localised warmth
- increased pain
- fever

Step 1
Manage any underlying causes
- venous insufficiency
- oedema

Step 2
Offer treatment to those with signs and symptoms of infection

Step 3
Take a sample if the symptoms are worsening despite treatment or have not improved.
Review the choice of treatment

Treatment options
Not severely unwell
1st line - flucloxacillin
Alternative - erythromycin/clarithromycin or doxycycline
2nd line - co-amoxiclav
Alternative- co-trimoxazole in pen allergies

Severely unwell
1st line -
- IV flucloxacillin +/- metronidazole or gentamicin
- iv co-trimoxazole +/- IV gentamicin or metronidazole (penicillin allergies)
2nd line
- IV pipercillin with tazobactam
- IV ceftriaxone +/- metronidazole

MRSA
+ IV vancomycin/teicoplanin/Linezolid

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38
Q

Treating insect bites and stings

A

DOES NOT NEED ANTIBIOTICS.

Redness, pain and swelling is often caused by inflammatory or allergic reactions.

Symptoms rarely last longer than 10 days

Tick bite = Lyme disease

Outside of UK - Treat

Signs and symptoms of infection
- TREAT AS CELLULITIS
1. Flucloxacillin
2. Clarithromycin/erythro/doxycycline

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39
Q

Treatment for human and animal bites

A

Assess for risk of tetanus, rabies or blood borne viral infection.

  1. Clean wound by irrigation and debrided as necessary
  2. Refer patient to hospital if signs of more serious infection or condition.
  3. Take swab
  4. Offer prophylaxis antibiotic

For cats, human and dogs and other traditional pets.

TREATMENT OPTIONS
1. Co-amoxiclav
2. Doxycycline with metronidazole
IV
3. Co-amoxiclav
4. Cefuroxime with metronidazole
5. Ceftriaxone with metronidazole

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40
Q

Drugs - Aminoglycosides

A
  • Not absorbed from the gut
  • Given by injection for systemic infections
  • when used for blind therapy, usually given with metronidazole or a penicillin (or both)
  • loading and maintenance dose is calculated based on pts weight and renal function.
  • adjustments of doses are made based on serum gentamicin concentration
  • high doses are occasionally needed for serious infection especially in neonates, CF, or immunocompromised.
  • treatment should usually not be longer than 7 days
  • neomycin is too toxic for parenteral administration.
  • once daily dozing is more convenient however should be avoided in 4 people
    1. Endocarditis caused by gram positive bacteria
    2. HÁČEK endocarditis
    3. Burns of more than 20% of total body SA
    4. If the creatinine clearance is less than 20ml/minutes.

MHRA - increased risk of deafness in patients with mitochondrial mutations

  • to minimise the risks of adverse effects continuous monitoring of renal and auditory function as well as hepatic and laboratory parameters

Side-effects
1. Ototoxicity
2. Nephrotoxicity

Pregnancy
- risk of auditory and vestibular nerve damage in infants when ahminoglycosides are used in the second and third trimester.

Monitoring requirements
- after 3/4 doses in multiple daily dose regimen and after a dose change.
- sample taken after an hour of administration.
- doses adjusted based on peak and trough concentration.

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41
Q

Gentamicin

A
  • to avoid excessive dosage in obese patients use ideal body weight for height to calculate parenteral dose
  • MHRA: histamine- related adverse drug reactions with some batches.
  • no longer than 7 days course

Must determine serum conc in:-
1. Elderly
2. Obese
3. High doses
4. Renal impairment
5. Cystic fibrosis

Monitoring - multiple daily dosing
- one hour peak conc 5-10mg/liter
- pre dose trough conc < 2mg/liter
Endocarditis = 2-5mg/l and < 1mg/l

Side effects
1. Ototoxicity
2. Nephrotoxicity

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42
Q

Drugs - carbapenams

A
  • beta lactam antibacterials
  • not active against MRSA
  • used in severe and complicated infections
  • IMIPENEM partially inactivated in the kidney by enzymatic activity and is given with CILASTATIN an enzyme inhibitor which blocks the renal metabolism. The other carbipenams are fine
  • MEROPENEM has less seizure inducing potential and can be used to treat CNS infections

AVOID if immediate hypersensitivity reactions to beta lactam antibacterials
AVOID in PREGNANCY

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43
Q

Drugs - Cephalosporins

A
  • Broad spectrum
  • excretion is principally renal
  • penetrate the cerebrospinal fluid poorly unless the meningis is inflamed.
  • cross reactivity between penicillin and 1st and 2nd generation cephalosporin - upto 10% and 2-3% with 3rd generation.
  • MoA :- attach to the penicillin binding protein to interrupt cell wall synthesis, leading to bacterial cell lysis and death.
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44
Q

The generations of cephalosporin.

A

Check image in favourites

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45
Q

Cefazolin

A
  • 1st generation
  • avoid in pregnancy
  • blood disorders - including leukopenia, granulocytopenia, thrombocytopenia, lymphopenia, eosinophilia, and increased leucocytes are reversible.
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46
Q

Cefaclor

A
  • 2nd generation
  • associated with protracted skin reactions especially in children.
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47
Q

Ceftriaxone

A
  • third generation
  • precipitates of calcium ceftriaxone can occur in the gall bladder and urine (in the young dehydrated or those immobilised) consider discontinuing if symptomatic.
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48
Q

Teicoplanin

A
  • glycopeptide antibiotic
  • similar to vancomycin but has significant longer duration of action which means it can be given as once daily dose after the loading dose.
  • active against aerobic and anaerobic gram positive bacteria including multi-resistance staph
  • should not be given by mouth for systemic infection because it’s not absorbed.
  • associated with a lower incidence of nephrotoxicity than vancomycin
  • pregnancy - only if benefits > risks
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49
Q

Vancomycin

A
  • narrow therapeutic index
  • active against aerobic and anaerobic gram positive bacteria including multi-resistant staph
  • penetration into the cerebrospinal fluid is poor
  • should not be given by mouth for systemic infections because it’s not absorbed significantly.

Side effects
- high incidence of nephrotoxicity
- ototoxic - discontinue if tinnitus occurs
- red-man syndrome - flushing of the upper body due to rapid infusion and can be associated with hypotension and bronchospasms
- blood dyscrasias
- skin disorders - Steven Johnson syndrome. Toxic epidermal necrolysis. Rash. Itching.
- thrombophlebitis - pain and inflammation at the injection site.

Pregnancy.
- pregnancy if benefits > risks (monitor plasma conc to reduce fetal toxicity)

Monitoring
- initial dose based on body weight and dose adjustment based on serum vancomycin concentration.
- serum vancomycin measurement is taken in the second day of treatment before the next dose if renal function is normal, earlier if there is impairment.
- pre-dose (trough) = 10-20mg/L
- RENAL FUNCTION
- AUDITORY AND VESTIBULAR FUNCTION.
- BLOOD COUNTS, hepatic and urinalysis

Interaction
- avoid drugs that cause ototoxicity - loop diuretics.

Avoid concurrent or sequential use of other ototoxic drugs.

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50
Q

Clindamycin

A
  • used in
    1. Steptococci
    2. Penicillin resistant staph
    3. Anaerobes
  • well concentrated in the bone and excreted in bile and urine
  • contra-indicated in diarrhoea
    (Discontinue)
  • associated with an increase risk of c.diff.
    Discontinue if suspected or confirmed.
  • pregnancy - not known to be harmful in 2nd and 3rd trimester
  • monitor liver and renal function if treatment longer than 10 days
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51
Q

Macrolids

A
  • alternative in penicillin allergy
  • take with or after food

Side-effects
1. QT interval prolongation
2. Hepatotoxicity
3. Ototoxic at high doses.

Interactions - enzyme inhibitor
- warfarin
- statins

  • azithro - once daily dosing

clairthromycin
- BD, dose based on weight
- Avoid in pregnancy (especially 1st trimester)

Erythromycin
- QDS dosing
- MHRA - drug interaction with rivaroxiban
(Increased risk of bleeding)
- MHRA - known risk of infantile hypertrophic pyloric stenosis (found the risk to be the highest in the 1st 14 days after birth) - parents should be advised to seek medical attention if vomiting or irritable with feeding occurs in infants during treatment.

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52
Q

Erythromycin

A
  • QDS dosing
  • MHRA - drug interaction with rivaroxiban
    (Increased risk of bleeding)
  • MHRA - known risk of infantile hypertrophic pyloric stenosis (found the risk to be the highest in the 1st 14 days after birth) - parents should be advised to seek medical attention if vomiting or irritable with feeding occurs in infants during treatment.
  • can use in pregnancy
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53
Q

Metronidazole

A
  • highest activity against anaerobic bacteria and protozoa
  • contra-indicated in infants less than 3 months.
  • manufactures advice is avoid high doses in pregnancy - AVOID at term
  • Take with or after food
  • colours the unite yellow/brown
  • clinical and lab monitoring of treatment exceeds longer than 10 days
54
Q

Penicillins
1. How it works
2. Side-effects

  1. Specifics about
    - benzylpenicillin
    - phenoxymethylpenicillin
    - flucloxacillin
    - ampicillin
    - amoxicillin
    - co-amoxiclav
A

how it works?
- Interferes with the bacterial cell wall synthesis. They diffuse well into the body tissue and fluid.
- penetration into the cerebrospinal fluid is poor unless the meninges is inflamed.

Side-effects
- diarrhoea (can cause antibiotic associated colitis)
- allergies to penicillin occurs in 1-10% of exposed individuals

Specifics
- benzylpenicillin is inactivated by gastric acid and absorption from the GI-tract is low; therefore given by injection.
- phenoxymethylpenicillin - less active than benP. - gastric acid stable - not used for serious infections because absorption is unpredictable.
- flucloxacillin - effective against penicillin-resistant staph infections. - acid stable and we’ll absorbed - given by both mouth and injection.
- Ampicillin - given by mouth but less than half the dose is absorbed and further decreased by the presence of food - maculopapular rashes can occur but not always related to true penicillin allergy
- amoxicillin - better absorbed than penicillin when given by mouth. So there’s high tissue and plasma concentration - not affected by the food in the stomach
- co-amoxiclav - amoxicillin with clavulanic acid (beta lactamase inhibitor)

55
Q

Co-amoxiclav

A
  • hepatic events have been reported mostly in males and elderly. May be associated with prolonged use. Signs and symptoms occur during treatment or shortly after. But can sometimes occur several weeks after discontinuation.
  • pregnancy - avoid in preterm prelabour rupture of the membrane. Possible increased risk of necrotising entercolitis in neonate.
56
Q

Flucloxacillin

A
  • hepatic disorders
    Cholestatic jaundice and hepatitis may occur very rarely upto 2 months, even after stopped.
    Administration for more than 2 weeks and increasing age are risk factors.
  • potentially life-threatening hypokaleamia can occur. Can be resistant to potassium supplementation. Regular monitoring is recommended in pts on high doses.
  • to take on an empty stomach.
57
Q

Quinolones

A
  • induces convulsions in patients with or without history of convulsions.
  • NSAIDS + quinolones also induces convulsions
  • tendon damage including rupture - within 48 hours of starting treatment and also several months after stopping.
  • increased risk of tendon damage if quinolones + corticosteroids
  • if tendinitis is suspected = discontinue.
  • increased risk of aortic aneurysm and dissection. - stop taking if symptoms develop (onset of severe abdominal pain, chest pain or back pain).
  • irreversible and long lasting side-effects - affecting MSK and nervous system.
  • small risk of heart valve regurgitation - to seek immediate medical attention if symptoms develop (shortness of breath especially when lying flat, swelling of ankles, feet or abdomen, or new onset heart palpitations)
  • cautions
    1. Qt prolongation
    2. Seizures
    3. Diabetes (may affect blood glucose)
    4. Exposure to excessive sunlight and UV radiation during and 48 hours after.
  • quinolones causes atrophy in weight bearing joints. Not recommended in growing children and adolescents.
  • avoid in pregnancy
58
Q

Levofloxacin

A
  • systemic side effects can occur with neubulised levofloxacin
  • BRONCHOSPASMS - if acute symptomatic brochospasms occour after receiving nebulised levofloxacin, patients may benefit from the use of short acting inhaled bronchodilator atleast 15 minutes to 4 hours prior to the doses.
59
Q

Co-trimoxazole

A
  • discontinue if blood disorders (including leucopenia, thrombocytopenia, megaloblastic, anemia, eosinophilia) or rash (Steven Johnson syndrome, or toxic epidermal necrolysis) develop.
  • teratogenic in pregnancy - 1st and 3rd trimester.
  • monitor - potassium and sodium
    Blood count
60
Q

Tetracyclines

A
  • B-road spectrum antibiotics but their use has now decreased due to increasing bacterial resistance.
  • have a role in the management of MRSA
  • little to choose between the different ones
  • minocycline has a broader spectrum. But no longer recommended because of the side effects (dizziness, vertigo). Also has a greater risk of lupus-erythematosus- like syndrome. And can also cause irreversible pigmentation
  • headaches and visual disturbances with tetracycline can indicate benign intracranial hypertension (discontinue if raised intracranial pressure develops)
  • AVOID in pregnancy - 1st trimester - effects on skeletal development and 2nd/3rd trimester - discolouration of the child’s teeth.
  • maternal hepatotoxicity has also been reported with high doses.
  • AVOID in breastfeeding. - teeth discolouration.
61
Q

Doxycycline (5)

A
  • avoid in pregnancy
    Can be used for malaria if no suitable alternatives. And if the treatment can be completed before 15 weeks gestation.
  • to take with plenty of fluid and sitting upright
  • photosensitivity
  • not to take indigestion remedies, zinc or iron
  • can have MILK
62
Q

Lymecycline (3)

A
  • contra-indicated in children under 8 years
  • avoid with indigestion remedies, iron and zinc
  • can have MILK
63
Q

Minocycline (5)

A
  • contraindicated in children under 12 years
  • if prescribed for longer than 6 months, monitor for hepatotoxicity, pigmentation, systemic lupus erythematosus. Discontinue if they develop.
  • swallow whole with plenty of fluid and sitting upright
  • not to take indigestion remedies, zinc and iron.
  • can have MILK.
64
Q

Oxytetracycline (3)

A
  • contraindicated in under 12 years
  • can NOT take with MILK , indigestion remedies, zinc and iron.
  • WITHOUT FOOD.
65
Q

Tetracycline (4)

A
  • contraindicated in under 12 years
  • swallow whole with plenty of fluid and sitting upright or standing.
  • NOT to take with MILK, indigestion remedies, zinc or iron
  • WITHOUT FOOD
66
Q

Chloramphenicol (2)

A
  • potent B-road spectrum antibiotic
  • side effect - serious haematological side effect when given systemically. Reserve for life-threatening infections
  • AVOID in pregnancy - grey baby syndrome when given in third trimester.
67
Q

Fusidic acid (3)

A
  • narrow spectrum antibiotic
  • with topical use - less than 10 days treatment to avoid development of resistance.
  • side-effect - elevated liver enzymes, hyperbilirubinaemia and jaundice can occur with systemic use. Reversible on withdrawl.
  • pregnancy not known to be harmful
68
Q

Linezolid (3)

A

reversible MAOI

  • optic neuropathy
    Severe, can occur rarely if used for longer than 28 days. Patients to report visual symptoms (blurred vision, visual field defects, changes in visual acuity and colour vision)
  • blood disorders
    Haemotopoietic disorders (thrombocytopenia, anemia, leucopenia) have been reported. Blood counts weekly.
  • Interactions
    hypertensive crisis. SSRI, MAOi, sympathomimetics, opioids, 5HT1 agonists, dopaminergics.
    avoid tyramine rich foods
  • caution - close observation and blood pressure monitoring possible.
    Linezolid needs to be avoided in
    1. Acute confusional states
    2. Bipolar depression
    3. Carcinoid tumour
    4. Phaechromocytoma
    5. Schizophrenia
    6. Thyrotoxicosis
    7. Uncontrolled hypertension
69
Q

Trimethoprim (1)

A
  • contra-indicated in blood dyscrasias
  • Blood disorders - patients need to be told how to recognise signs (fever, sore throat, rash, mouth ulcers, purpura, bruising or bleeding develops)
  • teratogenic in pregnancy - AVOID
  • monitoring
    1. FBC
    2. Serum electrolyte (hyperkalaemia)
    3. Renal function
    4. Plasma trimethoprim concentration with long-term use.
70
Q

Signs and symptoms of an infection

A
  • fever or malaise
  • aches and pain
  • pus, swelling or inflammation
  • drowsiness in children
  • confusion in elderly
  • worsening of renal function
71
Q

Clinical markers of infection

A
  • low Bp
  • raised blood glucose
  • high ESR
  • high C-reactive protein
  • temperature
  • high respiratory rate
  • high HR
72
Q

Antibiotics to avoid in children

A
  1. Tetracycline
  2. Quinolones
73
Q

Antibiotics to avoid in elderly

A
  1. Drugs that increase risk of c.diff
    Clindamycin
  2. Drugs that affect or affected by renal and liver function
  3. Drug interactions
74
Q

Antibiotics affected by renal impairment

A
  1. Aminoglycosides
  2. Glycopeptides - vancomycin
  3. Nitrofurantoin - AVOID if eGFR < 45
  4. Tetracyclines (except minocycline and doxycycline.
75
Q

Antibiotics affected by hepatic impairment

A
  1. Rifampicin - hepatotoxic
  2. Tetracycline - hepatotoxic
  3. Metronidazole- reduce dose if severely impaired
  4. Co-amoxiclav
  5. Flucloxacillin
76
Q

Drugs in pregnancy - contra-indicated

A
  1. Metronidazole
  2. Chloramphenicol
  3. Aminoglycosides
  4. Tetracycline
  5. Quinolones
  6. Sulphonamides
  7. Trimethoprim
  8. Nitrofurantoin - avoid at term
77
Q

Antibiotics safe in pregnancy

A
  1. Penicillin
  2. Cephalosporins
  3. Macrolids - erythromycin
78
Q

Tetracyclines - photosensitivity

A

DD
1. Demeclocycline
2. Doxycycline

Avoid exposure to sunlight and sunlamps

79
Q

Tetracycline - AVOID MILK

A

DOT
1. Demeclocycline
2. Oxytetracycline
3. Tetracycline

80
Q

Tetracycline - oesophageal irritation

A

DMT
1. Doxycycline
2. Minocycline
3. Tetracycline

Swallow whole - with fluid and standing up right

81
Q

Lyme disease
- causes
- signs and symptoms
- treatment

A

Caused by a bite of a infected tick.
Requires prompt and correct removal of the tick. This reduces the risk of infection.

Signs and symptoms
- erythema migrans rash (becomes visible 1-4 weeks after tick but can appear from 3 days to 3 months and can last for several weeks)
- can be accompanied by non focal symptoms such as fever, swollen glands, malaise, fatigue, neck pain or stiffness, joint or muscle pain, headache, cognitive impairment or paraesthesia.
- other signs and symptoms can appear months or years after the initial infection. Usually focal symptoms (including atleast 1 organ). Neurological, joint, cardiac or skin.

Drug treatment
Usual treatment options
- oral doxycycline
- amoxicillin
- azithromycin
- intravenous ceftriaxone.
(Treatment depends on the signs and symptoms and affected area)

82
Q

Treatment of mastitis during breast-feeding

A

Treat If
- severe
- systemically unwell
- symptoms do not improve after 12-14 hours of effective milk removal
- culture indicated infection

TREATMENT
treat for 10-14 days
1. Flucloxacillin
2. Erythromycin

83
Q

MRSA
Generally what’s added?

A

Generally - vancomycin/teicoplanin or Linezolid.

Skin and soft tissue infection
- normal options and adding + vancomycin/teicoplanin/ Linezolid.

Hospital acquired pneumonia
- IV first line - pipercillin with tazobactam
Add + vancomycin/teicoplanin/Linezolid
Other options - cephalosporin

Septicaemia
- to add vancomycin or teicoplanin

Endocarditis
- vancomycin + low dose gentamicin + rifampicin

Osteomyelitis
- vancomycin or teicoplanin

Septic arthritis
- vancomycin or teicoplanin

Urinary tract infection
- oral doxycycline
- trimethoprim
- ciprofloxacin
- co-trimoxazole
- glycopeptide - vancomycin

84
Q

Tuberculosis

A

Spread by breathing in infected respiratory droplets
Most common form is in the lung (pulmonary) but it can spread to other body parts (extra pulmonary)

In some cases the bacteria may become dormant and remain in the body with no symptoms (latent TB) or with symptoms (active TB).

Standard treatment is completed in 2 phases. Initial phase and continuation phase.

Two regimens: unsupervised or supervised.

85
Q

Treatment phases of TB

A

Initial phase
Offer 4 drugs
1. Rifampicin
2. Ethambutol
3. Pyrazinamide
4. Isoniazid with pyridoxine
Continued for 2 months.
Treatment to be started without waiting for culture results if the symptoms are consistent with TB diagnosis.
To complete the course even if subsequent culture results are negative.

Continuation phase
Offer 2 drugs
1. Rifampicin
2. Isoniazid
For 4 months if without CNS involvement
And for 10 months if it includes CNS involvement with or without spinal involvement.

86
Q

What is latent TB and how is it managed?

A

Latent TB is when you have TB but no symptoms.

Management
- 3 months of rifampicin and isoniazid
- 6 months of isoniazid

35-65
Offer treatment if hepatotoxicity is not concern

Under 35
Treatment with isoniazid + rifampicin
If hepatotoxicity is a concern after an assessment of both liver function.

Interaction with rifampicin or HIV
Offer isoniazid for 6 months.

87
Q

Supervised vs unsupervised treatment for TB?

A

Unsupervised for reliable patients
Supervised - usually daily or 3 times a week. Less than 3 times a week is not recommended.

88
Q

TB of the central nervous system?

A

Initial phase for 2 months with 4 drugs, and continuation for up-to 10 months.

Treatment should be offered if clinical signs and lab findings are consistent with the diagnosis even if the diagnostic test is negative.

An initial high dose of dexamethasone or prednisolone should be offered at the same time as the treatment then slowly withdrawn over 4-8 weeks.

89
Q

Pericardial TB?

A

Initial high dose of oral prednisolone offered at the same time as the TB drugs and then withdrawn over 2-3 weeks.

90
Q

What is latent TB?

A

TB with no symptoms. Some individuals are at risk of developing active TB. If for any reason the individuals do not have treatment for latent TB. They need to be informed of the risks and symptoms of active TB.

91
Q

What do you do if the person comes into contact with someone with active TB?

A

Test them for latent TB
Anyone under 65 with evidence of latent TB provide drug treatment.

92
Q

Treatment of latent TB?

A

Management
- 3 months of rifampicin and isoniazid
- 6 months of isoniazid

35-65
Offer treatment if hepatotoxicity is not concern

Under 35
Treatment with isoniazid + rifampicin
If hepatotoxicity is a concern after an assessment of both liver function.

Interaction with rifampicin or HIV
Offer isoniazid for 6 months.

93
Q

Treatment interruption in TB

A

A break in anti-TB drugs of atleast 2 weeks during the initial phase or missing more than 20% of the prescribed dose.

Need to re-establish.

94
Q

Drug - Rifampicin
- side - effects
- allergies
- contraception
- pregnancy
- monitoring
- patient advice

A

Side-effects: occurs with intermittent therapy includes - influenza-symptoms
- respiratory symptoms (SoB)
- collapse
- shock
- haemolytic anaemia.
- thrombocytopenic purpura
- acute renal failure.

Reduces the effectiveness of normal contraception.

Teratogenic at high doses in 1st trimester and in 3rd trimester increased risk of neonatal bleeding.

Monitoring of Renal, hepatic and FBC

If treatment is interrupted then re-introduce at low dose and increase gradually.

Discolours the contact lenses

Hepatic disorders - patients need to be advised on how to recognise signs and symptoms of liver problems and discontinue.

95
Q

Drugs - ethambutol
Side-effects
Pregnancy
Monitoring

A

Ocular symptoms. Discontinue treatment if any visual impairments. Early discontinuation almost always cause recovery in eyesight.

Causes ocular toxicity

Should not be given in children less than 5

Ok to use in pregnancy.

Monitoring
Peak (after 2-2.5 hours) 2-6mg/Liter
Trough (before dose) <1mg/liter
Renal function
Visual acuity

96
Q

Drugs - isoniazid
- side-effects (2)
- pregnancy

A

Peripheral neuropathy. Pyridoxine is given prophylactically. It is more likely if the patient has pre-existing risk factors like:
- diabetes
- alcohol dependence
- chronic renal failure
- pregnancy
- malnutrition
- HIV infection

Hepatitis - common in those aged over 35 years and those with a daily alcohol intake
- if hepatic symptoms develop - the discontinue and seek advice.

Pregnancy
Not known to be harmful

97
Q

Drugs - pyrazinamide

A
  • contra-indicated in gout
  • hepatitis - advise patients to report signs and symptoms of liver problems and to discontinue treatment.
98
Q

UTI in pregnancy

A

Associated with developmental delay, cerebral palsy in infants and fetal death

99
Q

Lower UTI in women

A

Acute, uncomplicated UTI
- self-limiting
- delayed antibiotics

If symptoms worsen or antibiotics needed
FOR 3 days.

  • oral 1st line
    1. Nitrofurantoin
    2. Trimethoprim
  • oral 2nd line (if no improvement after atleast 48 hours)
    1. Nitrofurantoin
    2. Pivmicilinum
    3. Amoxicillin
    4. Fosfomycin
100
Q

Lower UTI in men

A

Immidiate antibacterial
Mid-stream urine analysis
FOR 7 DAYS

Choices
- oral 1st line
1. Nitrofurantoin
2. Trimethoprim

  • oral 2nd line
    Consider pyelonephritis or Prostatitis
101
Q

UTI in pregnancy
Asymptomatic bacteriuria

A

Immediate antibiotics
Mid-stream urine sample
FOR 7 DAYS

CHOICES
Oral 1st line
1. Nitrofurantoin

Oral 2nd line
1. Amoxicillin
2. Cefalexin

Asymptomatic bacteriuria
Above 3 options

102
Q

Acute prostatitis

A

Immediate antibacterial
Mid-stream urine sample
Refer patients to hospital if no improvement in 48 hours or more serious condition is suspected

Choices
- Oral 1st line
1. Ciprofloxacin
2. Ofloxacin
3. Trimethoprim

  • oral 2nd line
    1. Levofloxacin
    2. Co-trimoxazole

IV 1st line
- amikacin/gentamicin
- ceftriaxone/cefuroxime
- ciprofloxacin/levofluoxacin

103
Q

Acute pyelonephritis
- men and women
- pregnant women

A

Immediate antibacterial
Mid-stream urine sample

Men and women
1st line oral options
1. Cefalexin
2. Ciprofloxacin
3. Trimethoprim
4. Co-amoxiclav

1st line IV options
1. Aminoglycoside
2. Ceftriaxone/cefuroxime
3. Ciprofloxacin
4. Co-amoxiclav

Pregnant women
Oral 1st line - cefalexin
IV 1st line - cefuroxime

104
Q

Drug - Nitrofurantoin

A

Discontinue if patients develop haematological or neurological syndrome (peripheral neuropathy)

Hepatic reactions - including fatal cases. Discontinue if signs of hepatitis develop

Pulmonary reactions - discontinue if pulmonary reactions develop. Can occur within the first week of treatment. Reversible on discontinuation.

105
Q

Treatment of vaginal candidiasis

A

Can be treated with either locally acting anti-fungal (clotrimazole) or oral fluconazole/itraconazole.

106
Q

Treatment of oropharyngeal candidiasis?

A

Topical therapy - nystatin or miconazole
Oral therapy - itraconazole

107
Q

Treatment of normal skin infection - tinea corporis, tinea cruris, tinea pedis?

A

Mild localised fungal infection responds to topical therapy.
Systemic therapy is given if topical fails, many sites are affected, or site of infection is too difficult to treat.

Options
- imidazole
- triazole - itraconazole
- terbinafine
(Broader spectrum of activity and shorter duration of treatment)

108
Q

Treatment of fungal scalp - tinea capatis?

A

Treated systemically
Additional topical antifungal can reduce transmission.

Options
- terbinafine
- griseofulvin

109
Q

Treatment or pityriasis versicolour (fungal patchy skin)?

A

Topical therapy can be given

If topical is ineffective then systemically.

Options
- itraconazole
- fluconazole

Terbinafine is not effective

110
Q

Fungal nail infections

A
  • asymptomatic no treatment is required
  • systemic antifungal is more effective than topical.

Options
- terbinafine
- itraconazole

Itraconazole can also be given as a intermittent ‘pulse’ therapy.

111
Q

Immunocompromised patients and fungal infections

A

These patients are at high risk of getting fungal infections. So anti-fungal may be given prophylactically.

Options
- fluconazole
- itraconazole (caused by aspergillus)
- posaconazole
- micafungin

112
Q

Polyene antifungals

A

Nystatin and amphotericin B

Nystatin is not absorbed when given by mouth

Amphotericin B - given by IV infusion. It is highly protein bound. And has toxic side effects like nephrotoxicity.

113
Q

Imidazole anti-fungals

A
  • miconazole
  • clotrimazole
  • evonazole
  • ketoconazole
  • ticonazole
114
Q

Triazole anti-fungals

A

fluconazole
- Well absorbed
- penertrates into the cerebrospinal fluid and used to treat fungal meningitis
- excreted largely unchanged

Itraconazole
- requires and acidic environment in the stomach for optimal absorption
- associated with liver damage

Posaconazole
- invasive fungal infections unresponsive to normal treatment options

Voriconazole
- B-road spec anti-fungal used in life-threatening infections.

115
Q

Amphotericin B

A

-polyene antifungal
- MHRA / CHM
Liposomal and lipid complex formulation. Name change to reduce medication errors.
Serious harm and fatal overdose have occurred.
Not interchangeable

Caution: further info
Anaphylaxis. Test dose should be given and monitor patient for 30 minutes before.

Infusion related reactions. Prophylactic antipyretic or hydrocortisone can used in patients who experienced previous reactions

116
Q

Fluconazole

A

Rash can occur. Discontinue
Severe cutaneous reactions are more likely in patients with AIDs

117
Q

Itraconazole

A
  • susceptibility to congestive heart failure. Especially with high doses and long duration, pts with cardiac disease, chronic lung disease, treatment with CCB. To avoid in patients with ventricular dysfunction and history of congestive heart failure.
  • potentially life threatening hepatotoxicity- discontinue if signs of hepatitis develop.
118
Q

Voriconazole

A
  • hepatotoxicity
  • phototoxicity - consider treatment discontinuation. Monitor for pre-malignant skin lesions and squamous cell carcinomas. Discontinue if they occurs.
  • to avoid direct sunlight. Seek help if sunburn occurs
  • keep alert card on them.
119
Q

Threadworm

A

Treat with medication and hygiene.
All members of the family are treated.
Adult threadworms don’t live longer than 6 weeks.

MEBENDAZOLE for those ages 6 months and over. Treat with a single dose then re-treat after 2 weeks.

120
Q

Hookworm

A

Live in the upper small intestine and draws blood from the site of attachment to the host. Causing anemia

Need to treat to get rid of the hookworm.
MEBENDAZOLE / ALBENDAZOLE
LEVAMISOLE

Also need to treat the anaemia.

121
Q

Non-drug prevention options for malaria?

A

1) mosquito bed nets impregnated with insecticide likes permethrin
2) vaporised insecticides
3) long sleeves, long trousers and socks
4) insect repellents
5) diethyltoluamide DEET

122
Q

Applying DEET and both sunscreen?

A

Apply the sunscreen first then DEET after. DEET reduces the SPF of sunscreen.

123
Q

Malaria prophylaxis drugs? (4)

A

1) chloroquine and proguanil
2) atovaquone and proguanil
3) mefloquine
4) doxycycline

124
Q

Chloroquine and proguanil
- length of prophylaxis
- epilepsy?
- pregnancy?

A

Length of prophylaxis
- 1 week before
- 4 weeks after

CANNOT be used in patients with epilepsy

Can be given during pregnancy however they are not very effective. Folic acid to be given alongside proguanil.

125
Q

Atovaquone with proguanil
- length of prophylaxis
- duration it can be used for?
- epilepsy?
- pregnancy?

A

Length of prophylaxis
- 1-2 days before
- 1 week after

Can be used for up-to 1 year

Can be used epilepsy

AVOID during pregnancy. Maybe considered in 2nd or 3rd trimester if no suitable alternative. Have to give Folic acid with proguanil.

126
Q

Mefloquine
- length of prophylaxis
- longest duration it can be given for?
- Epilepsy?
- pregnancy?

A

Length of prophylaxis
- 2-3 weeks before
- 4 weeks after

Can be used for up-to 3 years

CANNOT be used in epilepsy

Can be used in pregnancy in 2nd and 3rd trimester. Used in 1st with caution.

127
Q

Doxycycline - for malaria
- length of prophylaxis
- duration it can be used for?
- epilepsy?
- pregnancy

A

Length of prophylaxis
- 1-2 days before
- 4 weeks after

Can be used for up-to 2 years

Can be used in epilepsy
It may interact with anti-epileptic medication. Dose may need adjusting.

Avoid in pregnancy. Contra-indicated
If other regimens are unsuitable then it can be used as option if the entire course can be finished before week 15 gestation.

128
Q

Return from malaria region?

A

When you return from a malaria region…
Any illness that occurs within 1 year and especially within 3 months could be malaria.

129
Q

Anti-malarials and warfarin

A

Anti-malarials should be started 2-3 weeks before departure and INR should be stable before leaving.

INR to be measured before starting, after 7 days and after completing the course.

130
Q

Patients on hydroxychloroquine requiring anti-malaria medication?

A

For those whom chloroquine would be appropriate for prophylaxis, can stay on hydroxychloroquine.

131
Q

Emergency standby treatment for malaria?

A

Patients should carry a standby emergency treatment if they are going to be more than 24 hours away from medical care.

Written instructions should be provided which includes seeking urgent medical attention if fever is greater than 38 after 7 days of more from arrival to malaria area.

Self treatment if indicated if medical help is not available within 24 hours of fever onset.

Drug that is used for chemoprophylaxis should not be used for standby emergency treatment. - concerns if toxicity and drug resistance.

pre-reg material (6 decks)

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