Chapter 5: Infection Part 1 Flashcards
1
Q
What are the safest classes of antibiotics to use in pregnancy?
A
~ Penicillins
~ Erythromycin
~ Cephalosporins (1st gen cefalexin, 2nd gen ceftriaxone)
2
Q
What antibiotic treatment is indicated for septicaemia (community or hospital acquired)?
A
BROAD SPEC antibiotics: e.g. tazocin (pipericillin and tazobactam)
If MRSA suspected: add Vancomycin
Anaerobic: Metronidazole
Meningococcal: Benzylpenicillin
Pen/Ceph allergy: Chloramphenicol
3
Q
What antibiotic Is very good against anaerobic bacteria so usually infections of the colon?
A
Metronidazole
Used for bacteria growing where there isn’t much oxygen: Gut, Bacterial vaginosis, Leg ulcers
4
Q
How is bacterial meningitis empirically treated?
A
1) BENZYPENICILLIN- can be given before transfer to hospital
2) If penicillin allergy- CEFOTAXIME
3) If hypersensitivity to penicillin & cephalosporins: CHLORAMPHENICOL
4) Consider Vancomycin if multiple use of antibiotics in previous 3 months
5
Q
What is the treatment for meningococcal meningitis?
A
Benzylpenicillin or cefotaxime
2nd line: Chloramphenicol For 7 days
6
Q
What is the treatment for pneumococcal meningitis?
A
Benzylpenicillin
Cefotaxime (OR ceftriaxone)
If allergic: chloramphenicol
If resistant: vancomycin/rifampicin
7
Q
What is the treatment for meningitis caused by haemophilus influenza?
A
Cefotaxime or ceftriaxone
For 10 days
8
Q
What antibiotics are used in endocarditis (infection of the heart)?
A
1) Amoxicillin
If resistant MRSA or pen allergy: Vancomycin
+/- low-dose gentamicin hence lower target level range for gentamicin in endocarditis (trough<1, peak 3-5)
Staph: flucloxacillin
Strep: Benzylpenicillin
9
Q
What antibiotic is indicated for gastro-enteritis?
A
This is usually self-limiting and an antibiotic not indicated
10
Q
What is the antibiotic indicated for C. diff?
A
1st episode: oral Metronidazole (high anaerobic activity)
2nd episode/2nd line: oral Vancomycin
Use together if combo not worked: oral Fidaxomicin
10-14 day treatment length
11
Q
Which antibiotics are commonly used for genitourinary infections? Excluding UTI.
A
Azithromycin- used in chlamydia, gonorrhoea
Doxycycline- alternative in chlamydia, pelvic inflammatory disease, syphilis
Metronidazole- bacterial vaginosis, pelvic inflammatory disease
12
Q
What class of antibiotic is Amikacin? When is amikacin usually indicated?
A
aminoglycoside
~ usually indicated for gentamicin resistant infections as amikacin more stable than gentamicin to enzyme inactivation.
13
Q
What is the target one hour peak concentration of gentamicin? (multiple daily dosing)
A
5 - 10 mg/L
3-5mg/L if endocarditis
14
Q
What is the target pre-dose trough concentration of gentamicin? (multiple daily dosing)
A
Under 2 mg/L
<1mg/L if endocarditis
15
Q
What is the target one hour peak conc of gentamicin in treatment of ENDOCARDITIS? And target trough level?
A
Peak: 3 - 5 mg/L
Trough: <1mg/L
16
Q
Which aminoglycoside is too toxic to be administered parenterally, therefore is taken by mouth?
What is the indication for this?
A
NEOMYCIN
Used for bowel sterilisation before surgery
17
Q
Etrapenem, Imipenem and Meropenem are all examples of what kind of antibiotics?
A
Carbapenems- beta-lactam antibacterials
Imipenem is administered with cilastatin which is a specific enzyme inhibitor that stops it being renally metabolised
18
Q
Which two cephalosporins are suitable for infections of the CNS?
A
Cefotaxime + Ceftriaxone (TAX AND TRAX)
19
Q
What is used in the treatment of UTIs in pregnancy?
A
Nitrofurantoin: okay to use but avoid at term
Cefalexin: cephalosporin, safe in pregnancy
Trimethoprim: Teratogenic risk in 1st trimester as is folate antagonist
Cranberry juice or other cranberry products not recommended as no evidence to support their use
20
Q
What classes, other than penicillins, do we have to be wary of with penicillin allergic patients?
A
Cephalosporins- cefalexin, cefadroxil, ceftriaxone, cefixime, cefotaxime
(0.5-6.5% cross-sensitivity)
21
Q
What is co-trimoxazole? What is it used for?
A
Contains SULFAMETHOXAZOLE + TRIMETHOPRIM!
Resistance to sulphonamides increased so restrictions on use of co-trimoxazole.
LIMITED USE. Indicated for Pneumonia caused by p.jiroveci/ carinii.
Also for toxoplasmosis + nocardiasis
Should only be used in bronchitis exacerbation/ UTI’s/ otitis media in children when culture and sensitivities evident
22
Q
What antibiotics require reporting on blood disorders/ rash?
A
Co-trimoxazole (trimethoprim + sulfamethoxazole)
Discontinue immediately if signs of blood disorder - anaemia, thrombocytopenia, rash (SJS) photosensitivity
Trimethoprim- risk of blood disorders, signs include fever, sore throat, ulcers, bruising, bleeds
Penicillamine: used as DMARD but report fever, sore throat, ulcers, bruising
23
Q
What do you see fusidic acid commonly used for?
What formulations are available?
A
Staphylococcal infection of the SKIN e.g. impetigo & also EYES
Tablet, cream, eye drops
24
Q
What happens if a patient on clindamycin develops diarrhoea?
A
Antibiotic associated colitis with clindamycin can be fatal
Discontinue immediately + start vancomycin
25
What antibiotic has been associated with myopathy/muscle effects?
Daptomycin
Monitor creatinine kinase every 2 days if muscle effects reported
26
Which antibiotics can cause cholestatic jaundice?
Co-amoxiclav
Nitrofurantoin
Flucloxacillin (even upto 2 months after)
27
What is the important safety information associated with Flucloxacillin?
Hepatic disorders: Cholestatic Jaundice and HEPATITIS have been reported in patients even up to 2 months after the drug has been stopped.
Use flucloxacillin with caution in patients with liver impairment!!
28
A few antibiotics have been associated with visual problems. Name them.
**Linezolid**- optic nephropathy
**Quinolones** (Ciprofloxacin, Levofloxacin)- retinal detachment
**Ethambutol**- ocular toxicity
**Rifampicin**- colours tears/ contacts red
**Rifabutin**- uveitis (eye inflammation)
29
What two adverse events should be monitored during Linezolid treatment?
Optic neuropathy (visual problems)- report any visual disturbance IMMEDIATELY
Blood disorders- aneamia, thrombocytopenia
FBC monitored especially in treatment of 10-14 days or more
30
What are the two safety warnings with QUINOLONES (ciprofloxacin, levofloxacin)?
**CONVULSIONS**
Especially if also taking NSAIDS - even in those that are not epileptic.
Caution in EPILEPSY.
Caution with THEOPHYLLINE as also causes seizures.
**TENDON DAMAGE**
Tendonitis, tendon rupture
also been reported with prednislone!
**Can also prolong QTc interval- caution**
31
When should patients discontinue treatment with Quinolones?
If any of the following occur:
Psychiatric reactions- hallucinations, anxiety, depression
Neurological reactions- tremor, asthenia (abnormal weakness)
32
Which antibiotics can cause QT prolongation?
MACROLIDES
Erythromycin
Clarithromycin
Azithromycin
QUINOLONES
Ciprofloxacin
Levofloxacin
Especially Moxifloxacin
33
Linezolid is an antibacterial used in pneumonia. It also had Monoamine oxidase inhibition activity (part of MAOI family).
What should patients be advised to avoid?
Avoid consuming large amounts of Tyramine rich foods
Remember: Linezolid will still have interactions/tyramine effects 2 weeks after discontinuation
34
What can happen if vancomycin is infused too rapidly?
RED MAN SYNDROME
```
Severe Hypotension
Wheezing
Pruritis
Pain
Muscle spasm in back
```
35
After how many doses should Vancomycin plasma levels be measured?
Pre fourth dose if renal function is normal
36
What side effects do Vancomycin and Gentamicin both have in common? What drugs should be avoided with these?
Ototoxicity
Nephrotoxicity
Ototoxic drugs: Loop diuretics
Nephrotoxic drugs: ciclosporin, platinum chemotherapy
37
Treatment with Vancomycin requires full blood count monitoring. Why is this?
Risk of neutropenia
38
Which antibiotics could cause CHOLESTATIC JAUNDICE?
FLUCLOXACILLIN- may even occur up to 2 months after flucloxacillin stopped, more likely after TWO WEEKS of treatment.
Co-fluampicil (contains amoxicillin and flucloxacillin)
Co-amoxiclav
Nitrofurantoin
39
Which antibiotics are commonly used to treat acne??
Tetracyclines most common: tetracycline, doxycycline, oxytetracycline
Erythromycin (a macrolide) sometimes used
40
What conditions can Tetracyclines exacerbate?
```
Systemic Lupus Erythematosus
Myasthenia Gravis (increased muscle weakness)
```
41
Which antibiotics can cause photosensitivity?
Doxcycline
| Demeclocycline
42
Which antibiotics are not recommended in children and adolescences under 18 years old? And why?
Quinolones: Ciprofloxacin, levofloxacin, moxifloxacin
because of risk of TENDON DAMAGE/ JOINT DISEASE (Aropathy)
43
What is an important monitoring parameter with Linezolid?
WEEKLY FBC due to risk of blood disorder/ anaemia
44
Which antibiotics may cause a false positive result on urinary glucose tests- i.e. be careful when testing for diabetes?
CEPHALOSPORINS
| Cefalexin, Ceftriaxone etc
45
Which antibiotic is a FOLATE SYNTHESIS INHIBITORS and is therefore teratogenic?
Trimethoprim
Co-trimoxazole (contains sulfamethoxazole and trimethoprim)
Therefore AVOID in pregnancy- especially first trimester when folate is needed
46
What frequency of administration is Vancomycin given?
| What about Teicoplanin?
12 hourly due to long half life
Teicoplanin: even longer acting OD dosing after loading dose
47
Name 2 Glycopeptide antibiotics?
Vancomycin
| Teicoplanin (less nephrotoxic than vancomycin)
48
What are the target pre-dose TROUGH levels for vancomycin?
10 - 15 mg/ L
49
First line antibiotic for Cellulitis?
| And in penicillin allergy?
Flucloxacillin (250-500mg QDS)
If penicillin allergic: Clarithromycin
50
Which antibiotics/ antifungals may cause STEVEN-JOHNSON SYNDROME?
Co-trimoxazole
Clindamycin
Fluconazole
51
What are some of the more common side effects experienced with Metronidazole?
Lots of GI disturbance- sick, stomach pain
Mouth effects: Taste disturbance, oral mucositis (mouth ulcers), furry tongue
Alcohol- disulfiram like reaction
52
What is fusidic acid used for?
Narrow spectrum antibiotic used for STAPHYLOCOCCAL SKIN infections
Used for impetigo (topical)
Staph eye infections (topical)
53
Which antibiotic is cautioned in problems to do with the following?
Lungs
Liver
Neurones
```
Nitrofurantoin:
Pulmonary Fibrosis
Cholestatic Jaundice
Peripheral Neuropathy
Can cause Vit B/ Folate deficiency
```
54
Which antifungal medication can cause QT prolongation?
FLUCONAZOLE
55
What antibiotics/antifungals should be stopped if signs of dark urine, vomiting, fatigue, anorexia occur?
This indicated LIVER FAILURE
```
Discontinue drugs that are hepatotoxic: Itraconazole
Fluconazole
Ketoconazole
Terbinafine
Rifampicin
Isoniazid
Pyrizinamide
```
56
Which antifungal is cautioned in patients at a high risk of heart failure?
ITRACONAZOLE
As can worsen this
More at risk if on negatively ionotropic drug e.g. CCB
57
What skin condition may Terbinafine (antifungal) exacerbate?
Psoriasis
58
Which antifungal can cause renal toxicity?
AMPHOTERICIN
- also electrolyte disturbance- Hypokaleamia + hypomagneseamia
59
Which antimalarials are unsuitable in patients with epilepsy/history of epilepsy?
CHLOROQUINE
| MEFLOQUINE
60
Which antimalarials are ok to use in pregnancy?
Chloroquine and Proguanil can both be used at normal doses in pregnancy as benefit of malaria prophylaxis outweighs any risk
BUT recommend FOLIC ACID 5mg to be taken with proguanil
61
What does the antimalarial Malarone contain?
| What condition is this recommended in?
Proguanil & Atovaquone
| This is fine to use in epilepsy- does not contain chloroquine or mefloquine
62
What is the most common causative bacteria of a UTI?
E. coli
63
What is the main indication for clindamycin?
| Why?
Osteomyelitis
| Good bone penetration
64
```
Daktacort cream (containing Miconazole and Hydrocortisone) needs to be stored where?
What about Daktacort ointment?
```
Daktocort CREAM stored in fridge- creams are more water based so more liable to bacterial growth
Ointment on shelf- more stable, less water less bacteria
Similar to chloramphenicol eye drops/ ointment- DROPS in FRIDGE as more water based, ointment on shelf
65
What drugs are used to treat Bacterial Vaginosis?
Metronidazole vaginal gel
| Clindamycin cream
66
Which antifungal requires an Alert card as it is so Hepato-toxic?
Voriconazole
67
What two toxicities may Voriconazole cause?
Hepatotoxicity
| Phototoxcity
68
What antibiotics are commonly seen prescribed for chest infections?
**Penicillins**- Amoxicillin or Ampicillin
Or if not: **Macrolide** - Azithromycin, Clarithromycin or Erythromycin
**Co-amoxiclav** used for more serious chest infections as broader action over typical bacteria (e.g. H. influenzae)
69
How is oral thrush managed?
Initially topical treatment with either Miconazole oromucosal gel or NYSTATIN oral suspension
If these don't work or patient has a dry mouth can use Oral fluconazole capsule
70
What is the key drug interaction with meropenem?
Sodium Valproate level significantly reduced
71
What is the usual organism (Not atypical) causing Lower respiratory tract infections?
Streptococcus pneumoniae - major cause of pneumonia
S. pneumoniae is also one of the major causes of meningitis (pneumonococcal) along with Neisseria meningitidis (meningococcal)
72
What antibiotic should be used for resistant strains of pneumonia?
Co-amoxiclav
This contains amoxicillin plus clavulanic acid which is a beta lactamase inhibitor- this makes this antibiotic very effective against more resistant strains.
73
Aside from antibiotics like clindamycin etc, what can cause C.diff?
PPI
74
What is the difference between the discharge in bacterial vaginosis and Trichomoniasis Vaginalis?
Bacterial vaginosis- thick, white and fishy discharge- cottage cheese like in appearance
Trichomoniasis Vaginalis- frothy-smell, green/ yellow coloured
75
What are the most common causative organisms of Community Aquired pneumonia?
Streptococcus pneumoniae
Haemophilus influenzae
Atypical (less common):
Chlamydia pneumoniae
Mycoplasma pneumoniae
Legionella
76
What antibiotics are suitable in pregnancy?
Penicillins and Cephalosporins
77
What are the indications for aminoglycosides?
Used for serious infections
CNS infections e.g meningitis, TB
Pyelonephritis, pneumonia, endocarditis
78
What is the therapeutic range for gentamicin?
5-10mg/L
79
Which aminoglycoside is given orally? And why?
Neomycin
| Too toxic for IV use
80
What are the side effects of aminoglycosides?
1) Nephrotoxicity
2) Ototoxicity
3) Peripheral neuropathy
81
Aminoglycosides shouldn't be used in what conditions? Why?
1) Myasthenia gravis (impairs neuromuscular transmission)
2) Pregnancy (ear damage)
82
Aminoglycosides interact with what drugs?
1) Loop diuretics and Vancomycin (ototoxicity)
2) Cisplatin, Ciclosporin and vancomycin (nephrotoxicity)
83
IV treatment with aminoglycosides should not exceed how many days?
7 days
84
Monitoring requirements for aminoglycosides?
1) Plasma concentration (18-24 hours after dose)
2) Renal function (especially during periods of dehydration)
3) Auditory and vestibular function
85
Common bacteria in meningitis? (3)
1) Neisseria meningitidis
2) Streptococcus pneumoniae
3) Haemophilius influenza
86
Antibiotics used in meningitis?
Benzylpenicillin, cefotaxime, chloramphenicol
87
Name 8 cephalosporins?
1) Cefalexin 2) Cetrotide 3) Cefaclor 4) Cefuroxime 5) Cefixime 6) Ceftriaxone 7) Ceftaroline 8) Fosamil
88
Are cephalosporins broad spectrum?
Yes
89
Indications for cephalosporins?
2nd or 3rd line treatment for UTI and RTIIV for severe resistant organisms Pneumonia, meningitis, gonorrhoea
90
Side effects of cephalosporins? (2)
1) GI effects
| 2) Penicillin hypersensitivity (avoid in known allergy)
91
Do IV cephalosporins require approval by a microbiologist?
YES and are now mainly restricted to antibiotic associated colitis
92
What is the interaction between cephalosporins and warfarin?
Cephalosporins kill gut flora responsible for synthesizing vitamin K this results in reduction in production of vitamin K dependent blood clotting factors-results in **increased** **anticoagulant** **effect** **of warfarin**.
93
What is the first line antibiotic group for MRSA?
Glycopeptides e.g vancomycin, Teicloplanin etc
94
What indications are glycopeptides generally used for?
MRSA
C.diff
Endocarditis
surgical prophylaxis (MRSA risk)
95
What are the main side effects of glycopeptides? (5)
1) Nephrotoxicity
2) Blood disorders
3) Ototoxicity
4) Red man syndrome
5) Thrombophlebitis (IV)
96
When would you avoid using glycopeptides?
Elderly, history of deafness, renal impairment, pregnancy (ear damage)
97
What are the monitoring requirements for glycopeptides? (5)
1) FBC
2) WCC
3) Hepatic and renal function
4) Urinalysis
5) Auditory function in elderly
98
What drugs do glycopeptides interact with?
Ciclosporin, cisplatin, aminoglycosides, loop diuretics, suxamethonium (Increase vancomycin conc)
99
What are the indications for clindamycin (lincosamide)? (3)
1) Staphylococcal joint and bone infections
2) Intra abdominal sepsis
3) Cellulitis and skin and soft tissue infections (effective against penicillin resistant streptococci)
100
Important side effects of clindamycin? (4)
1) Antibiotic associated colitis-REPORT diarrhoea
2) Esophageal disorders
3) Jaundice
4) SJS, rash
101
In what patient groups is clindamycin contra-indicated?
Existing diarrhoea
| Caution in middle aged/ elderly women after operation
102
What are the indications for macrolides?
Respiratory infections (in addition to penicillin), Lyme disease, severe pneumonia (added to penicillin), skin and soft tissue infections (alternative to penicillin)
103
Important side effects of macrolides? (4)
1) Antibiotic associated colitis
2) QT prolongation
3) Ototoxicity
4) Cholestatic jaundice
104
Why would you avoid using macrolides in myasthenia gravis?
Macrolides cause electrolyte abnormalities which can aggravate myasthenia gravis
105
Main CI for macrolides?
1) Hepatic impairment (cholestatic jaundice)
| 2) Arrhythmia (QT prolongation)
106
What drugs interact with macrolides?
1) CYP450 substrates
| 2) Drugs that prolong QT interval
107
What are the main indications of metronidazole? and appropriate doses? (3)
1) Antibiotic associated colitis (400mg TD 5 days)
2) Oral infections (200mg TD 3 days for gingivitis)
3) Gynecological infections e.g trichomonas vaginal infection
108
Main side effects associated with metronidazole? (3)
1) Neurological effects e.g peripheral and optic neuropathy
2) Mouth-Taste disturbance, furred tongue and mucositis
3) Hearing loss
109
Is metronidazole a CYP450 inhibitor?
NO, it is a substrate of CYP450
110
What happens if you drink alcohol while taking metronidazole?
Di-sulfram like reaction will occur. Metronidazole inhibits the clearing of acetylaldehyde (intermediary metabolite)- this causes flushing, headache, tachycardia
111
How long after stopping metronidazole should you avoid alcohol?
2 days
112
What drugs does metronidazole interact with? (4)
1) CYP450 inhibitors
2) CYP450 inducers
3) CYP450 substrates
4) Lithium (reduces clearance of lithium resulting in toxicity)
113
What effect will ketoconazole have on metronidazole?
Ketoconazole = CYP450 inhibitor metronidazole = substrate of CYP450
ketoconazole will reduce metabolism of metronidazole.
Metronidazole = pro-drug so this will reduce efficacy of metronidazole.
114
What duration of treatment with metronidazole requires FBC and hepatic monitoring?
10 days
115
Are penicillins broad spectrum?
Yes
116
What are the main indications for penicillins? (7)
1) Tonsillitis (streptococcal)
2) Otitis media
3) Cellulitis
4) RTI5) Meningitis
6) Tetanus (C.diff)
7) Skin and soft tissue infections
117
Main side effects of penicillins? (2)
1) Penicillin allergy
| 2) CNS toxicity (convulsions, coma)
118
Main drug interaction of penicillins?
Methotrexate- reduced renal excretion and increased toxicity
119
What are the main indications for co-amoxiclav? (3)
| Main side effect of co-amoxiclav?
1) Pneumonia
2) UTI (250-500mg 8hrly)
3) H.pylori (combo therapy)
Same as penicillins- Cholestatic jaundice (no more than 14 days treatment)
120
What are the main indications for flucloxacillin? (3)
Main side effect of flucloxacillin?
1) Skin and soft tissue infections e.g cellulitis
2) Osteomyelitis/septic arthritis
3) Endocarditis
Same as penicillins +Cholestatic jaundice
121
Name two diaminopyrimidine antibiotics.
1) Trimethoprim
| 2) Co-trimoxazole
122
How do diaminopyrimidines work?
Bacteriostatic-inhibit folate synthesis
123
Main indications of diaminopyrimidines?
Uncomplicated UTI (200mg 12 hourly), RTI, pneumocystis pneumonia (co-trimoxazole)
124
What are the main side effects associated with diaminopyrimidines? (2)
1) Blood disorders (look out for bruising, bleeding, ulcers etc)
2) SJS
125
What are the main CI for diaminopyrimidines? (2)
1) Pregnancy (Teratogenic-especially in first trimester)
| 2) Caution in folate deficiency
126
Drugs that interact with diaminopyrimidines?
**K+ elevating drugs** e.g ACE inhibitors, ARB's
**Folate antagonists** e.g methotrexate
Phenytoin, warfarin (reduced clearance)
127
Name five Quinolone antibiotics?
1) Ciproflaxacin
2) Monoflaxacin
3) Levofloxacin
4) Ofloxacin
5) Norfloxacin
128
Why are quinolones typically 2nd and 3rd line drugs?
Rapid resistance developing
129
Main indications that quinolones are used for? (4)
1) UTI
2) severe GI infections including travelers diarrhoea
3) LRTI
4) Gonorrhoea
130
What are the main side effects associated with quinolones? (5)
1) C. diff
2) Neurological-seizures and hallucinations
3) Inflammation and rupture of tendons-STOP
4) Prolong QT interval-arrhythmia
5) Photosensitivity
131
What is an important side effect of moxifloxacin?
Life threatening hepatotoxicity
132
In what conditions should quinolones be use with caution?
1) Epilepsy
2) GPD6 deficiency
3) Joint disorders e.g myasthenia gravis
4) Children and adolescents (disease of joints)
133
What 5 drugs do quinolones interact with?
1) Calcium and antacids (reduce absorption)
2) Theophylline (quinolones inhibit CYP450)
3) NSAIDS
4) Prednisolone (tendon rupture)
5) QT prolonging drugs
134
What is the last resort antibiotic for MRSA?
Linezolid (vancomycin resistant cocci)
135
What types of infections is Linezolid used for?
Complicated skin and soft tissue infections and pneumonia
136
What type of drug is linezolid? (HINT-psychiatric effects)
MAOI
137
What are the main side effects associated with Linezolid?
1) Bipolar & confusional states
2) History of seizures
3) Uncontrolled hypertension
4) Elderly (increased risk of eosinophilia)
138
What foods should be avoided while taking linezolid?
Tyramine rich foods
139
What monitoring is required for Linezolid if the treatment exceeds 14 days?
FBC monitoring unless patient has existing myelosuppression, taking blood drugs and renal impairment (check for eosinophilia)
140
What monitoring is required for Linezolid if treatment exceeds 28 days?
Check for optic neuropathy
141
What drugs does Linezolid interact with and why?
SSRIs, triptans, tricylic antidepressants, sympathomimetics, buspirone, opioids, pethidine, antipsychotics (MAOI inhibitor)
142
Which TWO drugs cause peripheral neuropathy?
Metronidazole and nitrofurantoin
143
What type of infection is nitrofurantoin used for and what are the typical doses?
1st line for UTI (100mcg m/r BD for 3 days) and as prophylaxis for UTI (50-100mg nightly for max 6 months)
144
What are the main side effects associated with nitrofurantoin? (4)
1) Dark yellow/ brown urine
2) Pulmonary reactions
3) Peripheral neuropathy
4) Hepatitis
145
In what patient groups would nitrofurantoin be an inappropriate choice? (2)
1) Pregnancy
2) CI in renal impairment
146
What are the TWO monitoring requirements for LT nitrofurantoin use?
Hepatic and pulmonary function
147
In what patient groups would a specimen and culture be collected before treatment for UTI?
Men, pregnant women, children <3, Upper UTI, resistant organism suspected e.g Klebsiella suspected
148
What are the treatment options for an uncomplicated UTI in a child >3mo?
Trimethoprim, Nitrofurantoin, Cefalexin, amoxicillin
149
What are the treatment options for an uncomplicated UTI in a child <3mo?
IV ampicillin with gentamicin or cefotaxime in hospital, then oral treatment
150
What are the antibiotic treatment options for recurrent UTI's in children?
Trimethoprim or nitrofurantoin
151
Name FIVE tetracyclines?
Tetracyline, doxycycline, minocycline, lymecyline, oxytetracyline
152
What are the main indications for tetracylines? (4)
1) Chlamydia and PID
2) Acne
3) LRTI (including COPD)
4) Malaria, lyme disease, rickettsia
153
Main side effects associated with tetracylines? (5)
1) Photosensitivity
2) Esophageal irritation
3) Hepatotoxicity
4) benign intracranial pressure- headache and visual disturbances-STOP
5) Discoloration of tooth enamel
154
In what patient groups would you want to avoid tetracylines?
1) Children <12 (binds to teeth)
| 2) Pregnancy and breastfeeding
155
Name TWO conditions that require prolonged courses of antibiotics?
TB and osteomyelitis
156
Antibiotic used to prevent pneumococcal infection in sickle cell disease?
Phenoxymethylpenicillin, if CI then erythromycin
157
Antibiotic used as prevention for early onset neonatal infection?
Benzylpenicillin (IV)
158
Name FOUR beta lactam antibiotics?
1) Penicillins
2) Cephalosporins
3) Carbapenems
4) Monobactams
159
What is the main use for fusidic acid?
Narrow spectrum for staph infections, topically on the skin or eye or IV/oral for osteomyelitis and endocarditis
160
What is the first line treatment for C.diff?
Metronidazole(or vancomycin or fidoxamicin)
161
What can a tobramycin dry powder inhaler be used for?
Pseudomonas lung infection in CF
162
Name TWO carbapenems?
Imipenem and Meropenem
163
Name TWO cephalosporins that can be used for CNS infections?
1) Cefotaxime
| 2) Ceftriaxone
164
Which cephalosporin has good activity against haemophillus influenza?
Cefaclor
165
Which cephalosporin should be used in history of hypercalciuria (history of renal stones)?
Ceftriaxone
166
What is the maximum duration of treatment for fusidic acid?
10 days
167
What are the specific monitoring requirements for minocycline if the treatment is longer than 6 months?
Monitor every 3 months for hepatotoxicity, pigmentation of the skin and systemic lupus erythromtosus
168
Name TWO antimycobacterials?
Clofazimine and Dapsone (both used for leprosy)
169
Name the FOUR antibiotic groups that can be used in lyme disease?
1) Macrolides
2) Amoxicillin
3) Tetracycline
4) Cephalosporins
170
Name SEVEN bacteria that can cause UTI?
1) E coli
2) Staph saprophyticus
3) Proteus
4) Klebsiella
5) Pseudomonas aeruginosa
6) Staph epidermidus
7) Enterococcus Faecalis
171
What is the antibacterial prophylaxis and treatment of choice for animal bites?
Co-amoxiclav (if penicillin allergic- doxycyline + metronidazole for up to 5 days) and give the tetanus jab
172
What is the treatment for a >50 year old with meningitis?
Cefotaxime or ceftriaxone AND Amoxicillin or Ampicillin Consider adding vancomycin (10 days)
173
How long is the initial phase of TB treatment?
2 months
174
How long is the second phase of TB treatment?
4 months
175
What drugs are used in the initial phase of treatment for TB?
At what doses?
Isonazid (300mg OD)
Rifampicin (<50kg=450mg OD, >50kg=600mg OD)
Pyrazinamide (<50kg=1.5g, >50kg=2g OD)
Ethambutol (15mg/kg OD)
176
What drugs are used in the second phase of treatment for TB?
Isonazid (300mg OD)
| Rifampicin (same as initial)
177
Which TB drugs cause liver toxicity?
Isonazid
Rifampacin
Pyrazinamide
178
Which TB drugs cause peripheral neuropathy?
Isonazid
179
Which TB drugs cause occular toxicity?
Ethambutol
180
What are the monitoring requirements for TB treatment?
```
Plasma levels e.g ethambutol
Urinalysis
Visual acuity testing
Blood counts
Liver and hepatic function
Auditory function in the elderly
```
181
What is the duration of treatment for extrapulmonary TB?
10 months
182
What is a specific CI of pyrazinamide?
Acute attack of gout
183
Name the antibiotics in the aminoglycoside class
```
Amikacin
Gentamicin
Neomycin
Streptomycin
Tobramycin
```
184
What aminoglycosides are active against Pseudomonas and what one is the treatment of choice?
Gentamicin - treatment of choice
Amikacin
Tobramycin - usually via inhalation in CF
185
What aminoglycoside is active against TB?
Streptomycin (mainly reserved for this indication)
186
Can aminoglycosides be given orally?
No- destroyed by the gut so must be given via injection
187
Is gentamicin a broad or narrow antibiotic?What strains does it have poor activity against?
Broad but it is inactive against anaerobes and poor activity against haemolytic streptococci and pneumococciVery good for gram negative organisms
188
Which aminoglycoside is used for encocarditis?If it is resistant to this, what is an alternative aminoglycoside?
Gentamicin plus another antibiotic
| Streptomycin is an alternative if resistant to gentamicin
189
Are aminoglycosides more active against gram positive or gram negative?
Gram negative but are broad
190
What is the problem with using aminoglycosides in myasthenia gravis?
Contraindicated
| May impair neuromuscular transmission
191
What antibiotics can be used for prophylaxis in rheumatic fever?
Pen V or sulfadiazine
192
What anitbiotics can be used for prevention of secondary case of menincoccal meningitis?
Ciprofloxacin or rifampicin Or IM ceftriaxone (unlicensed)
193
What antibiotic can be used for prevention of secondary infection for Group A strep?
Pen V
194
What antibiotic can be used for prevention of secondary infection in Influenza Type B?
Rifampicin
195
What antibiotic can be used for prevention of secondary cases of diphtheria in non-immune patients?
Erythromycin
196
What is pertussis?
Whooping cough
197
What antibiotic is used for prophylaxis of pertussis (whooping cough)?
Clarithromycin
198
What antibiotic is used post splenectomy or in patients with sickle cell disease for prevention of pneumococcal infection?
Pen V (Erythromycin if penicillin allergic)
199
What antibacterial prophylaxis/treatment is used in animal and human bites?If the patient is penicillin allergic, what should be used instead?
Co-amox
If penicillin allergic: Doxycycline and metronidazole
Up to 5 days and give tetanus jab
200
What antibacterial prophylaxis do you use in hip and knee replacement?
Single dose IV cefuroxime/flucloxacillin
| Add in gent
201
What antibacterial prophylaxis do you use in high lower limb amputation?
Use i/v co-amoxiclav alone or i/v cefuroxime + i/v metronidazole
202
What antibacterial prophylaxis do you use in caesarean section?
Single dose cefuroxime
203
What is 1st line for aspergillosis?What is 2nd line if this cannot be used?
Voriconazole
| Liposomal amphotericin
204
If a patient with aspergillosis is intolerant/refractory to voriconazole and liposomal amphotericin, what other antifungals can be used?
Caspofungin
| Itraconazole
205
What systemic antifungal is used in vaginal candidiasis?For resistant organisms, what can be used?
Fluconazole
| Itraconazole as an alternative
206
What is micafungin licensed for?
Invasive candidiasis
Oesophageal candidiasis
Prophylaxis of candidiasis in patients undergoing haematopoietic stem cell transplantation
207
Cryptococcal meningitis, a fungal infection, is especially common in which group of immunocompromised patients?How is this treated?
HIV positive
IV amphotericin followed by PO fluconazole
208
What is tinea capitis?
Fungal infection (ringworm) of scalp
209
What is tinea pedis?
Athlete's foot
210
How do you treat tinea captis?
Systemically
Griseofulvin
Can also used an additional topical application
211
True or false:In fungal nail infections, topical therapy is more effective than systemic
False
| Systemic is more effective
212
Is fluconazole active against Aspergillus?
No
213
Is caspofungin effective against CNS fungal infections?
No
214
What is the advantage of lipid amphotericin formulations over conventional amphotericin?
Significantly less toxic + recommended when conventional formulation of amphotericin contra-indicated because of toxicity, especially nephrotoxicity or when response to conventional amphotericin inadequate
However, more expensive
215
What are echinocandin antifungals active against? (Caspofungin, micafungin)
Aspergillus and Candida
| Not active against CNS fungal infections
216
What can be used for MRSA?
```
Glycopeptides mainly:
Teicoplanin
Vancomycin
Alternatives:
Tigecyline
Daptomycin
Linezolid (if glycopeptide unsuitable)
Tetracyclines can be used for skin or soft tissue infections or UTI caused by MRSA
Clindamycin can be used for bone and joint MRSA infections
```
217
Are carbapenems useful against MRSA?
No
218
Do carbapenems have good activity against pseudomonas? What is the exception to this?
Yes apart from ertapenem
219
Why does imipenem have to be administered with cilastatin?
Imipenem is partially inactivated in the kidney by enzymatic activity and is therefore administered in combination with cilastatin, a specific enzyme inhibitor, which blocks its renal metabolism
220
If meningitis is suspected, what antibiotic should be given before being transferred to hospital (as long as this doesn't delay treatment)?What would be an alternative?
IV benpen
Cefotaxime if penicillin allergic / chloramphenicol if history of immediate hypersensitivity to penicillin and cephalosporins
221
When would you use dexamethasone in meningitis?
| In what situations would you avoid this?
* Particularly in pneumococcal meningitis in adults, either before starting antibacterial therapy or within 12 hours of starting
* Avoid using dex in septic shock, meningococcal septicaemia, immunocompromised, or meningitis following surgery
222
What is the recommended antibiotic therapy for children 3 months - adults 50 years in meningitis if the cause is unknown?What is the suggested duration of treatment?
Cefotaxime or ceftriaxone
Consider adding vancomycin
10 days
223
What is the recommended antibiotic therapy for adults over 50 years in meningitis if the cause is unknown?What is the suggested duration of treatment?
Cefotaxime or ceftriaxone AND amoxicillin or ampicillin
| Consider adding vanc10 days
224
What is the recommended antibacterial therapy for meningitis caused by meningococci (neisseria)?What would be an alternative if not suitable?What is the suggested duration of treatment?
Benpen Or cefotaxime/ceftriaxone
| Chloramphenicol is an alternative if history of immediate hypersensitivity to penicillins or cephalosporins 7 days
225
What bacteria can be the cause of meningitis?
Meningococcal (neisseria)
Pneumococcal
Haemophilus influenzae
Listeria
226
What is the recommended antibacterial therapy for meningitis caused by pneumococcal?
If the organism if penicillin and cephalosporin resistant, what can be added?
What is the suggested duration of treatment?
* Cefotaxime or ceftriaxone
* Consider adding dex before 1st dose or within 12 hours of starting ABX
* If penicillin sensitive, change to benpen
* If penicillin & cephalosporin resistant = vancomycin + rifampicin 14 days
227
What is the recommended antibacterial therapy for meningitis caused by Haemophilus influenzae?
What is the suggested duration of treatment?
Cefotaxime or ceftriaxone
| Consider adding dex before first dose or within 12 hours of starting antibacterial therapy 10 days
228
What is the recommended antibacterial therapy for meningitis caused by Listeria?What is the suggested duration of treatment?
If history of immediate penicillin hypersensitivity, what could be an alternative?
Amoxicillin/ampicillin AND gentamicin 21 days - can consider stopping gentamicin after 7 days
Alternative- co-trimoxazole for 21 days
229
Patients presenting with sinusitis symptoms of 10 days or lessHow should the following be managed:
Paracetamol, ibuprofen, nasal saline
* Antibiotics not usually required
230
How should the following be managed:Patients presenting with sinusitis symptoms of 10 days or more
* Consider high-dose nasal corticosteroid, i.e. mometasone furoate [unlicensed] or fluticasone [unlicensed] for 14 days
* Supply of back-up antibiotic prescription considered & used if symptoms do not improve within 7 days, or if worsen rapidly or significantly.
231
In what situations would you offer antibiotics for sinusitis?
~ systemically very unwell, signs & symptoms of more serious illness
~ bacterial sinusitis suspected
232
What is 1st and 2nd line in a non-penicillin allergic sinusitis patient if antibiotics are indicated?
1st line- Pen V
2nd line- Co-amox (especially if more serious illness)
233
What is 1st line in a penicillin allergic sinusitis patient if antibiotics are indicated?
Doxycycline or clarithyromycin
234
What is 1st line in a penicillin allergic sinusitis PREGNANT patient if antibiotics are indicated?
Erythromycin
235
What antibiotic can be used in a pregnant UTI patient?
Cefalexin
236
If antibiotics are clinically appropriate, what would be used for otitis externa?What if the patient is penicillin allergic?
Flucloxacillin
| Clarithromycin
237
If antibiotics are clinically appropriate, what would be used for otitis media?What if the patient is penicillin allergic?
Amoxicillin (or co-amox as second line)
| Clarithromycin
238
Otitis media is most common in which age group?
Children
239
What antibiotics are likely to cause C.Diff?
Clindamycin
Penicillins
Cephalosporins
Fluoroquinolones
240
What 3 antibiotics can be used in C.Diff?
Vancomycin
Metronidazole
Fidaxomicin
241
For first episode of mild-moderate C.Diff, what should be used and for how long?
Oral metronidazole for 10-14 days
242
For second/subsequent C.Diff infection not responding to metronidazole, what can be used and for how long?
Oral vancomycin
Fidaxomicin can be used for severe infection
10-14 days
243
What antibiotic is used for bacterial vaginosis and how long for?
Metronidazole 5-7 days
244
What antibiotics cover chlamydia?
Azithromycin (single dose)
Doxycycline
Erythromycin
245
What is the recommended length of treatment for osteomyelitis?
6 weeks
246
Osteomyelitis and septic arthritis antibiotic choice:
First line?
If penicillin allergic ?
? If MRSA suspected
1. Flucloxacillin
2. Clindamycin
3. Vancomycin or teicoplanin
247
What penicillins can you use for oral infections e.g. dental?
Pen V
Amoxicillin
However not effective against bacteria that produces beta lactamases
Co-amox can be used in severe cases
248
What is the drug of choice for acute ulcerative gingivitis?
Metronidazole
249
Is haemophilus influenzae a bacteria or a virus?
Bacteria - gram(-)
250
What is the recommended therapy for Haemophilus influenzae?
Cefotaxime or ceftriaxone
251
What antibiotics do you use to treat an acute exacerbation of chronic bronchitis and how long for?
Amoxicillin or a tetracycline for 5 days
252
What antibiotic therapy is recommended in low severity CAP and how long for? What would be alternatives?
Amoxicillin
Alternatives= doxycycline, clarithromycin
7 days (if infection caused by staph, it would be 14-21 days)
253
What antibiotic therapy is recommended in moderate severity CAP and how long for?
Amoxicillin AND clarithromycin
| Or doxycycline alone 7 days
254
What antibiotic therapy is recommended in high severity CAP and how long for?
Benpen AND clarithromycin/doxycycline
7-10 days
If MRSA suspected, add teic/vanc
255
For life-threatening CAP, what would be the recommended treatment and how long for?If the patient was penicillin allergic, what would be the alternative?
Co-amox + clarithromycin
7-10 days
Alternative to co-amox would be cefuroxime or ceftriaxone
256
In CAP, the usual treatment duration is 7-10 days. When would you extend this to 14-21 days?
If staphylococci suspected
257
If MSRA was suspected in CAP, what would you add on to the treatment?
Teic/vanc
258
What are the main organisms that cause pneumonia?
```
Streptococcus pneumoniae
Haemophilus influenzae
Chlamydia pneumoniae
Mycoplasma pneumoniae
Legionella pneumophila
```
259
What would you use to treat pneumonia caused by chlamydial/mycoplasma?
Doxycycline
260
What is the difference between early onset vs late onset HAP (in terms of days in hospital)?
Early onset = less than 5 days admission to hospital
| Late onset = more than 5 days after admission to hospital
261
How do you treat early onset HAP?
Co-amox or cefuroxime
262
How do you treat late onset HAP?
* Antipseudomonal penicillin e.g. Pip Taz OR
* Broad spectrum cephalosporin e.g. ceftazidime OR
* Quinolone e.g. ciprofloxacin
* MRSA- add vanc
263
What would you use to treat a small area of impetigo?
Fusidic acid
264
What would you use to treat a widespread infection of impetigo?If penicillin allergic, what would be an alternative?
Oral flucloxacillin
| Clarithromycin
265
What would you use to treat cellulitis?If penicillin allergic, what can be used?
High dose flucloxacillin Clindamycin/clarithromycin
266
What antibiotic would you use for mastitis during breastfeeding?What if penicillin allergic?
Flucloxacillin
Erythromycin
10-14 days
267
What are the side effects of aminoglycosides?
Hearing impairment (ototoxicity - patients should report tinnitus, hearing loss, vertigo)
Nephrotoxicity
May impair muscle transmission-c/i in myasthenia gravis
268
What is the risk of aminoglycosides to the infant in pregnancy?
Risk of auditory or vestibular nerve damage
269
What is a possible problem with carbapenems that means it is cautioned in CNS disorders?
Seizure inducing potential
- Also increased risk of seizures if renal impairment present
270
Should you give carbapenems if there is a history of immediate hypersensitivity to penicillins?
No
271
True or false:
Cephalosporins penetrate the meninges poorly unless they are inflamed
TRUE
272
What are some common side effects of cephalosporins?
Abdo pain
Eosoniphilia
Thrombocytopenia
273
Should you give cephalosporins if there is a history of penicillin allergy?
Used in caution
| But should not be given if there is immediate hypersensitivity
274
What are the glycopeptide antibiotics?
Dalbavancin
Teicoplanin
Telavancin
Vancomycin
275
Which of the following antibiotics has a lower incidence of nephrotoxicity:TeicoplaninVancomycin
Teicoplanin
276
What drugs are associated with red man syndrome?
Glycopeptides
Teicoplanin
Vancomycin
277
What is the main advice to give to patients on clindamycin and should stop taking if this happens?
Diarrhoea
| Stop and contact doctor
278
What are the cautions in macrolides?
QT prolongationand electrolyte disturbances
279
Amoxicillin can cause an increased risk of erythematous rash in what conditions?
Acute lymphocytic leukaemia
Chronic lymphocytic leukaemia
CMV
Glandular fever
280
Why should you maintain adequate hydration with high doses of IV amoxicillin?
Risk of crystalluria
| Especially in renal impairment
281
What is the dose of amoxicillin in susceptible infection for a child 1-11 months?
125mg TDS (increased up to 30mg/kg TDS if needed)
282
What is the dose of amoxicillin in susceptible infection for a child 1-4 years?
250mg TDS (increased up to 30mg/kg TDS if needed)
283
What is the dose of amoxicillin in susceptible infection for a child 5-11 years?
500mg TDS (increased up to 30mg/kg TDS if needed)
284
What is the dose of amoxicillin in susceptible infection for a child 12-17 years?
500mg TDS
| Increased up to 1g TDS if needed
285
What is the dose of amoxicillin in susceptible infection for an adult?
500mg TDS
286
What is the MHRA warning surrounding flucloxacillin?
Cholestatic jaundice and hepatitis
287
What is a side effect of oral amoxicillin and co-amox in terms of colouring the patient's tongue?
Black hairy tongue
288
Ciprofloxacin is a type of what antibiotic?
Quinolone
289
What is the important safety information regarding fluoroquinolones?
```
May induce convulsions in patients with or without a history of convulsions; taking NSAIDs at the same time may also induce them.
Tendon damage (including rupture) has been reported rarely in patients receiving quinolones.
Tendon rupture may occur within 48 hours of starting treatmentSmall increased risk of aortic aneurysm and dissection
```
290
Should quinolones be used in MRSA?
No
291
What quinolone is active against pseudomonas?
Ciprofloxacin
292
What are some common side effects of quinolones?
QT prolongation
Hearing impairment
Decreased appetite
Rhabdomylosis
Drug should be discontinued if psychiatric, neurological reactions occur
Cautioned in young adults and children- risk of arthropathy
293
What antibiotic would you use for PCP prophylaxis and treatment?
Co-trimoxazole
294
What is a rare but serious side effect of co-trimoxazole?
Blood disorders
| Rash - steven johnson's syndrome
295
What age group are tetracyclines contraindicated in?
Children < 12 due to deposition in growing bones and teeth Staining of teeth can occur
296
What are the common side effects of tetracyclines?
Angiodema
Henoch Schonlein purpura (spotty rash)
Photosensitivity reaction
Headaches and visual disturbances- may indicate benign intercranial hypertension - discontinue if intercranial pressure increases
297
Is there any special patient advice with doxycycline?
Should be taken with meals
Avoid exposure to sunlight and sun lamps
Do not take zinc, indigestion remedies 2 hours before or after
298
What is a serious side effect of chloramphenicol when given systemically?
Haemotological side effects (agranulocytosos, bone marrow disorder)
Aplastic anaemia- reports of leukaemia
Should only be reserved for life-threatening conditions e.g. typhoid fever
299
What muscle side effect can daptomycin cause?
Myopathy
Report any muscle weakness and monitor creatine kinase if necessary
Need to monitor CK twice a week whilst on it
300
What monitoring requirements are needed for systemic fusidic acid?
Elevated liver enzymes, hyperbilirubinaemia and jaundice can occur with systemic use
Manufacturer advises monitor liver function with high doses or on prolonged therapy
301
What is the important safety information regarding linezolid?
Severe optic neuropathy- patients should report visual impairment
Blood disorders - thrombocytopenia, anaemia
302
What food does linezolid interact with and why?
Tyramine-rich foods (such as mature cheese, salami)
Avoid consuming large amounts
Also is a reversible MAOI
303
Is linezolid active against gram-ve, gram+ve or both?
Gram +ve
304
What would be the dose of trimethoprim in an adult for UTI?
200mg BD
305
Can you use trimethoprim in renal impairment?
Yes- monitor
| May need to half normal dose
306
What is the patient advice surrounding rifampicin?
May stain contact lenses red
Report signs of liver disorder
May colour urine red - harmless
307
How does rifampicin interact with hormonal contraceptives?
Effectiveness of hormonal contraceptives are reduced - alternative method needed
308
What antibiotics are used in the initial phase of TB treatment?
```
Rifampicin
Isoniazid
Pyrazinamide
Ethambutol
Streptomycin- hardly used but may be useful if resistant to isoniazid
```
309
How many antibacterials are used in the initial phase of TB treatment and how long for?
42 months
310
How many antibacterials are used in the continuous phase of TB treatment and how long for?
2ABX
4 months
311
If someone is isoniazid, what else must be prescribed and why?
Pyridoxine (vitamin B6)
| Prophylaxis of isoniazid-induced neuropathy
312
Generally speaking, after 2 months of RIPE treatment for TB, what antibiotics are continued for a further 4 months?
Rifampicin and isoniazid (needs to be on pyridoxine for prevention of neuropathy)
313
What treatment for TB should be given in pregnancy and breastfeeding?
RIPE for 2 months and then RI (Rifampicin and isoniazid) for a further 4 months
Should NOT be given streptomycin
314
DOT TB therapy should be offered to which groups of people?
Directly observed therapy should be offered to patients who:
* Hx of non-adherence
* previously been treated for TB
* In denial of TB diagnosis- have multidrug-resistant tuberculosis, have a major psychiatric or cognitive disorder
* Hx of homelessness, drug or alcohol misuse
* Are in prison, or have been in past 5 years
* Are too ill to self-administer treatment
* Request directly observed therapy
315
In a patient with HIV and TB, starting antiretrovirals in the first 2 months of TB treatment can increase the risk of what?
Immune reconstitution syndrome
316
In patients with HIV and TB, how long should the TB treatment be for?What is the exception to this?
6 months
| However if the TB has CNS involvement, 12 months max
317
What is the general TB treatment regimen?
RIPE for 2 months and then RI (Rifampicin and isoniazid) for a further 4 months
318
What is the general CNS TB treatment?
* RIPE for 2 months
* RI (Rifampicin & isoniazid) for further 10 months
* Initial high dose of dexamethasone or prednisolone started at same time & slowly withdrawn over 4-8 weeks
319
What would be the treatment regimen for latent TB?
Isoniazid for 6 months - recommended if interactions with rifampicin a concern
OR rifampicin and isoniazid for 3 months - recommended if hepatotoxicity a concern
320
A break in TB treatment of how many weeks is classed as a treatment interruption?
2 weeks
321
What are the 6 toxicity syndromes associated with intermittent TB treatment?
Influenza-like, abdominal, and respiratory symptoms, shock, renal failure, and thrombocytopenic purpura
322
What is the brand name of the medicine that contains RIPE for TB?
Voractiv
323
What is the brand name of medicine that contains RI (rifampicin and isoniazid) for TB?
Rifinah
324
Why is ethambutol cautioned in young children?
Can cause visual impairment
Ethambutol should be used with caution in children until they are at least 5 years old and capable of reporting symptomatic visual changes accurately.
325
What kind of toxcity can ethambutol cause?
Ocular - report any visual disturbances
Nephrotoxicity
Other side effects include red-green colour blindness, hepatotoxicity
326
What are the main side effects to look out for in a patient on isoniazid?
Peripheral neuropathy
Hepatic disorders
Ototoxicity
327
What are the main side effects to look out for in a patient on pyrazinamide?
Hepatoxicity
| Aggravates gout
328
What antibiotics respond to a lower UTI?
```
Trimethoprim
Nitrofurantoin
Amoxicillin
Ampicillin
Cefalexin
```
329
What is the recommended duration of treatment for uncomplicated UTI in women?
3 days
330
What antibiotics for a UTI should be used in pregnancy?
Penicillins and cephalosporins are the best choices
331
At what EGFR should you avoid prescribing nitrofurantoin in?
<45
332
Does does caspofungin interact with and what should be done about the dose?
Some enzyme inducers e.g. rifampicin, carbamazepine, phenytoin increase dose to 70mg daily (if not already on it)
333
What is the risk of giving an infusion of amphotericin?
* Risk of arrhythmias if given too rapidly
* Anaphylaxis- test dose needed + close observation needed for first 30 mins after this test dose
334
Are different preparations of amphotericin interchangeable?
No
| Should preferably prescribe by brand to avoid confusion
335
What is a specific side effect with IV isavuconazole?
Hypotension, SOB, paraesthesia
Nausea, headache
Discontinue if these occur
336
What is the important safety information regarding itraconazole?
Reports of heart failure, especially in high risk patients:-
High dose and long courses
Patients on negative ionotropic drugs
CCBs
Elderly
Chronic heart disease
Should be avoided in those with a history of heart failure unless the infection is serious
Also, hepatotoxicity that can be life-threatening can occur.
Patient should be aware of liver disorder signs
337
What are the specific side effects for voriconazole that requires patient counselling?
Hepatotoxicity- patients should be aware of liver disorder signs
Phototoxicity- patients should avoid intense or prolonged exposure to direct sunlight, avoid sunbeds If they get sunburnt, seek medical attention
It is the antifungal that is most associated with hallucinations
Keep an alert card on them
338
What is the contraception and conception advice for both men and women who are on griseofulvin (antifungal for dermatophyte infections of the skin)?
Women: Should continue effective contraception at least 1 month after administration. The effectiveness of the pill may reduce so use an additional barrier method
Men: Avoid fathering a child during and for at least 6 months after administration
339
What adjunctive therapy is recommended in PCP treatment in patients with HIV?
For moderate to severe infections, prednisolone for 21 days
340
True or false:All members in a household must be treated if one person in the house has threadworm
TRUE
341
What is the drug of choice for threadworm?
Mebendazole
342
For malaria prophylaxis, what are mosquito nets usually impregnated with?
Permethrin (insecticide)
343
Can DEET spray be used during pregnancy and breastfeeding?
Yes
344
When applying DEET and suncream, what should be applied first?
Suncream then DEET
345
How does DEET spray affect the SPF of suncream?
Lowers it so a factor 30-50 should be used
346
Generally speaking, how much time before travelling should malaria prophylaxis be started? What are the exceptions to this?
1-2 weeks before
Mefloquine is 2-3 weeks before
Malarone and doxycycline is 1-2 days before
In warfarin patients 2-3 weeks before
347
How much time before travelling should malaria prophylaxis with Malarone be started?
1-2 days before
348
How much time before travelling should malaria prophylaxis with doxycycline be started?
1-2 days before
349
How much time before travelling should malaria prophylaxis with mefloquine be started?
2-3 weeks before
350
How long can Malarone be used for in malaria prophylaxis?
Up to 1 year
351
How long can doxycycline be used for in malaria prophylaxis?
Up to 2 years
352
How long can mefloquine be used for in malaria prophylaxis?
Up to 1 year
353
What antimalarials are unsuitable for those with epilsepy?What would be alternatives?
Chloroquine
Mefloquine
Proguanil is recommended in areas with chloroquine resistance
Doxycyline or Malarone is recommended in areas without chloroquine resistance
354
Which group of patients are at a particularly high risk of severe malaria?
Those without a spleen
355
What antimalarials can be given at their usual dose during pregnancy?
Chloroquine
Proguanil
However, resistance exists so may have to look at other options, only if benefit outweighs risk and travel is unavoidable
356
If a pregnant lady is on proguanil during malaria prophylaxis, what else must she be on?
Folic acid at high dose (5mg) for at least the first trimester
357
How long should malaria prophylaxis continue after leaving the at risk country?What is the exception to this?
Continue for 4 weeks after
| Except for Malarone which is 1 week
358
In warfarin patients, when should malaria prophylaxis begin?
2-3 weeks before travelling
| INR should be stable before departure
359
When should INR be checked in warfarin patients on malaria prophylaxis?
Before starting the course
7 days after starting the course
After completing the course
For prolonged stays, INR needs to be checked at regular intervals
360
What is standby malaria treatment?
* Travellers visiting remote, malarious areas for prolonged periods should carry standby treatment if they likely to be more than 24 hours away from medical care.
* Self-medication avoided if medical help accessible.
* In order to avoid excessive self-medication, traveller should be provided with written instructions that urgent medical attention should be sought 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.
361
When travelling to different places that require 2 different malaria prophylaxis regimens, what do you do?
The regimen for the higher risk area should be used for the whole journey
362
What combination of antimalarials is in Malarone/Maloff?
Atovaquone and proguanil
363
For the treatment of malaria, is the infective species is unknown/mixed, what are the options?
Malarone
Riamet
Quinine
364
What is P. Falciparum resistant to?
Chloroquine
365
What are the treatment options for malaria caused by P.Falciparum?
Quinine (with doxycycline or clindamycin)
Malarone
Riamet
366
What are the treatment options for malaria caused by P.Falciparum in pregnancy?
Quinine followed by clindamycin
| cannot use doxycycline
367
What are the treatment options for non-falciparum malaria?
Chloroquine
| However, if resistant- Malarone or Riamet
368
What are the treatment options for non-falciparum malaria in pregnancy?
Chloroquine
369
What antimalarials does Riamet contain?
Artemether and lumefantrine
370
What is the important safety information with chloroquine?
Occular toxicity
| Very toxic in overdose
371
What is a main neurological side effect of mefloquine?
~ Abnormal dreams, insomnia, anxiety, & depression = common
~ contraindicated in if history of psychiatric disorders including depression
~ long half life so persist up to several months after discontinuation
372
What screening should be done before a patient starts taking primaquine and why?
G6PD as if deficient, can cause haemolysis
373
What is the difference between quinine sulphate and quinine bisulphate?
Bisulphate has less quinine in
| Should not be used for malaria, only quinine sulphate
374
What is the important safety information regarding quinine?
QT prolongation
375
What are the initial treatment options for chronic Hep B?
Peginterferon alphaInterferon alpha
Treatment with the above should be stopped if no improvement after 4 months
Entecavir
Tenofovir
Treatment should be changed to other antivirals if no improvement after 6-9 months
376
What determines treatment route for chronic Hep C?
Before starting treatment, 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.
377
What is used for the initial treatment of chronic Hep C?
Combination of ribavirin and peginterferon alpha
| Ribavirin monotherapy=ineffective
378
What is the MRHA warning regarding direct-acting antivirals to treat chronic Hep C?
Risk of interaction with Vitamin K antagonists and changes in INR.
INR needs to be monitored closely
Risk of Hep B reactivation (if patient has both B and C)
Need to be screened for Hep B before starting treatment
379
What is herpes labialis?
Cold sore
380
What is herpes zoster?
Shingles
381
What is varicella?
Chicken pox
382
In shingles, within how many hours of rash onset should antivirals be started?
How long is it continued for?
Within 72 hours
| Continued for 7-10 days
383
In adults with chickenpox, within how many hours of rash onset should antivirals be started to reduce duration and severity of symptoms?
Within 24 hours
384
What kind of drug is foscarnet?
Antiviral
385
What antivirals are used for Cytomegalovirus (CMV)?
Ganciclovir IV
Valganciclovir PO
Foscaret - toxic & causes renal impairment
386
During CMV treatment, what does ganciclovir cause if given with zidovudine (for HIV)?
Myelosuppression
387
Initial treatment of HIV-1 includes what combination types of antiretroviral drugs?
Triple therapy
2 nucleoside reverse transcriptase inhibitors and ONE of the following
Boosted protease inhibitor
Non-nucleoside reverse transcriptase inhibitor
Integrase inhibitor
388
What is used for HIV pre-exposure prophylaxis?
Emtricitabine with tenofovir
389
Why are some HIV medicines used in combination with cobicistat?
It is a pharmacokinetic enhancer that boosts the concentrations of other antiretrovirals, but it has no antiretroviral activity itself.
390
Name the nucleoside reverse transciptase inhibitors for HIV
```
Zidovudine
Abacavir
Didanosine
Emtricitabine
Lamivudine
Stavudine
Tenofovir disoproxil.
```
391
Name the protease inhibitors used for HIV.
```
Atazanavir
Darunavir
Fosamprenavir
Ritonavir
Saquinavir
Tipranavir*
```
Metabolised by cytochrome P450 enzyme systems*
392
Name the integrase inhibitors used for HIV
Dolutegravir, elvitegravir and raltegravir
393
Name the non-nucleoside reverse transcriptase inhibitors used for HIV
Efavirenz, etravirine, nevirapine, and rilpivirine
394
What is Maraviroc?
Antagonist of the CCR5 chemokine receptor. It is licensed for patients exclusively infected with CCR5-tropic HIV.
395
What has been reported in patients with advanced HIV disease or following long-term exposure to antiretroviral treatment?
Osteonecrosis
396
What is the MHRA advice regarding preparations containing dolutegravir (integrase inhibitor used for HIV)?
Increased risk of neural tube defects; do not prescribe to women seeking to become pregnant; exclude pregnancy before initiation and advise use of effective contraception
397
What CNS effects can efavirenz cause and how can this be reduced?
Depression, psychosis, confusion, hallucination, abnormal behaviour, suicidal ideations
Take the dose at bedtime, especially during the first 2-4 weeks of treatment
398
What reaction can occur with HIV medicines?
Hypersensitivity e.g. Rash, lesions, oedema, SOB
399
Which HIV medicine is associated with a high incidence of rash including Stevens-Johnson syndrome?
Nevirapine
400
Efavirenz for HIV is associated with an increase in plasma concentration of what substance?
Cholesterol
401
What are the long term effects of HIV treatment?
Immune reconstitution syndrome: as the immune system stands up on its feet again due to antiretroviral treatment, marked inflammatory reactions happen against opportunistic organisms
Lipodystrophy syndrome: this is made up of insulin resistance, fat redistribution and dyslipidaemia
Blood lipids and sugars should be measured before, 3-6 months after and yearly after HIV treatment.
Osteonecrosis: following long-term exposure to treatment.
402
Protease inhibitors are mainly associated with what side effects?
Lipodystrophy and metabolic effects.
403
What can be used for the treatment of influenza and within how many hours of symptom onset should it be started?
Oseltamivir (Tamiflu) first line and zanamivir is reserved for those who are immunocompromised or when oseltamivir cannot be usedWithin 48 hours
404
What can be used for post-exposure prophylaxis of influenza and within how many hours of exposure?
Oseltamivir (Tamiflu) within 48 hours of exposure and zanamivir within 36 hours of exposure
405
How long should influenza treatment be for?
Twice daily dosing for 5 days
406
How long should post-exposure prophylaxis for influenza be for?
Once daily dosing for 10 days
407
What is a particular caution with co-amoxiclav in in terms of side effects?
Cholestatic jaundice can occur either during or shortly after the use of co-amoxiclav
408
What is a rare but potentially fatal side effect of ketoconazole?
Associated with fatal hepatotoxicity. The CSM advise that prescribers shouldweigh the potential benefits of ketoconazole treatment against the risk of liver damage and shouldcarefully monitor patients both clinically and biochemically.
409
What penicillin based antibiotics must you take on an empty stomach?
Flucloxacillin
Ampicillin
Penicillin V
410
What shouldn't a patient take at the same time as tetracycline antibiotics?
Do not take milk, indigestion remedies, or medicines containing iron or zinc at the same time of day as this medicine (prevents absorption of the antibiotic and should be taken 2-3 hours apart)
Oxytetracycline and tetracycline should be taken on an empty stomach
411
Which tetracycyline antibiotics should be taken on an empty stomach?
Oxytetracycline and tetracycyline
412
What is the patient advice surrounding trimethoprim?
On long-term treatment, patients and their carers should be told how to recognise signs of blood disorders and advised to seek immediate medical attention if symptoms such as fever, sore throat, rash, mouth ulcers, purpura, bruising or bleeding develop.
413
True or false:
| Rifampicin should be taken on an empty stomach
TRUE
414
True or false:
| Metronidazole should be taken on an empty stomach
False
| Take with or just after food
415
What shouldn't a patient take at the same time as ciprofloxacin?
Do not take milk, indigestion remedies, or medicines containing iron orzinc at the same time of day as this medicine.
416
What specific monitoring should you do with daptomycin?
Creatine kinase twice a week
417
What is the CHMP advice regarding the use of oral ketoconazole to treat fungal infections?
Marketing authorisation for oral ketoconazole to treat fungal infections should be suspended.
The CHMP concluded that risk of hepatotoxicity associated with oral ketoconazole greater than the benefit in treating fungal infection
People with a prescription for oral ketoconazole should be referred back to their doctors
418
How does calcium carbonate interact with doxycycline? What do you recommend the patient does if the patient is normally on calcium carbonate e.g. Adcal and is prescribed doxycycline?
Calcium carbonate is predicted to decrease the absorption of doxycycline
Separate administration by 2-3 hours
419
What CD4 count is classed as AIDs?
<200
420
Which of the following is active against pseudomonas:- Benpen- Flucloxacillin- Ampicillin- Piperacillin
Piperacillin (Pip taz)
421
```
Which antibacterial drug increases the risk of serotonin syndrome?
Linezolid
Vancomycin
Telvancin
Septrin
```
```
Linezolid as = weak MAOI Serotonin syndrome risk increases with:
SSRIs
TCAs
Macrolides
Amiodarone
Fluoroquinolones
Antipsychotics
Quinine
Risk of hypertensive crisis
```
422
Which drug class is most associated with lipodystrophy?Antiretroviral drugsAlkylating agentsTCAsARBs
Antiretroviral drugs can cause redistribution of fat around the body
423
Quinine can be very toxic - what are the signs of toxicity?
Life-threatening features = arrhythmias (very rapid onset) and convulsions (intractable).
424
What are adverse effects of quinine?
```
Tinnitus
Deafness
Blindness
QT prolongation
Hypoglycaemia
GI upset
Hypersensitivity reactions
```
425
What advice should you give to a patient on metronidazole regarding their urine?
May darken urine (brown)
426
```
Which of these is used to boost the effects of protease inhibitors?
Elvitegravir
Maraviroc
Ritonavir
Etravirine
```
Ritonavir = protease inhibitor itself but inhibits CYP enzymes that would otherwise metabolise other protease inhibitors
427
What are the side effects of trimethoprim?
```
Megaloblastic anaemia
GI effects
Taste disturbance
Elevated creatinine levels
Skin rash
Hyperkalaemia
```
428
Trimethoprim can cause high levels of what electrolyte?
Potassium
429
What is the advice surrounding ribavirin and contraception?
Effective contraception essential during treatment and for 4 months after treatment in females and for 7 months after treatment in males of childbearing age.
430
What is the standard dose of oseltamivir in:i) Treatment of fluii) Prevention of flu
i) 75mg BD for 5 days for treatment
| ii) 75mg OD for 10 days for prophylaxis
431
Is vancomycin good for treating gram negative or positive organisms?
Gram positive
432
Is teicoplanin good for treating gram negative or positive organisms?
Gram positive
433
Allopurinol and what antibiotic can result in a skin rash?
Amoxicillin
434
True or false:NSAIDs and fluoroquinolones together increase seizure risk
TRUE
435
Can macrolides cause QT prolongation?
Yes
436
What tetracyclines can you take with milk?
Does Like Milk acronym
Doxycline
Lymecycline
Minocycline
437
What is 1st line treatment for chlamydia (both the patient and partner)?
If this is not suitable, what regimes can be used instead?
Doxycycline 100 mg BD for 7 days
Alternatives:
Azithromycin 1 g orally for one day, then 500mg orally once daily for two days
Erythromycin 500 mg BD for 10–14 days
438
How do you manage a pregnant lady with chlamydia?
Azithromycin 1 g orally for one day, then 500mg orally once daily for two days
Erythromycin 500 mg BD for 10–14 days
439
If a patient is thought to have chlamydia and presents in a primary care setting, where should you refer to?
GUM clinic
440
When should you do an STI screen in a patient with chlamydia?
1 week after completing treatment
441
If a patient and their partner are being treated for chlamydia, how long should they abstain from sexual intercourse? With what antibiotic is this different?
Until they have both finished treatmentWith azithromycin, you need to wait 7 days after
442
Does a partner of someone of chlamydia need to be treated if their screen result is negative?
Yes
443
How many weeks after the start of treatment do you do a test of cure treatment for chlamydia?
5 weeks
444
What age should you offer repeat testing of chlamydia in 3-6 months after treatment?
<25 years
445
What can a high ESR indicate?
Inflammation, infection
446
Is ESR usually low or raised in infection?
Raised
447
Why aren't quinolones e.g. ciprofloxacin, ofloxacin generally used in children?
Quinolones cause arthropathy and therefore are not recommended in children and growing adolescents.
448
What is the cut off eGFR for nitrofurantoin?
45
449
Can you use tetracyclines in renal impairment?
No - should not be given at all in renal impairment
| Apart from doxycycline and minocycline (but these should be used with caution)
450
Can tetracyclines cause hepatotoxicity?
Yes
451
True or false:
| Tetracyclines can be used during pregnancy
FALSE
452
True or false:Trimethoprim can be used during pregnancy
False - teratogenic in first trimester
453
True or false:Nitrofurantoin can be used during pregnancy
True
| But avoid at term
454
Can metronidazole be used during pregnancy?
No
| Only use if benefit outweighs risk
455
Is Ben Pen active against streptococci?
Yes
456
Is linezolid active against MRSA?
Yes
457
Can chloramphenicol be used in pregnancy?
No
458
Should metronidazole be taken with or without food?
With or just after food
459
What electrolyte disturbances can be caused by aminoglycosides?
Hypokalaemia
Hypo Mg
Hypo Ca
460
What is the MHRA warning about gentamicin?
Potential for histamine-related adverse drug reactions with some batches
461
Is gentamicin used for MRSA?
No
462
Red man syndrome caused by vancomycin causes is associated with what other clinical features?
Hypotension
Bronchospasms
Caused by rapid infusion
463
Which is associated with a higher incidence of nephrotoxicity?TeicoplaninVancomycin
Vancomycin
464
If a patient on a tetracycline develops a headache, what should they do?
Stop
Side effect of tetracyclines- benign intracranial hypertension
465
What tetracyclines should you avoid milk in? (DOT)
Demeclocycline
Oxytetracycline
Tetracycline
466
What tetracyclines can you have milk with? (DLM)
Doxycycline
Lymecycline
Minocycline
467
What tetracyclines cause oesophageal irritation and is recommended to take with plenty of fluid?
Doxycycline
Minocycline
Tetracycline
468
Can ciprofloxacin cause QT prolongation?
Yes
469
Are quinolones active against MRSA?
No
470
If a patient on a quinolone develops psychiatric disturbances, what should you recommend?
They should stop the drug
471
What is the interaction between ciprofloxacin and theophylline?
Ciprofloxacin = enzyme inhibitor = causes theophylline toxicity - convulsions risk
472
With which quinolone should you protect yourself from sunlight?
Ofloxacin
473
Cholestatic jaundice risk is increased with amoxicillin/flucloxacillin if on it for more than how many days?
14 days
474
What is the dosing regimen for Malarone for the prophylaxis of malaria?
1 tablet OD
| Started 1-2 days before, during, and 7 days after
475
Should Malarone be taken on an empty stomach or with food?
Take with food/milky drink to maximise absorption
476
What is the renal cut off for Malarone?
<30 mL/min
477
What is the dosing regimen for doxycycline for the prophylaxis of malaria?
1 tablet OD
| Start 1-2 days before, during and 4 weeks after
478
How long do you continue malaria prophylaxis with doxycycline after leaving the area of risk?
4 weeks after
479
What is the dosing regimen for chloroquine in the prophylaxis of malaria?
2 tablets once a week
| Start 1 week before, during and 4 weeks after
480
Should chloroquine be taken on an empty stomach?
No Take just after food
481
Should proguanil be taken on an empty stomach?
No Take just after food
482
What is the dosing regimen for proguanil in the prophylaxis of malaria?
2 tablets OD
Started 1 week before
Continue for 4 weeks after
483
Should mefloquine be taken on an empty stomach?
No, take just after food
484
What are the side effects associated with glycopeptides?
Infusion reactions, headache, nausea, diarrhea, skin rash and pruritus
C. diff
485
What is the dose of trimethoprim for a UTI?
200mg BD
486
What is the safest macrolide to use in pregnancy?
Erythromycin
487
What is penicillin G?
Benzylpenicillin
488
What is first line for acute infective exacerbation of COPD? Treatment duration?
Amoxicilin, clarithromycin or doxycycline for 5 days
489
What is first line for acute exacerbation of bronchietasis? Treatment duration?
Amoxicilin, clarithromycin or doxycycline for 7-14 days
490
What is low severity CAP in terms of CURB score?
0-1
491
What is moderate severity CAP in terms of CURB score?
2
492
What is high severity CAP in terms of CURB score?
3-5
493
What is the CURB score and what does each marker mean?
```
Confusion - mental test 8 or less
Urea > 7 mmol/L
Resp rate 30 breaths/min or more
Blood pressure systolic < 90 or diastolic 60 or less
65 years and older
```
