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NAPLEX Review > ID Fungal and Viral > Flashcards

ID Fungal and Viral Flashcards

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1
Q

Organisms from the candida species and cryptococcus neoformans are from what fungal class?

A

Yeasts

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2
Q

Aspergillus adn zygomycetes species are from what fungal class?

A

Molds

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3
Q

Histoplasma capsulatum, blastomyces dermatitidis, and coccidioides immitus are from what fungal class?

A

Dimorphic fungi

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4
Q

What is the difference in amphotericin B deoxycholate and amphotericing b lipid formulations?

A

Lipid formulations are bound to lipid and has fewer toxicities

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5
Q

What is amphotericin B used to treat?

A

Invasive fungal infections caused by
Candida species and cryptococcus neoformans
Aspergillus species, zygomycetes
Histoplasma capsulatum, blastomyces dermatidis, and coccidioides immitis

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6
Q

Amphotericin B MOA

A

binds to ergosterol altering cell membrane permeability and causing cell death

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7
Q

Amphotericin B BBW and SE

A

BBW: Amphotericin B max 1.5mg/kg/day, lipid complex formulation max 5mg/kg/d, liposomal formulation max 6mg/kg/d
SE: infusion-related, fever, chills, HA, malaise, rigors, low K and Mg, nephrotoxicity

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8
Q

Which formulation of amphotericin B needs to be diluted in D5W? Which need to be filtered? Which needs premedication?

A

D5W: all
Filtered: lipid formulations
Premedication: deoxycholate (non-lipid formulation)

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9
Q

What premedication should be given for amphotericin B deoxycholate?

A

APAP or NSAID
Diphenhydramien and/or hydrocortisone
NS boluses to decrease nephrotoxicity
+/- meperidine to decrease duration of severe rigors

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10
Q

Flucytosine MOA

A

Converted to fluorouracil in fungi which interferes with fungal RNA and protein synthesis

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11
Q

Invasive cryptococcal meningitis infection treatment

A

Amphotericin B + Flucytosine

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12
Q

Why should flucytosine not be used alone?

A

Developing resistance

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13
Q

Flucytosine BBW and SE

A

BBW: use with caution in renal dysfunction, monitor renal and hepatic status
SE: Dose-related myelosuppression, increase SCr and BUN, liver injury, increased bilirubin, many CNS effects, hypoglycemia, low K

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14
Q

Azole antifungals MOA

A

Decrease ergosterol synthesis and cell membrane formation

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15
Q

Azole antifungal effect on CYP enzymes

A

CYP3A4 inhibitors

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16
Q

What candida orgnaism is resistant to fluconazole?

A

C. krusei

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17
Q

What fungal infections is fluconazole used to treat?

A

yeast (vaginal, esophageal, mouth), nail bed infections

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18
Q

What fungal infections is itraconazole used to treat? Why is it’s use limited?

A

Blastomycosis and histoplasmosis

Limited by drug interactions, lack of data, and expense

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19
Q

Why is ketoconazole only used topically?

A

toxicities and many drug interactions

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20
Q

What is voriconazole DOC for?

A

Aspergillus

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21
Q

Azole antifungals Class effects and IV:PO ratio

A

Can increase LFTs
Risk for QT prolongation (except isavuconazonium)
Many drug interactions
IV:PO is 1:1

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22
Q

Which is the only azole antifungal that

requires renal dose adjustment

A

Fluconazole

If CrCl <50 decrease dose by 50%

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23
Q

Which is the only azole antifungal that

has hepatotoxicity that can lead to liver transplantation

A

Ketoconazole

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24
Q

Which is the only azole antifungal that

can cause HF

A

Itraconazole

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25
Which is the only azole antifungal that | can cause visual changes and phototoxicity
Voriconazole
26
Fluconazole dosing for vaginal candidiasis
150mg x 1
27
Itraconazole BBW
Can worsen HF | Can increase plasma concentrations and cause QT prolongation, ventricular tachycardia, and torsades
28
Ketoconazole BBW
Hepatotoxicity (liver transplant), QT prolongation
29
Voriconazole CI
Coadministration with barbiturates, carbamazapine, efavirenz, ergot alkaloids, pimozide, quinidine, rifabutin, rifampin, ritonavir, sirolimus, or st johns wort
30
Posaconazole CI
Coadministration with sirolimus, ergot alkaloids, pimozide, quinidine, atorvastatin, lovastatin, and simvastatin
31
Isavuconazonium CI
Use with strong CYP3A4 inhibitors or inducers, familial short QT syndrome
32
Which azole antifungal is not hepatically cleared?
Fluconazole
33
Which azole antifungals penetrate CNS?
Fluconazole and voriconazole
34
Which azole antifungal causes QT shortening rather than prolongation?
Isavuconazonium
35
Azole antifungals interaction with apixiban and rivaroxaban
Increase concentration of DOAC - monitor for s/sx of bleeding
36
Azole antifungals interaction with warfarin
Increase effects of warfarin and INR
37
Absorption of which azole antifungals is pH dependent?
Itraconazole and ketoconazole Higher pH will decrease absorption Can take with non-diet cola or orange juice to provide acidic environment for absorption
38
Echinocandin MOA
Inhibit synthesis of beta (1,3)-D-glucan, an essential component of the fungal cell wall
39
What medications are echinocandins
Caspofungin and micofungin
40
What do echinocandins cover?
Most candida species and some aspergillus species (not preferred for aspergillus as monotherapy)
41
Echinocandin warnings and SE
Warnings: histamine-mediated symptoms (rash, flushing, hypotension), anaphylaxis SE: increased LFTs, HA, hypotension, low Mg, fever, N/V/D, hyperglycemia, anemia, increased SCr, rash
42
How often are echinocandins administered and what are their renal adjustments?
Once daily | No renal adjustments
43
What dosage form is preferred for topical fungal infections?
``` Topical products (gel, cream, solution, etc) Oral are second line ```
44
Griseofulvin indication, CI, SE
Indication: Fungal infections of skin, hair, nails CI: Pregnancy, severe liver disease, porphyria SE: Photosensitivity, increased LFTs, HA, rash, urticaria, dizziness, leukopenia, severe skin reactions
45
Terbinafine CI, warnings, SE
CI: Chronic or acute liver disease Warnings: hepatotoxicity, taste/smell disturbance, hematologic abnormalities, hemolytic uremia syndrome, SJS SE: HA, increased LFTs, skin rashes
46
Which antifungal agent can increase metabolism of hormonal contraceptives? What should be used instead?
Griseofulvin | Use non-hormonal methods
47
Preferred and alternative regimens for | candida albicans - oropharyngeal infection (thrush)
Preferred: topical clotrimazole or miconazole (mild), fluconazole (mod/severe or HIV+) Alternative: nystatin
48
Preferred and alternative regimens for | candida albicans - esophageal infection
Preferred: fluconazole Alternative: echinocandin
49
Preferred and alternative regimens for | candida krusei and glabrata - bloodstream infection
Preferred: echinocandin Alternative: amphotericin B
50
Preferred and alternative regimens for | Aspergillus - invasive
Preferred: voriconazole Alternative: Amphotericin B, isavuconazonium
51
Preferred and alternative regimens for | cryptococcus neoformans - meningitis
Preferred: amphotericin B + flucytosine Alternative: none
52
Preferred and alternative regimens for | Dermatophytes - nail bed infection
Preferred: terbinafine or itraconazole Alternative: fluconazole
53
Which antifungals should be taken with food?
With food: itraconazole tablets and capsules, posaconazole | Without food: itraconazole solution, voriconazole
54
Neuraminidase inhibitors indication and MOA
Indicated for influenza | MOA: inhibit the enzyme that enables release of new viral particles from infected cells
55
When should neuraminidase inhibitors be started
<48 hours of illness onset in mild cases | Anytime if hospitalized for severe illness
56
What drugs are neuaminidase inhibitors?
Oseltamivir (Tamiflu) Zanamivir (Relenza diskhaler) Peramivir (Rapivab)
57
Oseltamivir treatment and prophylaxis doses
Treatment >12 years: 75mg BID x 5 days | Prophylaxis >12 years: 75mg BID x 10 days
58
Oseltamivir renal adjustment
CrCl < 60 reduce dose
59
Oseltamivir warnings and SE
Warnings: neuropsychiatric events, serious skin reaction, anaphylaxis SE: HA, N/V/D, abdominal pain, delirium
60
Which neuroaminidase inhibitor is preferred over the others in pregnancy
Oseltamivir
61
What drugs are endonuclease inhibitors?
Baloxavir marboxil
62
Baloxavir marboxil dosing, warnings, and SE
``` <40kg: do not use <80kg: 40mg PO x1 >80kg: 80mg PO x1 Use within 48 hours of symptom onset Warnings: hypersensitivity SE: diarrhea ```
63
Which HSV virus is associated with oropharyngeal disease and which is associated with genital disease?
HSV-1: oropharyngeal | HSV-2: genital
64
What virus causes chicken pox?
Varicella zoster virus
65
What antivirals are used for HSV and varicela zoster virus?
Acyclovir Valacyclovir Famiciclovir
66
What is valacyclovir a prodrug of?
Acyclovir
67
What is famiciclovir a prodrug of?
penciclovir
68
Acyclovir, valacyclovir, and famiciclovir warnings, SE
Warnings: Caution in renal impairment, elderly, and concurrent nephrotoxic medication use SE: malaise, HA, N/V/D, rash, increased LFTs, seizures
69
What antiviral can cause increased SCr and BUN with crystal nephropathy?
IV acyclovir
70
Topical treatment for herpes labialis (cold sore)
OTC: Docosanol (abreva) Rx: Acyclovir cream (Zovirax) and buccal tablet, Penciclovir
71
Systemic treatment for herpes labialis (cold sore)
Initial episode: acyclovir 200-400mg 5x daily for 7-10 days OR 400mg TID x 7-10 days; valacyclovir 2g BID x1 day Recurrent episode: acyclovir 200-400mg 5x daily for 5 days OR 400mg PO TID x 5 days OR 800mg PO BID x 5 days; valacyclovir 2g PO BID x 1 day Chronic suppression: acyclovir 400mg PO BID
72
If an organism is resistant to acyclovir it will also be resistant to what medication?
Valacyclovir because it is a prodrug of acyclovir | Will usually be resistant to famciclovir too
73
Genital herpes treatment with acyclovir
Initial episode: 400mg TID x 7-10 days OR 200mg 5x daily for 7-10 days Recurrent episodes: 400mg TID x 5 days OR 800mg BID x 5 days OR 800mg TID x 2 days Chronic suppression: 400mg BID
74
Genital herpes treatment with valacyclovir
Initial episode: 1g PO BID x 7-10 days Recurrent episodes: 500mg BID x 3 days OR 1g daily x 5 days Chronic suppression: 500-1000mg daily
75
Treatment of invasive HSV
Encephalitis: Acyclovir 20mg/kg/dose q8h x 14-21 days | Esophagitis and pneumonitis: 5mg/kg/dose q8h x 14-21 days
76
Treatment for shingles (herpes zoster)
Acyclovir 800mg 5x daily for 7-10 days Valacyclovir 1g TID x 7 days Famciclovir 500mg TID x 7 days
77
What does cytomegalovirus (CMV) usually cause?
Retinitis, colitis, or esophagitis
78
What medications are the treatments of choice for cytomegalovirus (CMV)? What should be reserved for refractory CMV?
Treatment of choice: Ganciclovir and valganciclovir | Refractory: foscarnet and cidofovir
79
What is leteromovir and what is it indicated for?
Non-nucleoside CMV inhibitor | Indicated for prophylaxis of CMV in patients receiving a hematopoietic stem cell transplant who screen positive for CVM
80
Ganciclovir and valganciclovir BBW and SE
myelosuppression, teratogenic effects | SE: Fever, N/V/D, hemotologic abnormalities, increased SCr, seizures, retinal detachment (valganciclovir)
81
Cidofovir BBW, CI, and SE
BBW: dose-dependent nephrotoxicity, neutropenia, carcinogenic/teratogenic CI: SCr > 1.5, CrCl <55 urine protein >100, sulfa allergy, nephrotoxic drugs \SE: nephrotoxicity, lower risk of myelosuppression, metabolic acidosis
82
Foscarnet indication
CMV retinitis and resistant HSV
83
Foscarnet BBW and SE
BBW: renal impairment, seizures d/t electrolyte imbalances SE: electrolyte abnormalities (low K, Ca, Mg, Phos), increased SCr/BUN, and QT prolongation
84
Epstein-Barr Virus (EBV) is also known as what?
Mononucleosis or "mono"

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