BNF - Chapter 5 - Infection - (Part 2) Flashcards
(350 cards)
1
Q
What is latent tuberculosis?
A
The initial infection with tuberculosis clears in the majority of individuals. However, in some cases the bacteria may become dormant and remain in the body with no symptoms (latent tuberculosis) or progress to being symptomatic (active tuberculosis) over the following weeks or months.
2
Q
Does everyone with latent TB go on to develop active tuberculosis?
A
In individuals with latent tuberculosis only a small proportion will develop active tuberculosis.
3
Q
The standard treatment of tuberculosis is treated in how many phases?
A
In two phases.
An initial phase and a continuation phase
4
Q
How many drugs are used in the initial phase?
A
4 drugs
5
Q
How many drugs are used in the continuation phase?
A
2 drugs in fully sensitive cases
6
Q
Within the UK there are two regimens recommended for the treatment of tuberculosis, what are they?
A
Unsupervised and supervised
7
Q
For standard treatment for individuals with active tuberculosis which four drugs are given for the initial phase?
A
Rifampicin
Isoniazid (with pyridoxine)
Pyrazinamide
Ethambutol
(RIPE - acronym)
8
Q
How long is initial phase of TB treatment continued for?
A
For 2 months
9
Q
What is offered in the continuation phase after the initial phase?
A
Rifampicin Isoniazid (with pyridoxine)
(RI of the RIPE - acronym)
10
Q
How long is the continuation phase treatment for TB offered for?
A
For 4 months after the 2 months initial phase - for patients with active TB without central nervous involvement
11
Q
Longer treatments should be offered in individuals with active TB of the central nervous system with or without spinal involvement - how long for?
A
Longer treatment for 10 months after the 2 months initial phase.
12
Q
Who is unsupervised treatment offered to?
A
The unsupervised treatment regimen is for individuals who are likely to take antituberculosis drugs reliably and willingly without supervision.
13
Q
What does supervised TB treatment involve?
A
(directly observed therapy, DOT), this is offered as part of enhanced case management.
14
Q
How many times a week administration can be considered for supervised TB treatment if daily directly observed therapy is not available?
A
A 3 times weekly dosing schedule can be considered in individuals with tuberculosis if they require enhanced case management and daily directly observed therapy is not available.
15
Q
Are anti TB treatment dosing regimens of fewer than 3 times a week recommended?
A
No
16
Q
Directly observed therapy should be offered to which individuals?
A
To individuals who:
have a current risk or history of non-adherence;
have previously been treated for tuberculosis;
have a history of homelessness, drug or alcohol misuse;
are in prison or a young offender institution, or have been in the past 5 years;
have a major psychiatric, memory or cognitive disorder;
are in denial of the tuberculosis diagnosis;
have multi-drug resistant tuberculosis;
request directly observed therapy after discussion with the clinical team;
are too ill to self-administer treatment.
17
Q
Who should individuals with comorbidities or coexisting conditions such as HIV, severe liver disease etc. be treated by for TB?
A
should be managed by a specialist multidisciplinary team with experience in managing tuberculosis and the comorbidity or coexisting condition.
18
Q
For individuals who are HIV positive with active TB, treatment with the standard regimen should not routinely exceed how many months?
A
6 months, unless the TB has central nervous system involvement, in which cases should not routinely extend beyond 12 months
19
Q
Care should be taken to avoid drug interactions when co-prescribing antituberculotic drugs with which drugs?
A
Antiretrovirals with antituberculosis
20
Q
Summarise the treatment initial phase and continuation phase and their duration of treatment for individuals with central nervous system tuberculosis?
A
standard treatment with initial phase drugs for 2 months (RIPE)
After completion of the initial treatment phase, standard treatment with continuation phase drugs should then be offered (RI) for a further 10 months)
21
Q
What other treatment should be considered if there are signs and clinical symptoms to suggest it?
A
Treatment for tuberculous meningitis should be offered if clinical signs and other laboratory findings are consistent with the diagnosis, even if a rapid diagnostic test is negative.
22
Q
Which drug should be offered at the same time as antituberculosis treatment in patients with central nervous system involvment?
A
An initial high dose of dexamethasone or prednisolone should be offered at the same time as antituberculosis treatment, then slowly withdrawn over 4–8 weeks.
23
Q
In which patients would you consider referral for surgery?
A
Referral for surgery should only be considered in individuals who have raised intracranial pressure; or have spinal TB with spinal instability or evidence of spinal cord compression.
24
Q
What is the pericardium?
A
The pericardium is a membrane, or sac, that surrounds your heart. It holds the heart in place and helps it work properly. Problems with the pericardium include: Pericarditis - an inflammation of the sac.
25
What drug should also be prescribed at the start same time as antituberculosis treatment for patients with active pericardial tuberculosis?
An initial high dose of oral prednisolone should be offered to individuals with active pericardial tuberculosis, at the same time as antituberculosis treatment, then slowly withdrawn over 2–3 weeks.
26
Some individuals with latent TB are at an increased risk of developing active tuberculosis - which groups?
such as individuals who are HIV-positive, diabetic, injecting drug users, or receiving treatment with an anti-tumor necrosis factor alpha inhibitor).
27
What information about close contacts of those with active or recently treated for TB should you know?
Anyone aged under 65 years who is a close contact (prolonged, frequent or intense contact, for example household contacts or partners) of a person with pulmonary or laryngeal tuberculosis should be tested for latent tuberculosis.
Drug treatment should be offered to all individuals aged under 65 years with evidence of latent tuberculosis, if the close contact has suspected infectious or confirmed active pulmonary or laryngeal drug-sensitive tuberculosis.
28
What is the treatment for latent TB?
RI -
Rifampicin + Isoniazid (with pyridoxine) for 3 months
```
or
Isoniazid (with pyridoxine) for 6 months
```
29
What should individuals be tested for before starting treatment for latent TB?
Testing for HIV, hepatitis B and hepatitis C should be offered before starting antituberculosis treatment as this may affect choice of therapy.
30
What are the major causes of treatment failure?
incorrect prescribing by the clinician and inadequate compliance by the infected individual.
31
What can multidisciplinary tuberculosis team implement to help?
Multidisciplinary tuberculosis teams should implement strategies (such as random urine tests, pill counts, home visits, health education counselling, and language appropriate reminder services) to help with adherence to, and successful completion of treatment.
32
What is classified as a treatment interruption for antituberculosis treatment?
A break in antituberculosis treatment of at least 2 weeks (during the initial phase) or missing more than 20% of prescribed doses is classified as treatment interruption.
33
In individuals with severe or highly infection tuberculosis who need to interrupt the standard regimen due to drug-drug hepatoxicity - which drugs should be continued?
onsider continuing treatment with at least 2 drugs with low risk of hepatotoxicity, such as ethambutol hydrochloride and streptomycin (with or without a fluoroquinolone antibiotic, such as levofloxacin or moxifloxacin), with ongoing monitoring by a liver specialist.
34
What is the treatment regime for TB that is resistant to isoniazid?
First 2 months (initial phase): rifampicin, pyrazinamide and ethambutol hydrochloride;
Continue with (continuation phase): rifampicin and ethambutol hydrochloride for 7 months (up to 10 months for extensive disease).
35
What is the treatment regimen for TB that is resistant to Pyrazinamide?
First 2 months (initial phase): rifampicin, ethambutol hydrochloride and isoniazid (with pyridoxine hydrochloride);
Continue with (continuation phase): rifampicin and isoniazid (with pyridoxine hydrochloride) for 7 months.
36
What is the treatment regime for TB that is resistant to ethambutol?
First 2 months (initial phase): rifampicin, pyrazinamide and isoniazid (with pyridoxine hydrochloride);
Continue with (continuation phase): rifampicin and isoniazid (with pyridoxine hydrochloride) for 4 months.
37
What is the treatment regime for TB that is resistant to rifampicin?
Offer treatment with at least 6 antituberculosis drugs to which the mycobacterium is likely to be sensitive.
38
Which drug class does rifampicin belong to?
Antimycobacterials - Rifamycin
39
Can rifampicin affect contact lenses?
Yes - discolour soft contact lenses
40
What is a common side effect of rifampicin?
Nausea, thrombocytopenia and vomiting
41
Does rifampicin affect hormonal contraceptive use?
Yes - effectiveness of hormonal contraception is reduced
42
List other drugs that are used in multiple resistant tuberculosis?
- Aminosalicylic acid
- Bedaquiline
- Capreomycin
- Cycloserine
- Delamnid
43
What toxicity is tubercolusis drug treatments (RIPE) associated with?
Link with liver toxicity, so liver function should be checked before treatment begins.
44
Is rifampicin an enzyme inhibitor or inducer?
• Rifampicin induces hepatic enzymes which accelerates the metabolism of corticosteroids, phenytoin and anticoagulants. Combined oral contraceptive pills will become ineffective (metabolised)
45
What is a common side effect of isoniazid?
- peripheral neuropathy
| - should be given with pyridoxine
46
During treatment with isoniazid, which B vitamin may become deficient?
Vitamin B6
47
As part of RIPE - is ethambutol essential?
Ethambutol is not essential as RI since its main purpose is a backup in case there is isoniazid resistance
48
What side effect can ethambutol cause which requires patients to stop and report it?
Ethambutol can cause visual problems including blurry vision + colour blindness – patients should be told to stop using ethambutol if this is the case
49
What is pyrazinamide useful for - specifically which type of TB condition/ complication?
• Pyrazinamide is a bactericidal drug which exerts its main effect only in the first 2 or 3 months. It is particularly useful for tuberculous meningitis because of good meningeal penetration
50
Is streptomycin used commonly for treatment of TB?
• Streptomycin is rarely used except for resistant organisms.
51
Following treatment interruption due to drug-induced hepatotoxicity… once hepatic function has recovered; anti-tuberculosis therapy should be re-introduced at the same dose within how many days?
Within 10 days
52
Which part of the urinary tract can be affected by Urinary-tract-infections (UTIs)?
It can affect any part of the urinary tract
53
Who do urinary tract occur more in?
More frequently in women, and are usually independent of any risk factor.
54
How are UTIs predominantly caused?
Caused by bacteria from the GI tract entering the Urinary tract.
55
Which is the most common causative organism responsible for UTIs?
Escherichia Coli
56
Is UTIs due to Candida albicans common or rare?
Rare - but may occur in hospitalised patients who are immunocompromised or have an indwelling catheter
57
What is inflammation of the bladder known as?
Cystitis
58
What is inflammation of the urethra known as?
Urethritis
59
What are lower UTIs associated with?
Associated with inflammation of the bladder (cystitis) and urethra (Urethritis).
60
What parts do upper UTIs affect?
Upper UTIs affect the proximal part of the ureters (pyelitis) or the proximal part of the ureters and the kidneys (pyelonephritis), and can cause renal scarring, abscess or failure, and sepsis
61
What are the most common signs and symptoms of lower UTIs?
- Dysuria
- Increased urinary frequency and urgency
- urine that is strong smelling
- cloudy or contains blood
- persistent lower abdominal pain
62
What symptoms do upper UTIs usually present additionally with?
- Loin pain and
| - fever
63
In pregnant women, asymptomatic bacteriuria is a risk factor for what?
For pyelonephritis (a type of urinary tract infection where one or both kidneys become infected) and premature labour.
64
What have UTIs in pregnancy been associated with?
been associated with developmental delay and cerebral palsy in the infant, as well as fetal death.
65
Is inserting a catheter a risk factor for developing UTIs?
Insertion of a catheter into the urinary tract increases the risk of developing a UTI, and the longer the catheter is in place for, further increases the risk of bacteriuria.
66
How many episodes within how many months is considered as having recurrent UTIs?
At least two episodes within 6 months or three or more episodes within 12 months
67
What is acute prostatitis?
It is an infection of the prostrate gland and is usually caused by a UTI?
68
What are the common symptoms of UTIs?
Common symptoms include sudden onset of fever, acute urinary retention or irritative voiding symptoms.
69
What are some complications of acute prostatitis?
Possible complications include prostatic abscess, bacteraemia, epididymitis, and pyelonephritis.
70
What is chronic prostatitis?
Chronic prostatitis is a complication of acute prostatitis and is defined as at least 3 months of urogenital pain usually associated with lower urinary tract symptoms
71
What are the non-drug treatment advice to give for UTIs?
- drink plenty of water to avoid dehydration
- self care strategies to reduce risk of infection (such as wiping front to back after defaecation, not delaying urination, and not wearing occlusive underwear
72
Can you recommended cranberry products for UTIs?
To reduce the risk of recurrent infections, some women (non-pregnant) with recurrent UTIs may wish to try cranberry products (evidence of benefit uncertain) or D-mannose.
Patients should be advised to consider the sugar content of these products. There is no evidence to support the use of cranberry products for the treatment of UTIs.
73
Is asymptomatic bacteriuria routinely treated with antibacterials?
With the exception of pregnant women, asymptomatic bacteriuria is not routinely treated with antibacterials.
74
Can both paracetamol and ibuprofen be used for pain relief in UTIs?
Yes
75
Can codeine be used for pyelonephritis or prostatitis?
Yes where appropriate
76
Is there much evidence to support the use of alkalinising agents for the treatments of UTIs?
No evidence
77
For non-pregnant women with acute uncomplicated lower UTIs is it self-limiting?
Yes it is self-limiting and for some, delaying antibacterial treatment with a backup prescription to see if symptoms will resolve, may be an option.
78
What is the choice of antibacterial therapy for non-pregnant women (acute, uncomplicated lower UTI)?
Oral first line:
Nitrofurantoin, or trimethoprim (if low risk of resistance).
Oral second line (if no improvement after at least 48 hours, or first line not suitable):
Nitrofurantoin (if not used first line), fosfomycin, pivmecillinam hydrochloride, or amoxicillin (high rate of resistance, so only use if culture susceptible)
79
For men with UTI, what must be taken or done before treatment?
An immediate antibacterial prescription should be given and a midstream urine sample obtained before treatment is taken and sent for culture and susceptibility testing.
80
What is the choice of antibacterial for treatment of lower UTI in men?
Oral first line:
Nitrofurantoin, or trimethoprim.
Oral second line (if no improvement after at least 48 hours, or first line not suitable):
Consider pyelonephritis or prostatitis. See pyelonephritis, acute, or prostatitis, acute below for guidance.
81
For pregnant women must a midstream urine sample be obtained before treatment like men?
An immediate antibacterial prescription should be given and a midstream urine sample obtained before treatment is taken and sent for culture and susceptibility testing.
82
What is the choice of antibacterial for treating lower UTI in pregnant women?
Oral first line:
Nitrofurantoin.
Oral second line (if no improvement after at least 48 hours, or first line not suitable):
Amoxicillin (only if culture susceptible), or cefalexin.
Alternative second line:
Consult local microbiologist.
83
What are the treatment options for pregnant women for asymptomatic bacteriruria?
Amoxicillin, cefalexin or nitrofurantoin
84
Before treating prostatitis (acute) what must be done?
An immediate antibacterial prescription should be given and a midstream urine sample obtained before treatment is taken and sent for culture and susceptibility testing.
85
What is the choice of antibiotics to treat prostatitis?
Oral first line:
Ciprofloxacin, or ofloxacin.
Alternative first line (if unable to take fluoroquinolones): trimethoprim.
Oral second line (on specialist advice):
Levofloxacin, or co-trimoxazole.
Intravenous first line (if severely unwell or unable to take oral treatment). Antibacterials may be combined if concerned about sepsis.
Amikacin, ceftriaxone, cefuroxime, ciprofloxacin, gentamicin, or levofloxacin.
86
What should be considered before the pyelonephritis (infection of the kidneys)?
An immediate antibacterial prescription should be given and a midstream urine sample obtained before treatment is taken and sent for culture and susceptibility testing.
Consider referring or seeking specialist advice for patients with acute pyelonephritis who are significantly dehydrated or are unable to take oral fluids and medicines, are pregnant, or have a higher risk of developing complications.
87
What is the treatment (antibiotics) choice for treating pyelonephritis for non-pregnant women and men?
Oral first line:
Cefalexin, or ciprofloxacin. If sensitivity known: co-amoxiclav, or trimethoprim.
Intravenous first line (if severely unwell or unable to take oral treatment). Antibacterials may be combined if concerned about susceptibility or sepsis.
Amikacin, ceftriaxone, cefuroxime, ciprofloxacin, or gentamicin. Co-amoxiclav may be used if given in combination or sensitivity known.
Intravenous second line:
Consult local microbiologist.
88
What is the treatment (antibiotics) choice for treating pyelonephritis for pregnant women?
Oral first line:
Cefalexin.
Intravenous first line (if severely unwell or unable to take oral treatment):
Cefuroxime.
Second line or combining antibacterials if concerned about susceptibility or sepsis:
Consult local microbiologist.
89
For recurrent UTIs in non-pregnant women what can you consider?
In non-pregnant women, consider a trial of antibacterial prophylaxis if behavioural and personal hygiene measures, and vaginal oestrogen (in postmenopausal women) are not effective or appropriate.
Single-dose antibacterial prophylaxis [unlicensed indication] should be considered for use when exposed to an identifiable trigger. Daily antibacterial prophylaxis should be considered in non-pregnant women who have had no improvement after single-dose antibacterial prophylaxis, or who have no identifiable triggers.
90
If on antibacterial prophylaxis for UTI, within how many months should the patient return for a review?
Within 6 months
91
Which antibiotics can be used as prophylaxis for men and women?
Oral first line:
Trimethoprim, or nitrofurantoin.
Oral second line:
Amoxicillin [unlicensed indication], or cefalexin.
92
What should you consider for a patient with a catheter associated urinary tract infection?
onsider removing or changing the catheter as soon as possible if it has been in place for longer than 7 days, without delaying antibacterial treatment
An immediate antibacterial prescription should be given and a urine sample obtained before treatment is taken and sent for culture and susceptibility testing
93
For non pregnant women and men what is the antibiotic treatment for UTIs associated with catheters?
Oral first line (if no upper UTI symptoms):
Amoxicillin (only if culture susceptible), nitrofurantoin, or trimethoprim (if low risk of resistance).
Oral second line (if no upper UTI symptoms and first-line not suitable):
Pivmecillinam hydrochloride.
Oral first line (upper UTI symptoms):
Cefalexin, ciprofloxacin, co-amoxiclav (if culture susceptible), or trimethoprim (if culture susceptible).
Intravenous first line (if severely unwell or unable to take oral treatment). Antibacterials may be combined if concerned about susceptibility or sepsis.
Amikacin, ceftriaxone, cefuroxime, ciprofloxacin, gentamicin, or co-amoxiclav (only in combination, unless culture results confirm susceptibility).
94
For pregnant women what is the antibiotics of choice for UTI associated with catheter?
Oral first line:
Cefalexin.
Intravenous first line (if severely unwell or unable to take oral treatment):
Cefuroxime.
95
What type of drug is methanamine hippurate?
Antibacterial
96
What are the indications of methanamine hippurate?
prophykaxis and long term treatment of chronic or recurrent uncomplicated lower urinary-tract infections
and also in patients with catheters
97
Is methanamine hippurate suitable for use in upper tract infections?
No
98
Can nitrofurantoin be used in renal impairment?
Avoid if eGFR less than 45ml/min/1.73m2 may be used with caution if eGFR 30-44ml/min/1.73m2 as a short course only (3 - 7 days) to treat uncomplicated lower urinary tract infection.
99
A urine sample should be collected for culture and sensitivity testing before starting treatment in which patients?
- Men
- Pregnant women
- children under 3
- Suspected upper UTI
- If resistant organisms are suspected
100
Once a sample has been taken, can treatment begin while waiting for test results?
Yes
101
For women uncomplicated Lower UTI - how long is the treatment?
Usually 3 days
| pregnant women - 7 days
102
What is the treatment and suggested duration for acute pyelonephritis?
• Acute Pyelonephritis can lead to septicaemia and is treated initially by injection of a broad-spectrum antibacterial e.g. cephalosporin, quinolone or gentamicin. Suggested duration of treatment is 10-14 days
103
What is the duration treatment for prostatitis?
• Prostatitis can be difficult to cure and requires treatment for several weeks with an antibacterial that penetrates the prostatic tissue e.g. quinolone like ciprofloxacin or trimethoprim. Suggested duration of treatment is 28 days.
104
In pregnancy which antibiotics are useful and safe to use for UTIs?
In pregnancy Penicillin’s and Cephalosporins can be used but avoid Nitrofurantoin during 3rd Trimester and Trimethoprim during 1st Trimester.
105
What is the treatment of choice for aspergillosis (fungal infection)?
Variconazole
Liposomal amphotericin B is an alternative first-line treatment when voriconazole cannot be used.
Caspofungin, or itraconazole, can be used in patients who are refractory to, or intolerant of voriconazole
106
What is posaconazol licensed for?
Posaconazole is licensed for use in patients with invasive aspergillosis who are refractory to, or intolerant of itraconazole or amphotericin B.
107
What are the options for vaginal candidiasis?
Vaginal candidiasis may be treated with locally acting antifungals or with fluconazole given by mouth; for resistant organisms in adults, itraconazole can be given by mouth.
108
What are the options for oropharyngeal candidiasis?
Oropharyngeal candidiasis generally responds to topical therapy; fluconazole is given by mouth for unresponsive infections; it is effective and is reliably absorbed. Itraconazole may be used for infections that do not respond to fluconazole. Topical therapy may not be adequate in immunocompromised patients and an oral triazole antifungal is preferred.
109
What should be considered for the initial treatment of CND candidiasis?
Amphotericin B
110
Which antifungal can be used for infections caused by fluconazole-resistant Candida spp.?
Voriconazole can be used for infections caused by fluconazole-resistant Candida spp. when oral therapy is required, or in patients intolerant of amphotericin B or an echinocandin.
111
Is cryptococcosis common?
Cryptococcosis is uncommon but infection in the immunocompromised, especially in HIV-positive patients, can be life-threatening; cryptococcal meningitis is the most common form of fungal meningitis
112
What is the treatment choice in cryptococcal meningitis?
Amphotericin B by intravenous infusion and flucytosine by intravenous infusion for 2 weeks, followed by fluconazole by mouth for 8 weeks or until cultures are negative.
113
In cryptococcosis can fluconazole be used as an alternative?
In cryptococcosis, fluconazole is sometimes given alone as an alternative in HIV-positive patients with mild, localised infections or in those who cannot tolerate amphotericin B. Following successful treatment, fluconazole can be used for prophylaxis against relapse until immunity recovers.
114
What is the treatment for histoplasmosis?
Itraconazole can be used for the treatment of immunocompetent patients with indolent non-meningeal infection, including chronic pulmonary histoplasmosis.
Amphotericin B by intravenous infusion is used for the initial treatment of fulminant or severe infections, followed by a course of itraconazole by mouth. Following successful treatment, itraconazole can be used for prophylaxis against relapse until immunity recovers.
115
What is infection of the nails known as?
- Onchomycosis
116
What is a fungal infection of the scalp known as?
- Tinea Capitis
117
Why are oral imidazole or triazole antifungals (particularly itraconazole) used for systemic skin and nail infections?
Oral imidazole or triazole antifungals (particularly itraconazole) and terbinafine are used more frequently than griseofulvin because they have a broader spectrum of activity and require a shorter duration of treatment.
118
What is the treatment for tinea capitis?
Tinea capitis is treated systemically; additional topical application of an antifungal may reduce transmission. Griseofulvin is used for tinea capitis in adults and children; it is effective against infections caused by Trichophyton tonsurans and Microsporum spp. Terbinafine is used for tinea capitis caused by T. tonsurans [unlicensed indication]. The role of terbinafine in the management of Microsporum infections is uncertain.
119
For tine infection of the nails what is used?
Antifungal treatment may not be necessary in asymptomatic patients with tinea infection of the nails. If treatment is necessary, a systemic antifungal is more effective than topical therapy.
120
What is the drug of choice for onychomycosis?
terbenafine
Terbinafine and itraconazole have largely replaced griseofulvin for the systemic treatment of onychomycosis, particularly of the toenail
121
For immunocompromised patients due to increased risk of fungal infections what is the drug of choice for prophylactic antifungal therapy?
Oral triazole antifungals are the drug of choice for prophylaxis
122
Is fluconazole or itraconazole more reliably absorbed?
Fluconazole, but fluconazole is not effective against Aspergillus spp.
123
When is itraconazole preferred?
Itraconazole is preferred in patients at risk of invasive aspergillosis
124
Name the triazole antifungals?
Fluconazole
Itraconazole
Posaconazole
Voriconazole
125
Does fluconazole penetrate the cerebrospinal fluid?
achieves good penetration into the cerebrospinal fluid to treat fungal meningitis.
126
Can fluconazole be used to treat candiduria?
Fluconazole is excreted largely unchanged in the urine and can be used to treat candiduria.
127
What environment in the stomach do itraconazole require?
. Itraconazole capsules require an acid environment in the stomach for optimal absorption.
128
What has itraconazole been associated with?
With liver damage and should be avoided or used in caution in patients with liver disease
129
Which is more frequently associated with liver disease - fluconazole or itraconazole?
Fluconazole
130
What is posaconazole licensed for?
is licensed for the treatment of invasive fungal infections unresponsive to conventional treatment.
131
When is voriconazole used?
Voriconazole is a broad-spectrum antifungal drug which is licensed for use in life-threatening infections.
132
List the imidazole antifungals?
clotrimazole, econazole nitrate, ketoconazole, and tioconazole.
Miconazole
133
List the polyene antifungals?
- amphotericin B and Nystatin
134
Are polyene antifungals absorbed when given by mouth?
No neither of them are
135
What are the uses of nystatin?
Nystatin is used for oral, oropharyngeal, and perioral infections by local application in the mouth. Nystatin is also used for Candida albicans infection of the skin.
136
When is amphotericin B used?
Amphotericin B by intravenous infusion is used for the treatment of systemic fungal infections and is active against most fungi and yeasts.
137
why doesnt amphotericin B penetrate well into body fluids and tissues?
It is highly protein bound and penetrates poorly into body fluids and tissues. When given parenterally amphotericin B is toxic and side-effects are common.
138
What formulations of amphotericin B are significantly less toxic?
Lipid formulations
139
List the enchinocandin antifungals?
anidulafungin, caspofungin and micafungin.
140
Are enchinocandins effective against fungal infections of the CNS?
No
141
which drug is flucytosine used with?
Amophotericin B in a synergistic combination
142
What limits the use of flucytosine?
Bone marrow depression can occur which limits its use, particularly in HIV-positive patients; weekly blood counts are necessary during prolonged therapy.
Resistance to flucytosine can develop during therapy and sensitivity testing is essential before and during treatment
143
What role does flucytosine have?
. Flucytosine has a role in the treatment of systemic candidiasis and cryptococcal meningitis.
144
What is Griseofulvin used for?
Use has reduced alot due to newer antifungals.
It is the drug of choice for trichophyton infections in children. Duration of therapy is dependent on the site of the infection and may extend to a number of months.
145
What is the drug of choice for fungal nail infections?
Terbinafine and is also used for ringworm infections where oral treatment is considered appropriate
146
Can fluconazole be given in pregnancy
No - avoid
147
Which drugs may fluconazole interact with?
It may interact with statins, warfarin, diazepam, phenytoin and theophylline (all effects are increased).
148
Does amphotericin need to be prescribed by brand?
Yes since formulations are not interchangable
149
To use amphotericin what must be given first?
A test dose
150
Who does pneumocytis pneumonia occur in?
Pneumonia caused by Pneumocystis jirovecii (Pneumocystis carinii) occurs in immunosuppressed patients; it is a common cause of pneumonia in AIDS.
151
What is used to assess disease severity of pneumocystis pneumonia?
Blood gas measurement
152
What is the treatment for mild to moderate disease of pneumocystis pneumonia?
Co-trimoxazole in high dosage is the drug of choice for the treatment of mild to moderate pneumocystis pneumonia.
Atovaquone is licensed for the treatment of mild to moderate pneumocystis infection in patients who cannot tolerate co-trimoxazole. A combination of dapsone with trimethoprim is given by mouth for the treatment of mild to moderate disease [unlicensed indication].
A combination of clindamycin and primaquine by mouth is used in the treatment of mild to moderate disease [unlicensed indication]; this combination is associated with considerable toxicity.
153
What is the treatemtn of pneumocystis pneumonia for severe disease?
Co-trimoxazole in high dosage, given by mouth or by intravenous infusion, is the drug of choice for the treatment of severe pneumocystis pneumonia.
Pentamidine isetionate given by intravenous infusion is an alternative for patients who cannot tolerate co-trimoxazole, or who have not responded to it
154
What side effect can pentamidine cause?
Pentamidine isetionate is a potentially toxic drug that can cause severe hypotension during or immediately after infusion.
155
Which class of drug may be life saving in those with severe pneumocystis pneumonia?
Corticosteroid
156
Which corticosteroids are given as adjunctive therapy?
In moderate to severe infections associated with HIV infection, prednisolone is given by mouth for 5 days (alternatively, hydrocortisone may be given parenterally); the dose is then reduced to complete 21 days of treatment. Corticosteroid treatment should ideally be started at the same time as the anti-pneumocystis therapy and certainly no later than 24–72 hours afterwards. The corticosteroid should be withdrawn before anti-pneumocystis treatment is complete.
157
Who should prophylaxis against pneumocystis pneumonia be given to?
Prophylaxis against pneumocystis pneumonia should be given to all patients with a history of the infection.
158
What is the drug choice for prophylaxis of pneumocystis pneumonia?
Co-trimoxazole
It is given daily or on alternate days (3 times a week); the dose may be reduced to improve tolerance.
159
Which is better tolerated - pentamidine inhaled or parenteral pentamidine?
Inhaled is better tolerated
160
In patients unable to tolerate co-trimoxazole - which drug is used for prophylaxis of pneumocystis pneumonia?
- Intermittent inhalation of pentamidine isetionate
161
Pentamidine is effect for prophylaxis but may cause extrapulmonary infection, which other drug can be used as an alternative?
- Dapsone
162
Which drug class does pentamidine belong to?
Antiprotozoals
163
Which class of drugs are effective in treating threadworms and what does it needs to be done in combination with this?
Anthelmintics are effective in threadworm (pinworms, Enterobius vermicularis) infections, but their use needs to be combined with hygienic measures to break the cycle of auto-infection
164
For treating threadworms, does only the infected individual need to be treated or everyone in the family?
All members of the family require treatment.
165
Adult threadworms do not live longer than how many weeks?
6 weeks
166
Where do adult female worms lay ova?
On the perianal skin which causes pruritus; scratching in the area then leads to ova being transmitted on fingers to mouth, often via food eaten with unwashed hands.
167
what is essential advice to do to prevent and to break the cycle?
ashing hands and scrubbing nails before each meal and after each visit to the toilet is essential.
A bath taken immediately after rising will remove ova laid during the night.
168
What is the drug of choice to treat threadworm infection in patients of all ages over 6 months?
Mebendazole - single dose
169
As reinfection of threadworm is very common, when may a second dose be given?
After 2 weeks.
170
Which is the drug of choice for common roundworm infections?
Mebendazole is effective against Ascaris lumbricoides and is generally considered to be the drug of choice.
Levamisole [unlicensed] (available from ‘special-order’ manufacturers or specialist importing companies) is an alternative when mebendazole cannot be used. It is very well tolerated.
171
can mebendazole be used in pregnant women?
No
172
What is the OTC licensing age of mebendazole?
2 years and over
173
What should the choice of drug for prophylaxis of malaria for a particular individual take into account?
- Risk of exposure to malaria
- Extent of drug resistance
- Efficacy of the recommended drugs
- side effects of the drugs
- patient-related factors (e.g. age, pregnancy, renal or hepatic impairment, compliance with prophylactic regimen)
174
Is protection against prophylaxis of malaria 100% effective?
Prophylaxis is not absolute, and breakthrough infection can occur with any of the drugs recommended.
175
Is personal protection against bite important?
Personal protection against being bitten is very important and is recommended even in malaria-free areas as a preventive measure against other insect vector-borne diseases.
176
Which pyrethroid insecticide may help?
Mosquito bed nets impregnated with a pyrethroid insecticide (such as permethrin), improve protection and should be used unless sleeping in a well screened room, or the room is fitted with functioning air conditioning and sufficiently well sealed into which mosquitoes cannot enter; vaporised insecticides are also useful.
177
What other advice can be given to provide protection against mosquito biteS?
Long sleeves, long trousers, and socks worn after sunset also provide protection against bites.
178
What formulation is available (ingredient) which gives protection against insect bites?
Diethyltoluamide (DEET) is available in various preparations, including sprays and modified-release formulations.
179
What % DEET based repellent is recommended as first choice?
A 50% DEET-based insect repellent is recommended as the first choice; there is no further increase in duration of protection beyond a DEET concentration of 50%
180
DEET is safe to apply in adults and children over what age?
Children over 2 months of age
181
Can DEET be used during pregnancy and breast feeding?
Yes, However, ingestion should be avoided, therefore breast-feeding mothers should wash their hands and breast tissue before handling infants.
182
When sunscreen is also needed to be applied, which do you apply firsrt sunscreen or DEET?
When sunscreen is also required, DEET should be applied after the sunscreen
183
Does DEET increase or decrease the SPF of sunscreen?
DEET reduces the SPF of sunscreen, so a sunscreen of SPF 30–50 should be applied.
184
How long before travel chloroquine and proguanil be used?
1 week before travel
185
How long before travel should mefloquine be used?
2-3 weeks before trave;
186
How long before travel should atovaquone with proguanil or doxycycline be used?
1-2 days before travel
187
Prophylaxis should continue for how many weeks after leaving the area?
4 weeks after leaving the area (except for atovaquone with proguanil hydrochloride prophylaxis which should be stopped 1 week after leaving)
188
In those requiring long term prophylaxis of malaria which drugs can be used?
Chloroquine and proguanil
189
Mefloquine is licensed for use up to how long?
use up to 1 year (although, if it is tolerated in the short term, there is no evidence of harm when it is used for up to 3 years).
190
How long can doxycycline be used up to for malaria prophylaxis?
Doxycycline can be used for up to 2 years
191
How long can atovaquone with proguanil be used for?
For up to 1 year
192
I important to consider that any illness that occurs within how long might indicate malaria?
any illness that occurs within 1 year and especially within 3 months of return
193
Is malaria a notifiable disease for HCPs?
Yes
194
Which antimalarial drug is unsuitable for malaria prophylaxis in patients with history of epilepsy?
Both chloroquine and mefloquine are unsuitable for prophylaxis in individuals with a history of epilepsy
195
Which antimalarial can be sued in patients with a history of epilepsy?
Doxycycline or
Atovaquone with proguanil
However, doxycycline may interact with some antiepileptics and its dose may need to be adjusted
196
Are asplenic individuals at higher or lower risk for severe malaria?
Asplenic individuals (or those with severe splenic dysfunction) are at particular risk of severe malaria. If travel to malarious areas is unavoidable, rigorous precautions are required against contracting the disease.
197
Which antimalarial can be used in prophylaxis in pregnant women?
Chloroquine and proguanil but these drugs are not appropriate for most areas because their effectiveness has declined.
198
When proguanil is being used in pregnancy which other drug should be given with it?
folic acid (dosed as a pregnancy at 'high-risk' of neural tube defects) should be given for the length of time that it is used during pregnancy.
199
If travelling to high risk areas or there is resistance to the other drugs (chloroquine or proguanil for pregnant women) then which drug can be used?
mefloquine may be considered during the second or third trimester of pregnancy.
Mefloquine can be used in the first trimester with caution if the benefits outweigh the risks
200
Can doxycycline be used for antimalaria in pregnancy?
it is CI in pregnancy,
however, it can be used for malaria prophylaxis if other regimens are unsuitable, and if the entire course of doxycycline can be completed before 15 weeks’ gestation.
201
Is prophylaxis required in breast-fed infants if the mother is receiving antimalaria prophylaxis?
Yes they are still required to be on prophylaxis treatment; although the antimalarials are present in milk; the amounts are too variable to give reliable protection
202
What must be noted for travellers on warfarin?
Travellers taking warfarin sodium should begin chemoprophylaxis 2–3 weeks before departure and the INR should be stable before departure.
It should be measured before starting chemoprophylaxis, 7 days after starting, and after completing the course.
For prolonged stays, the INR should be checked at regular intervals.
203
What should travellers visiting remote malarious areas carry?
should carry standby emergency treatment if they are likely to be more than 24 hours away from medical care.
Standby emergency treatment should also be considered in long-term travellers living in or visiting remote, malarious areas that may be far from appropriate medical attention; this does not replace the need to consider prophylaxis.
204
In order to use standby treatment appropriately, what should the traveller be provided with?
should be provided with written instructions which include seeking urgent medical attention if fever (38°C or more) develops 7 days (or more) after arriving in a malarious area and that self-treatment is indicated if medical help is not available within 24 hours of fever onset.
205
What should be noted for those that have migrated from a malarious country to the UK
Settled immigrants (or long-term visitors) in the UK may be unaware that any immunity they may have acquired while living in malarious areas is lost rapidly after migration to the UK, or that any non-malarious areas where they lived previously may now be malarious.
206
How many codes for regimens are there for prophylaxis of malaria used for ranking risk in coutries?
4
207
What are the different code regimens?
- No risk
1 = chemoprophylaxis not recommended, but avoid mosquito bites and consider malaria if fever present
2 = chloroquine only (very rare)
3 = (Risk present) chloroquine with proguanil
4 = (High risk) Atovaquone with proguanil or doxycycline or mefloquine
208
For the treatment of malaria - if infective species is not known, or if the infection is mixed and includes falciparum parasites then what must initial treatment be treated as?
initial treatment should be as for falciparum malaria.
209
Falciparum malaria is caused by which organism?
Plasmodium falciparum
210
Patients with falciparum malaria should usually be admitted where?
usually be admitted to hospital initially due to the risk of rapid deterioration even after starting treatment.
211
what is the treatment for falciparum malaria?
Artemisinin combination therapy is recommended for the treatment of uncomplicated P. falciparum malaria.
Artemether with lumefantrine is the drug of choice;
artenimol with piperaquine phosphate is a suitable alternative.
Oral quinine or atovaquone with proguanil hydrochloride can be used if an artemisinin combination therapy is not available
212
Can quinine be used in prolonged treatment?
Quinine is highly effective but poorly-tolerated in prolonged treatment and should be used in combination with an additional drug, usually oral doxycycline (or clindamycin [unlicensed] in pregnant women and young children).
213
In most parts of the world, P.falciparum is now resistant to which antimalarial drug?
Chloroquine which should not therefore be used for treatment of malaria
214
why is mefloquine no longer recommended for treatment of maria?
Mefloquine is also no longer recommended for treatment because of concerns about adverse effects and non-completion of courses.
215
What organism is non-falciparum malaria usually caused by?
Plasmodium Vivax and less commonly by P. ovale, P. malariae, and P. knowlesi. P. knowlesi is present in the Asia-Pacific region.
216
What should be sued for treatment of non-falciparum malaria?
Either an artemisinin combination therapy (such as artemether with lumefantrine or artenimol with piperaquine phosphate) or chloroquine can be used for the treatment of non-falciparum malaria.
217
What should patients be screened for before initiating primaquine?
Patients should be screened for G6PD deficiency before initiating primaquine treatment, as primaquine may cause haemolysis in G6PD deficient individuals.
218
Which drug can be used in pregnancy for non-falciparum malaria treatment?
Chloroquine can be given for non-falciparum malaria treatment throughout pregnancy
Artemisinin combination therapy can be used in the second and third trimesters, and quinine may be used in the first trimester if there is concern about chloroquine-resistant P. vivax.
In the case of P. vivax or P. ovale however, the radical cure with primaquine should be postponed until the pregnancy (and breast-feeding) is over; instead weekly chloroquine prophylaxis should be continued until delivery or completion of breast-feeding.
219
To summarise which two antimalarials are not suitable in history of epilepsy?
- Mefloquine and chloroquine
220
What type of malaria can chloroquine be used to treat?
It is no longer recommended for the treatment of falciparum malaria due to widespread resistance.
- But it is still recommended for the treatment of non-falciparum malaria.
221
What caution is required for mefloquine - what has it been associated with?
Associated with serious neuropsychiatric reactions
222
What other side effects may occur with mefloquine?
- dreams, insomnia, anxiety and depression
Adverse reactions may occur and persist for several months after discontinuation due to the long half-life of the drug.
223
What is malarone a combination of?
Atovaquone and proguanil
224
Which type of malaria is malarone licensed to treat?
Acute flaciparum malaria
225
Why is malrone (atovaquone and proguanil) suitable for short trips to chloroquine resistant areas?
It only needs to be taken for 7 days after leaving an endemic area
226
Is quinine suitable for prophylaxis of malaria?
No it is not suitable but can be used for the treatment of falciparum malaria, for malaria caused by unknown species and for mixed species.
227
Is quinin bisulphate dose equivalent to quinine hydrochloride, dihydrochloride and sulphate?
doses are valid for quinine hydrochloride, dihydrochloride and sulphate. They are not valid for quinine bisulphate which contains a smaller amount of quinine.
228
For malarone and doxycycline how long before travel should malaria prophylaxis start?
1-2 days before
229
How long should prophylaxis generally be continued after leaving the endemic area?
4 weeks except for malrone which should be stopped 1 week after leaving
230
Which antimalarials can be used in pregnancy?
Chloroquine and proguanil
231
If proguanil is used for prophylaxis then what must be given alongside it?
Folic acid - high risk dose
232
Can malarone be given during pregnancy?
• Malarone should be avoided during pregnancy but it can be considered during 2nd and 3rd trimester if there is no suitable alternative
233
How long before travel should patient taken warfarin begin their prophylaxis for malaria?
2-3 weeks before
234
When is promaquine given?
It is given after chloroquine to destroy parasites in the liver + thus prevetn relapses. in the treatment non-falciparum malaria
235
What about in the treatment of non-falciparum malaria treatment in pregnancy?
The adult treatment doses of chloroquine can be given during pregnancy, however the radical cure with Primaquine should be postponed until pregnancy is over.
236
What is Riamet a combination of?
Artemether with lumefantrine
- used for treatment of acute uncomplicated falciparum malaria
237
Is chloroquine or hydroxychloroquine more retinotoxic?
Chloroquine
238
What dose-dependent effect has quinine be associated with?
Quinine has been associated with dose-dependent QT-interval-prolonging effects and should be used with caution in patients with risk factors for QT prolongation or in those with atrioventricular block.
239
What is the drug of choice for acute amoebic dysentery?
Metronidazole is drug of choice
Tinidazole is also effective
Treatment with metronidazole (or tinidazole) is followed by a 10-day course of diloxanide furoate.
240
What is the drug of choice for asymptomatic patients with E.histolytica custs in the faeces?
Diloxanide furoate
metronidazole and tinidazole are relatively ineffective
Diloxanide furoate is relatively free from toxic effects and the usual course is of 10 days, given alone for chronic infections or following metronidazole or tinidazole treatment.
241
What is the drug of choice for Trichomonas vaginalis infection?
Metronidazole
Contact tracing is recommended and sexual contacts should be treated simultaneously
If metronidazole is ineffective then tinidazole may be tried.
242
What is the treatment of choice for Giardia lamblia?
Metronidazole
243
Do most infections caused by Toxoplasma gondii require treatment?
Most infections caused by Toxoplasma gondii are self-limiting, and treatment is not necessary.
Exceptions are patients with eye involvement (toxoplasma choroidoretinitis), and those who are immunosuppressed.
244
Toxoplasmic encephalitis is a common complication of which medical condition?
AIDs
245
What is the treatment of choice for toxoplasmosis?
The treatment of choice is a combination of pyrimethamine and sulfadiazine, given for several weeks (expert advice essential). Pyrimethamine is a folate antagonist, and adverse reactions to this combination are relatively common (folinic acid supplements and weekly blood counts needed
246
What are the common symptoms of COVID-19?
new continuous cough, loss or change in sense of smell or taste, loss of appetite, shortness of breath, and fatigue. Other symptoms, such as muscle aches, headache, sore throat, nasal congestion, nausea and vomiting, diarrhoea, chest pain, and skin rashes may also be present.
247
Long COVID is symptoms that persist for how many weeks?
More than 4 weeks
248
Individuals with COVID-19 have an increased risk of what?
Venous thromboembolism (VTE)
249
Who should dexamethasone be offered to in COVID-19 management?
Dexamethasone should be offered to patients with COVID‑19 who need supplemental oxygen, or who have a level of hypoxia that requires supplemental oxygen but are unable to have or tolerate it. If dexamethasone is unsuitable or unavailable, either hydrocortisone or prednisolone can be used.
250
Which monoclonal antibody can be used in the management of COVID-19?
Tocilizumab (a monoclonal antibody against interleukin-6)
251
What are some of the other treatment options of COVID-19?
include antivirals (such as remdesivir, or molnupiravir, or a combination of nirmatrelvir with ritonavir), or SARS-CoV‑2 neutralising monoclonal antibodies (such as sotrovimab, or a combination of casirivimab with imdevimab).
252
Are antibacterials recommended for preventing or treating pneumonia if it is likely to be caused by SARS-CoV-2, another virus or a fungal infection?
No
253
When should antibiotics be used in COVID-19?
Empirical antibacterials should be started if a secondary bacterial infection is suspected in patients with COVID‑19
254
should patients with cough be encouraged to lay down on their backs?
Patients with a cough should be encouraged to avoid lying on their backs, if possible, because this may make coughing less effective.
255
What can be used for cough associated with COVID-19?
Cough should be initially managed using simple non-drug measures (such as honey). For cough that is distressing in a patient with COVID‑19, consider short-term use of a cough suppressant (such as codeine phosphate or morphine).
256
Can patients with COVID-19 take ibuprofen or paracetamol?
Patients with fever should be advised to drink fluids regularly to avoid dehydration, and to take antipyretics (such as paracetamol or ibuprofen) as appropriate (whilst both fever and other symptoms that antipyretics would help treat are present)
257
Which drugs are options for treatment of hepatitis B?
Entecavir, peginterferon alfa, tenofovir alafenamide, and tenofovir disoproxil are options for the treatment of chronic hepatitis B infection.
258
Which of the previous drugs can be used to treat hep B for patients with decompensated liver disease?
Entecavir and tenofovir disoproxil
259
What should you do if drug resistance emerges?
If drug-resistance emerges during treatment, consider switching to, or adding another antiviral drug to which the virus is sensitive; ensure the antiviral drug does not share cross-resistance.
260
before starting treatment for hep C, what should be determined?
the genotype of the infecting hepatitis C virus should be determined and the viral load measured as this may affect the choice and duration of treatment.
261
Give an example of a nucleoside reverse transcriptase inhibitor that is used in Hep B treatment?
Tenofovir alafenamide
262
Give an example of a nucleotide analogue used in Hep B treatment?
Adefovir Dipivoxil
263
Give an example of a nucleoside analgoue used in Hep C treatment?
Ribavirin
264
What is herpes infection of the mouth and lips and in the ye generally associated with?
With herpes simplex virus serotype 1 (HSV-1); other areas of the skin may also be affected, especially in immunodeficiency
265
What type of herpes is genital infection associated with?
most often associated with HSV-2 and also HSV-1.
266
It topical antiviral treatment routinely recommended in immunocompetent individuals with uncomplicated infection of the lips (herpes labialis or cold sores) or herpetic gingivostomatitis?
No
267
For herpes simplex can oral paracetamol and/or ibuprofen be given to relieve pain?
Yes
268
What formulation is primary or recurrent genital herpes simplex infection treated with?
oral - given by mouth
269
Can ocular herpes simplex be treated the same way?
No - if suspected they should be referred for urgent same day specialist referral.
270
Does herpes simplex in pregnancy require referral?
Yes
271
Give an example of a varicella-zoster infection?
Chicken pox - which is an acute disease caused by the varicella-zoster virus.
272
When is chickenpox more severe?
In neonates - can cause complications
Adolescents (14 years and over) and in adults.
273
In this high severity patients what may be considered?
Antiviral treatment started within 24 hours of the onset of rash may be considered, particularly for those with severe infection or at risk of complications.
274
Which virus is shingles caused by?
herpes zoster
275
What is shingles?
Shingles (herpes zoster) is a viral infection of an individual nerve and the skin surface affected by the nerve.
The infection is caused by the reactivation of the varicella-zoster virus, the same virus that causes chickenpox.
276
Who should oral antiviral treatment for shingles be given to?
Oral antiviral treatment should be offered to patients with shingles who are immunocompromised, have non-truncal involvement (e.g. neck, limbs, perineum), or to those with moderate to severe pain or rash. Consider oral antiviral treatment for patients aged over 50 years to reduce the risk of post-herpetic neuralgia.
277
For shingles, how long within should treatment with antiviral start?
Treatment with the antiviral should be started within 72 hours of the onset of rash.
278
Is aciclovir active aginst herpes viruses?
Aciclovir is active against herpesviruses but does not eradicate them
279
What are some uses of aciclovir?
Uses of aciclovir include systemic treatment of varicella-zoster and the systemic and topical treatment of herpes simplex infections of the skin and mucous membranes. Aciclovir eye ointment is licensed for herpes simplex infections of the eye.
280
What can famciclovir be used for?
Famciclovir, a prodrug of penciclovir, is similar to aciclovir and may be used in the treatment of herpes zoster (shingles) and genital herpes.
281
What is the uses of valaciclovir?
Valaciclovir is an ester of aciclovir, which may be used in the treatment of herpes zoster and herpes simplex infections of the skin and mucous membranes (including genital herpes); it is also licensed for preventing cytomegalovirus disease following solid organ transplantation.
282
Which group of viruses does cytomegalovirus (CMV) belong to?
Cytomegalovirus (CMV) is a member of the herpesvirus group
283
Does CMV show symptoms in every patients?
In immunocompetent patients, CMV infection is often asymptomatic and self-limiting therefore treatment is not always required.
In immunocompromised patients, such as those with AIDS and transplant recipients, the infection manifests more severely causing diseases associated with greater morbidity and mortality.
284
Which drugs are licensed for use in the management of CMV disease?
Drugs licensed for use in the management of CMV disease include ganciclovir (related to aciclovir), cidofovir, foscarnet sodium, letermovir, valaciclovir, and valganciclovir (an ester of ganciclovir). There is a possibility of ganciclovir resistance in those who repeatedly have a poor treatment response or when viral excretion continues despite treatment.
285
What type of antiviral does aciclovir belong to?
Nucleoside analogue
286
Name other nucleoside analgoues used in herpes treatment?
Famciclovir (pro drug of panciclovir)
Valaciclovir
287
List the drugs that can be used in cytomegalovirus infections?
```
Cidofovir
Ganciclovir
Valganciclovir
Foscarnet sodium
Letermovir
```
288
Is aciclovir safe to take in pregnancy?
Yes and usually taken 5 times a day
289
What is HIV?
The human immunodeficiency virus (HIV) is a retrovirus that causes immunodeficiency by infecting and destroying cells of the immune system, particularly the CD4 cells
290
What does AIDS stand for?
Acquired immune deficiency syndrome
291
When does AIDS occur?
Acquired immune deficiency syndrome (AIDS) occurs when the number of CD4 cells fall to below 200 cells/microlitre;
292
Why has prognosis of HIV and AIDS greatly improved?
The prognosis of HIV and AIDS has greatly improved due to more effective and better tolerated antiretroviral therapy (ART).
293
What does HIV treatment aim to do?
Treatment aims to achieve an undetectable viral load, to preserve immune function, to reduce the mortality and morbidity associated with chronic HIV infection, and to reduce onward transmission of HIV, whilst minimising drug toxicity.
294
Should all patients with diagnosed HIV be offered immediate treatment?
All patients diagnosed as being HIV positive should be offered immediate treatment, irrespective of CD4 cell counts.
295
What can low adherence to HIV treatment lead to?
Low adherence can be associated with drug resistance, progression to AIDS, and death.
296
What is treatment of HIV infection in treatment-naive patients initiated with?
with a combination of two nucleoside reverse transcriptase inhibitors (NRTIs) as a backbone regimen plus one of the following as a third drug: an integrase inhibitor (INI), a non-nucleoside reverse transcriptase inhibitor (NNRTI), or a boosted protease inhibitor (PI).
297
For the regimen of choice for HIV what are the options?
The regimen of choice contains a backbone of emtricitabine and either tenofovir disoproxil or tenofovir alafenamide. An alternative backbone regimen is abacavir and lamivudine. The third drug of choice is either atazanavir or darunavir both boosted with ritonavir, or dolutegravir, or elvitegravir boosted with cobicistat, or raltegravir, or rilpivirine. Efavirenz may be used as an alternative third drug.
298
What should patients who require treatment for both HIV and chronic hepatitis B be treated with?
with antivirals active against both diseases as part of fully suppressive combination ART.
299
What are the choices of regimen in patients who require treatment for both HIV and Chronic hep B?
Regimens of choice are tenofovir disoproxil and emtricitabine, or tenofovir alafenamide and emtricitabine.
300
Can ART be used during pregnancy?
Yes
301
What is the recommended regimen for treating HIV in pregnant women?
The recommended regimen is a NRTI backbone of either tenofovir disoproxil or abacavir with either emtricitabine or lamivudine; the third drug should be efavirenz or atazanavir boosted with ritonavir.
302
Can HIV positive women breastfeed?
No - Breast-feeding by HIV-positive mothers may cause HIV infection in the infant and should be avoided.
303
What is the treatmetn for prophylaxis of HIV following potential sexual exposure to HIV?
The recommended treatment for post-exposure prophylaxis is emtricitabine with tenofovir disoproxil plus raltegravir for 28 days.
304
Which nucleoside reverse transcriptase inhibitors (NRTI) are licensed for the treatment of HIV/AIDS?
abacavir (ABC); emtricitabine (FTC), lamivudine (3TC); tenofovir alafenamide fumarate (TAF), tenofovir disoproxil fumarate (TDF), and zidovudine (AZT).
305
Which non-nucleoside reverse transcriptase inhibitors (NNRTI) are licensed for the treatment of HIV/AIDS?
doravirine (DOR), efavirenz (EFV), etravirine (ETR), nevirapine (NVP), and rilpivirine (RPV).
306
Which protease inhibitors (PI) are licensed for the treatment of HIV/AIDS?
atazanavir (ATZ), darunavir (DRV), fosamprenavir (FOS-APV), lopinavir (LPV), ritonavir (RTV), saquinavir (SQV), and tipranavir (TPV).
307
Which other drug classes are licensed to be used in treatment of HIV/AIDS?
CCR5 antagonists: maraviroc (MVC).
Integrase inhibitors (INI): bictegravir (BIC), cabotegravir (CAB), dolutegravir (DTG), elvitegravir (EVG), and raltegravir (RAL).
Fusion inhibitors: enfuvirtide (T-20).
Attachment inhibitors: fostemsavir (FTR).
Pharmacokinetic enhancers: cobicistat (c), and low-dose ritonavir (r). They boost the concentrations of other antiretrovirals metabolised by CYP3A4.
308
To summarise, is there a cure for HIV?
There is no cure for infection caused by the Human Immunodeficiency Virus (HIV) but a number of drugs can slow disease progression, known as Antiretrovirals (stop the virus replicating in the body).
309
treatment for HIV includes a combination of drugs known as what?
'highly active antiretroviral therapy'
310
Summarise the treatment for HIV?
• Treatment is initiated with 2 nucleoside reverse transcriptase inhibitors (usually Tenofovir + Emtricitabine) and either a non-nucleoside reverse transcriptase inhibitor (usually Efavirenz) or a boosted protease inhibitor (e.g. ritonavir) or an integrase inhibitor.
311
The risk of acquiring HIVE is increased in which individuals?
* Men/transgender individuals who have had unprotected anal sex intercourse with men
* Sexual partners of people who are HIV-positive with a detectable viral load,
* HIV-negative heterosexual individuals who have unprotected intercourse with a HIV-positive person.
312
Which antiretroviral is appropriate to use in prophylaxis of HIV?
Emtricitabine with Tenofovir are appropriate for pre-exposure prophylaxis to reduce the risk of sexually-acquired HIV infection.
313
What is the role of ritonavir in low doses?
It boosts the activity of protease inhibitors - increasing their plasma concentration.
314
What side effects are protease inhibitors associated with?
with lipodystrophy and metabolic effects
315
What disorders are common with Efavirenz (NNRTI)?
Psychiatric and CNS disturbances
CNS disturbances are often self-limiting and can be minimised by taking the dose at bedtime.
Also associated with raised plasma-cholesterol concentration
316
Is influenza highly infectious?
Yes
317
How many types of influenza are there?
3 types (A,B and C)
318
Which type of influenza is more virulent?
Influenza A and occurs more frequently
319
Which is least symptomatic?
Influenza C - causes mild or asymptomatic disease, similar to the common cold
320
How does transmission occur for influenza?
Transmission occurs via droplets, aerosols, or direct contact with respiratory secretions from an infected person, and the usual incubation period is 1–3 days.
321
What are the symptoms of influenza?
Symptoms usually appear suddenly and may include chills, fever, headache, extreme fatigue, and myalgia. Dry cough, sore throat and nasal congestion may also be present.
322
The risk of more serious illness caused by influenza is greater in which individuals?
for those in at-risk groups, such as children aged under 6 months; pregnant females (including females up to 2 weeks post-partum); adults aged over 65 years; patients with long-term conditions such as respiratory, renal, hepatic, neurological or cardiac disease, diabetes mellitus, or morbid obesity (BMI ≥ 40 kg/m²); or those with severe immunosuppression.
323
Which two antivirals can be used for both the treatment and post exposure prophylaxis of influenza?
OZ
Oseltamivir
Zanamivir
324
Which conditions of type of influenza has a higher risk of resistance to oseltamavir?
In general, the risk of developing oseltamivir resistance is considered to be greater for influenza A(H1N1)pdm09 compared to other strains (such as influenza A(H3N2) and influenza B), with the risk of resistance being higher in patients who are severely immunosuppressed.
325
Where treatment with oseltamivir is indicated, it should be started as soon as possible, ideally within how many hours?
Within 48 hours of symptom onset
treatment initiation beyond 48 hours of onset is unlicensed and clinical judgement should be used.
326
Where treatment with inhaled zanamivir is indicated, it should also be started as soon as possible, ideally within houw many hours?
8 hours (36 hours in children) of symptom onset;
treatment initiation beyond this time is unlicensed and clinical judgement should be used.
327
Where treatment with intravenous zanamivir is indicated, it should be commenced as soon as possible and within how many days?
Within 6 days of symptom onset
328
For patients who are otherwise healthy (excluding pregnant females), is antiviral treatment usually needed (uncomplicated influenza)?
No
329
For those considered to be at serious risk of developing complication from influenza what drug should they be offerd?
Oseltamivir
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What about patients in at risk group (including pregnant females but excluding those who are severely immunosuppressed?
Offer oseltamivir - do not wait for laboratory test results to treat
331
What about treatment of influenza for severely immunosuppressed patients?
For severely immunosuppressed patients, consider the subtype of influenza causing the infection, or if not yet known, take into account the current dominant circulating strain.
Offer oseltamivir first-line unless the strain has a higher risk for oseltamivir resistance, in which case inhaled zanamivir should be offered.
For patients unable to use inhaled zanamivir due to underlying severe respiratory disease or inability to use the device (including children under 5 years), offer oseltamivir and assess response to therapy.
332
How long within should prophylaxis if required for influenza be started?
as soon as possible following exposure—ideally within 48 hours for oseltamivir and 36 hours for inhaled zanamivir. Initiation beyond these times is unlicensed and specialist advice should be sought.
333
For patients in an at-risk group (including pregnant females but excluding severely immunosuppressed patients and children aged under 5 years), what should be offered first line for prophylaxis?
- Oseltamivir first line regardless of the risk of resistance of the circulating or index case strain
For patients exposed to a strain with suspected or confirmed oseltamivir resistance, offer inhaled zanamivir.
334
Can oseltamivir be used for children under the age of 1? (unlicensed)
Yes for the treatment or post exposure of prophylaxis of influenza
335
What is immune reconstitution syndrome?
Improvement in immune function as a result of antiretroviral treatment may provoke a marked inflammatory reaction against residual organisms. These reactions occur within the first few weeks or months of initiating treatment. Autoimmune disorders (e.g. graves’ disease) have also been reported.
336
What is respiratory syncytial virus?
Respiratory syncytial (sin-SISH-uhl) virus, or RSV, is a common respiratory virus that usually causes mild, cold-like symptoms. Most people recover in a week or two, but RSV can be serious, especially for infants and older adults.
337
Which drug is licensed for administration by inhalation for the treatment of severe bronchiolitis caused by the respiratory syncytial virus (RSV) in infants?
Ribavirin is licensed for administration by inhalation for the treatment of severe bronchiolitis caused by the respiratory syncytial virus (RSV) in infants, especially when they have other serious diseases.
However, there is no evidence that ribavirin produces clinically relevant benefit in RSV bronchiolitis.
338
Which monoclonal antibody is licensed for preventing serious lower respiratory tract disease caused by respiratory syncytial virus in children at high risk of the disease?
Palivizumab
339
Who is palivizumab recommended for?
recommended for:
children under 9 months of age with chronic lung disease (defined as requiring oxygen for at least 28 days from birth) and who were born preterm;
children under 6 months of age with haemodynamically significant, acyanotic congenital heart disease who were born preterm.
340
Who else should palivizumab be considered for?
children under 2 years of age with severe combined immunodeficiency syndrome;
children under 1 year of age who require long-term ventilation;
children 1–2 years of age who require long-term ventilation and have an additional co-morbidity (including cardiac disease or pulmonary hypertension).
341
With use of Linezolid what symptoms should patients report?
1. Severe optic neuropathy may occur rarely particularly if used for longer than 28 days. Thus, patients should report symptoms of visual impairment + visual function should be monitored regularly if treatment is for longer than 28 days.
342
Why should FBC be monitored when on Linezolid?
2. Blood disorders (Inc. thrombocytopenia, anaemia and leucopenia) have been reported, so FBC’s must be monitored weekly. If significant bone marrow suppression occurs… treatment should be stopped unless it is considered essential.
343
Which side effect should be looked out for when using daptomycin?
muscle effects if unexplained muscle pain, tenderness, weakness or cramps develop during treatment, measure creatine kinase every 2 days and discontinue if unexplained muscular symptoms and creatine elevated markedly.
344
In which patients should itraconazole be avoided in?
following reports of heart failure, caution is advised when prescribing to patients at high risk of heart failure (older adults + those with cardiac disease, patients with chronic lung disease associated with pulmonary hypertension and those receiving negative inotropic drugs). Itraconazole should be avoided in patients with ventricular dysfunction or a history of heart failure.
345
Which potentially life threatening side effect has been reported with itraconazole use?
: potentially life-threatening hepatotoxicity has been rarely reported. Discontinue if signs of hepatitis develop. Signs of liver disorder include anorexia, nausea, vomiting, fatigue, abdominal pain and dark urine -> patients should be told to recognise these symptoms. Thus, liver function should be monitored.
346
What should patients on voriconazole be advised?
Hepatotoxicity (hepatitis, cholestasis and acute hepatic failure) has been reported.
: patients should be told to recognise symptoms of liver disorder and seek immediate medical attention if nausea, malaise, vomiting or jaundice develop.
Patients should be advised to avoid intense or prolonged exposure to sunlight and to avoid the use of sunbeds. In sunlight, patients should cover sun-exposed areas of the skin and use a sunscreen with a high sun protection factor. If patients experience sunburn or a severe skin reaction following exposure to sunlight… they should seek immediate medical attention
347
Is the risk of hepatoxicity with oral ketoconazole greater it less than the benefit in treating fungal nail infections?
the risk of hepatotoxicity with oral ketoconazole is greater than the benefit in treating fungal infections. Thus, patients receiving ketoconazole should be reviewed with a view to stopping treatment or choosing an alternative.
348
What monitoring requirements are there for ketoconazole?
Monitor ECG before and 1 week after initiation. Monitor adrenal function within one week of initiation, then regularly thereafter.
When cortisol levels are normalised or close to target and effective dose established, monitor every 3-6 months as there is a risk of autoimmune disease development after normalisation of cortisol levels.
349
For oral ketoconazole - what are the symptoms suggestive of adrenal insufficiency?
fatigue, anorexia, nausea, hypoglycaemia, hyponatraemia, hypotension)
If these occur - measure cortisol levels and discontinue treatment temporarily, or reduce dose.
350
With ketoconazole treatment, what should you do if liver enzymes increases?
Reduce dose if liver enzymes increase less than 3 times the normal limit but if liver enzymes are raised to 3 times or greater the normal limit, discontinue treatment permanently.
