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NAPLEX Review UWorld > ID Part 2 > Flashcards

ID Part 2 Flashcards

1
Q

VK is a 67-year-old female with diabetes, overactive bladder and hypothyroidism who has been started on Cipro for treatment of a urinary tract infection, based on susceptibility testing. All of the following counseling points are appropriate for VK EXCEPT:

A. This medication can cause tendon rupture.

B. Separate this medication from antacids such asMaalox.

C. This medication is associated with a risk of myelosuppression.

D. Thismedication can make the skin more sensitive to the sun. Use sunscreen and protective clothing.

E. Monitor blood glucose carefully while taking this medication if you have diabetes.

A

This medication is associated with a risk of myelosuppression.

Quinolones can cause many CNS toxicities (including seizures) and muscle toxicities (including tendon rupture).

They cause photosensitivity.

They should be separated from divalent cations to avoid chelation and reduced absorption.

Quinolones can cause hypoglycemia or hyperglycemia, so patients with diabetes should monitor blood glucose closely during therapy.

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2
Q

Extended infusion piperacillin-tazobactam is a dosing strategy that optimizes which of the following pharmacodynamic parameters?

A. Peak:MIC ratio

B. AUC:MIC ratio

C. Peak concentration

D. Time above MIC (T > MIC)

E. Minimum bactericidal concentration

A

Time above MIC (T > MIC)

As a beta-lactam antibiotic, piperacillin/tazobactam kills or inhibits bacterial growth when drug concentrations exceed the minimum inhibitory concentration (MIC).

Extending the infusion (from the traditional 30 minutes to infusing over 4 hours) results in greater T > MIC and is one way to optimize the activity of beta-lactams and effectively treat more resistant (higher MIC) organisms.

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3
Q

KD is a 35-year-old female with no known past medical history. She is married to an HIV-positive man. She has received a prescription for pre-exposure prophylaxis. Which labs must be performed before beginning therapy? (Select ALL that apply.)

A. TB skin test

B. CD4+ count

C. HIV test

D. Hepatitis B test

E. Hepatitis A test

A

HIV test
Hepatitis B test

Patients eligible for pre-exposure prophylaxis (PrEP) must be screened and test negative for HIV prior to initiation and then every 3 months after starting PrEP. It is important to evaluate this information, as the 2-drug NRTI PrEP regimen is not adequate for treatment of a patient diagnosed with HIV.

Patients must also be screened for hepatitis B and STI’s. Abrupt discontinuation of PrEP in patients with hepatitis B can exacerbate the condition.

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4
Q

PrEP

Before starting

A

Confirm the patient is HIV negative (blood test)

Screen for recent symptoms of HIV

Lab tests: SCr, hepatitis B serologies

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5
Q

PrEP

Treatment options

A

Oral Truvada or Descovy, 1 tablet once daily (≤ 90-day supply)

IM cabotegravir (Apretude) monthly x 2 doses, then Q2 months

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6
Q

PrEP

Follow-up

A

Test for HIV every 3 months (if negative, continue PrEP)

Screen for STIs, monitor renal function and other potential adverse effects PRN (schedule varies)

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7
Q

PEP

Before starting

A

Obtain HIV test, SCr, and hepatitis B serologies

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8
Q

PEP

Treatment

A

Start ASAP (ideally within 72 hours) of exposure

Complete 3-drug regimen x 28 days:
Truvada (if CrCl ≥ 60)
+
Dolutegravir (Tivicay) or raltegravir (Isentress)

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9
Q

PEP

Follow-up

A

Follow-up HIV testing

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10
Q

Commonly Used Drugs for Specific Pathogens

Methicillin-susceptible Staphylococcus aureus (MSSA)

A

Dicloxacillin, nafcillin, oxacillin

Cefazolin, cephalexin (and other 1 and 2nd generation cephalosporins)

Amoxicillin/clavulanate, ampicillin/sulbactam (Unasyn)

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11
Q

Commonly Used Drugs for Specific Pathogens

Methicillin-resistant Staphylococcus aureus (MRSA)

A

Ceftaroline

Daptomycin (not in pneumonia)

Linezolid

Vancomycin (consider using alternative if MIC ≥ 2)

SMX/TMP (CA-MRSA SSTIs)

Clindamycin (CA-MRSA SSTIS)

Doxycycline, minocycline (CA-MRSA SSTIs)

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12
Q

Commonly Used Drugs for Specific Pathogens

Vancomycin-resistant Enterococcus (VRE)

A

Pen G or ampicillin (E. faecalis only)

Linezolid

Daptomycin

Cystitis only: nitrofurantoin, fosfomycin (Monurol), doxycycline (Vibramycin)

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13
Q

Commonly Used Drugs for Specific Pathogens

Atypical Organisms

A

Azithromycin, clarithromycin

Doxycycline, minocycline

Quinolones

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14
Q

Commonly Used Drugs for Specific Pathogens

HNPEK

Haemophilus, Neisseria, Proteus, E Coli, Klebsiella

A

Beta-lactam/beta-lactamase inhibitor

Cephalosporins (except 1st generation)

Carbapenems

Aminoglycosides

Quinolones

SMX/TMP

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15
Q

Commonly Used Drugs for Specific Pathogens

Pseudomonas aeruginosa

A

Aztreonam

Cefepime

Ceftazidime

Ceftazidime/avibactam

Ceftolozane/tazobactam (Zerbaxa)

Carbapenems (except ertapenem)

Ciprofloxacin, levofloxacin

Piperacillin/tazobactam (Zosyn)

Tobramycin

Colistimethate, polymyxin B

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16
Q

Commonly Used Drugs for Specific Pathogens

CAPES

Citrobacter, Acinetobacter, Providencia, Enterobacter, Serratia

A

Aminoglycosides

Cefepime

Carbapenems

Colistimethate, polymyxin B

Piperacillin/tazobactam

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17
Q

Commonly Used Drugs for Specific Pathogens

Extended-spectrum beta- lactamase (ESBL) producing gram-negative rods (E. coli, K. pneumoniae, P. mirabilis)

A

Carbapenems

Ceftazidime/avibactam

Ceftolozane/tazobactam (Zerbaxa)

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18
Q

Commonly Used Drugs for Specific Pathogens

Carbapenem-resistant gram-negative rods (CRE)

A

Ceftazidime/avibactam

Colistimethate, polymyxin B

Meropenem/vaborbactam (Vabomere)

Imipenem/cilastatin/relebactam (Recarbrio)

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19
Q

Commonly Used Drugs for Specific Pathogens

Gram-negative anaerobes (Bacteroides fragilis)

A

Beta-lactam/beta-lactamase inhibitor

Cefotetan, cefoxitin

Carbapenems

Metronidazole

Moxifloxacin (reduced activity)

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20
Q

Commonly Used Drugs for Specific Pathogens

C. difficile

A

Vancomycin (oral)

Fidaxomicin (Dificid)

Metronidazole

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21
Q

Refrigeration Required After Reconstitution

A

Penicillin VK

Ampicillin

Amoxicillin/Clavulanate

Cephalexin

Cefadroxil

Cefpodoxime

Cefprozil

Cefuroxime

Cefaclor

Vancomycin oral

Valganciclovir

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22
Q

Antibiotics

That do not require renal adjustment

A

Antistaphylococcal penicillins (e.g., dicloxacillin, nafcillin)

Ceftriaxone

Clindamycin

Doxycycline

Macrolides (azithromycin and erythromycin only)

Metronidazole

Moxifloxacin

Linezolid

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23
Q

How should efavirenz be administered to decrease CNS side effects?

A. In the morning with a large meal

B. At bedtime on an empty stomach

C. Twice a day with a pharmacokinetic booster

D. 30 minutes before breakfast

E. With the largest meal of the day

A

At bedtime on an empty stomach

NNRTI; Brand: Sustiva

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24
Q

NNRTIs Meds

A

REDEN
Rilpivirine (Edurant)
Efavirenz (Sustiva)
Doravirine (Pifeltro)
Etravirine (Intelence)
Nevirapine

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25
NNRTIs MOA
Non-competitively inhibit the reverse transcriptase enzyme, preventing the conversion of **HIV RNA to HIV DNA in stage 3 (reverse transcription)** of the HIV life cycle
26
NNRTIs SE
Hepatotoxicity Severe rash, including SJS/TEN
27
Which NNRTI has the highest risk of SJS/TEN?
nevirapine
28
NNRTI Drug Intxn
Is a 3A4 substrate Efavirenz & etravirine are moderate 3A4 inducers Rilpivirine needs an acidic environment for absorption
29
Efavirenz SE ## Footnote =
Psychiatric symptoms (depression, suicidal thoughts) CNS effects (impaired concentration, abonormal/vivid dreams, confusion): usually resolve after 2-4 weeks ↑ TC & TGC
30
Rilpivirine SE
Depression Artificial ↑ SCr (no effect on GFR) Not rec if preTx VL > 100,000 or CD4 ct < 200 (higher failure rate)
31
How do you take rilpivirine?
Take with a meal and water (do not substitute with a protein drink) Requires an acidic environment for absorption; do not use with PPIs and separate from H2RAs and antacids
32
Chlamydia Tx
Azithromycin 1 g PO x 1 OR Doxycycline 100 mg PO BID 7d
33
Rifaximin may be used in management of all of the following EXCEPT:  A. Hepatic encephalopathy  B. IBS with diarrhea  C. Refractory C. difficile  D. Spontaneous bacterial peritonitis  E. Travelers' diarrhea
Spontaneous bacterial peritonitis | PO only ## Footnote Rifaximin (Xifaxin) is an antibacterial agent that is structurally related to rifampin. It is indicated for the treatment of non-invasive E. coli travelers' diarrhea, for reduction in the risk of overt hepatic encephalopathy and for IBS-D. Since systemic drug absorption is minimal, it is not useful for spontaneous bacterial peritonitis (SBP).
34
# Acute Cystitis Empiric treatment
Nitrofurantoin 100 mg BID × 5 days Fosfomycin 3 grams × 1 dose Sulfamethoxazole/trimethoprim DS 1 tablet BID × 3 days (if no sulfa allergy) ## Footnote Nitrofurantoin CI CrCl < 60
35
Treatment of Pyelonephritis
Bactrim Urinary quinolones (ciprofloxacin, levofloxacin)
36
Which of the following statements are correct with regard to sulfamethoxazole/trimethoprim? (Select ALL that apply.) A. It is a potent hepatic enzyme inducer resulting in reduced drug concentrations. B. It has excellent bioavailability, thus can transition from intravenous to oral formulations in a 1:1 fashion. C. It is active against Gram-positive pathogens, including Staphylococci, Gram-negative pathogens and opportunistic pathogens. D. It should be avoided in a patient with a G6PD deficiency. E. A negative Coombs test with sulfamethoxazole/trimethoprim indicates hemolytic anemia.
It has excellent bioavailability, thus can transition from intravenous to oral formulations in a 1:1 fashion. It is active against Gram-positive pathogens, including Staphylococci, Gram-negative pathogens and opportunistic pathogens. It should be avoided in a patient with a G6PD deficiency. ## Footnote TMP/SMX is a potent CYP2C9 inhibitor (not inducer). It has 1:1 conversion from IV:PO dosing. It is a broad spectrum agent with excellent Gram-positive, Gram-negative (not Pseudomonas) and opportunistic pathogen coverage. It is partially cleared by the kidney and should be dosed reduced for CrCl < 30 mL/min. A positive Coombs test in the labs (along with decreasing hemoglobin/hematocrit) would indicate the presence of hemolytic anemia and Bactrim should be discontinued.
37
Bactrim CI
Sulfa Allergy Pregnant or breastfeeding
38
Bactrim Warnings
Skin Reactions (SJS/TEN) G6PD deficiency
39
Bactrim SE
Photosensivity ↑ K hemolytic anemia (+ Coombs test) crystalluria
40
Bactrim Common Uses
Ca-MRSA UTI Pneumocystis pneumonia
41
Bactrim Drug Intxn
2C9 inhibitor → ↑ INR w/ warfarin
42
Ciprofloxacin IV:PO
80%
43
Which azole antifungal requires an acidic environment for absorption?  A. Fluconazole  B. Voriconazole  C. Ketoconazole  D. Isavuconazonium  E. Posaconazole
Ketoconazole ## Footnote Ketoconazole requires an acidic environment for absorption. If a PPI or H2RA must be used while on ketoconazole, taking an acidic beverage (such as non-diet soda) can improve absorption by providing an acidic environment. 
44
Azole Class Effects
↑ LFTs Risk for QT prolongation (except isavuconazonium)
45
What is the DOC for Aspergillus
Voriconazole
46
Which azole is mostly used for onychomycosis?
Itraconazole
47
Meningitis Empiric Tx
Ceftriaxone + vancomycin ± Ampicillin (> 50 y/o)
48
Neisseria meningitidis (Meningococcus) close contacts vaccine & antibiotics prophylaxis
Rifampin 600 mg PO BID for 2 days OR Cipro 500 mg PO single dose OR Ceftriaxone 250 mg single IM inj (most effective)
49
Which of the following statements are accurate with regard to aminoglycosides? (Select ALL that apply.) A. Active against most aerobic Gram-negative pathogens B. Active against most Gram-positive pathogens as monotherapy C. Demonstrate post-antibiotic effect D. Cause hepatotoxicity E. Demonstrate concentration-dependent bacterial killing
Active against most aerobic Gram-negative pathogens Demonstrate post-antibiotic effect Demonstrate concentration-dependent bacterial killing ## Footnote Aminoglycosides are concentration-dependent killers and are active against Pseudomonas. They are cleared by the kidney and associated with nephrotoxicity and ototoxicity, especially when trough levels remain high or when given for prolonged treatment courses. When used in complicated Gram-positive infections (Staphylococcus and Enterococcus) they are used for synergy, which means that they must be given in combination with beta-lactams or vancomycin.
50
Aminoglycosides Coverage
Gram-negatives, including Pseudomonas Synergy for Gram-positives (Staphylococci/Enterococci) w/ beta-lactams | Low resistance & Cost
51
Aminoglycosides Monitoring
Renal Functions Serum Levels | Renal Damage & Ototoxicity
52
Aminoglycosides Dosing
Gentamicin/tobramycin Traditional (1-2.5 mg/kg IV Q8H) * Peaks and troughs Extended-interval: (4-7 mg/kg IV Q24H) * Draw a random level and use nomogram ## Footnote Concentration-dependent killing → give larger doses less frequently (extended interavl dosing) → allow the kidneys to recover
53
# Aminoglycosides: Traditional Dosing: Target Drug Concentations When to draw trough and peak?
Draw trough 30 mins before 4th dose Draw peak 30 mins after the end of the 4th dose infusion
54
# Aminoglycosides: Traditional Dosing: Target Drug Concentations Gentamicin/tobramycin Peak/Trough Range
Peak: 5-10 mcg/mL **Trough: < 2 mcg/mL**
55
A hospitalized patient with no known drug allergies has cellulitis and the physician ordered vancomycin 1,000 mg IV Q12H and imipenem-cilastatin 1,000 mg IV Q8H. The medications were administered at the same time over 30 minutes. During the infusion, the patient experienced a profound drop in blood pressure. Her upper body, mostly in the trunk area, was covered with an erythematous rash. What is the likely cause of the patient's symptoms?  A. Rhabdomyolysis  B. Vancomycin flushing reaction  C. Drug-induced lupus erythematosus  D. CYP2C9 drug interaction  E. Photosensitivity reaction
Vancomycin flushing reaction ## Footnote The patient has experienced symptoms of vancomycin flushing, an infusion reaction due to a rapid administration of vancomycin. Symptoms can include rash, pruritus, erythema and, less frequently, hypotension or angioedema. Infusions should be limited to no more than 1 gram per hour.
56
Vancomycin Coverage
Gram-positives (MRSA), Streptococci, Enterococci, C. difficile (PO only)
57
Vancomycin Dosing
IV: **15**-20 mg/kg Q8-12H, using **TBW** Dose/interval adjustment in renal failure
58
Vancomycin Monitoring
SCr and avoid other nephrotoxic or ototoxic drugs (e.g., furosemide, aminoglycosides, cisplatin)
59
What is 1st line for MRSA infections?
Vancomycin | e.g., pneumonia, meningitis, bacteremia, some skin infections
60
Vancomycin Target Trough
15-20 mcg/mL
61
Vancomycin C. difficile
PO only for C. difficile infections (125 mg QID x 10 days)
62
Which antibiotic cause Red Man Syndrome?
Vancomycin | Infuse 1 g over 1 hr
63
43 y/o Male Physical Exam / Vitals:  Height: 5’9”  Weight: 209 pounds    BP: 102/59 mmHg  HR: 100 BPM  RR: 28 BPM Temp: 102°F  Pain: 6/10 Plan: Acetaminophen per feeding tube for fever, empiric antibiotics for ventilator-associated pneumonia, to include meropenem + vancomycin + gentamicin (extended-interval dosing).          What dose of gentamicin should be initiated in MV as part of the empiric antibiotic regimen?  A. 95 mg   B. 160 mg   C. 560 mg   D. 665 mg   E. 1125 mg 
560 mg  ## Footnote MV is obese, so his adjusted body weight (~80 kg) should be used for aminoglycoside dosing. The dose used most commonly for extended interval dosing is 7 mg/kg (but may range from 4-7 mg/kg).
64
When to use an alternative to vancomycin?
MIC ≥ 2
65
Echinocandins Covers
Candida glabrata & krusei
66
Echinocandins Forms
IV only | Warning for infusion reactions
67
Echinocandins MOA
Blocks Beta-glucans synthesis ## Footnote Few drug intxn No renal dose adjustment
68
Which antifungal is CI in pregnancy?
Griseofulvin | Can cause contraceptive failure
69
# Treatment Of Opportunistic Infections Candidiasis (oropharyngeal/ esophageal)
Fluconazole Alternatives: Itraconazole Posaconazole
70
# Treatment Of Opportunistic Infections Cryptococcal meningitis
Induction: Amphotericin B (deoxycholate or liposomal) + flucytosine Alternative: Fluconazole + flucytosine Secondary PPx: Fluconazole (low dose)
71
# Treatment Of Opportunistic Infections Cytomegalovirus (CMV)
Valganciclovir (PO) or Ganciclovir (IV) If toxicities to ganciclovir or resistant strains: foscarnet, cidofovir Secondary PPx: No agents recommended Maintain CD4+ count> 100 cells/mm³ ## Footnote Foscarnet & cidofovir - nephrotoxicity
72
# Treatment Of Opportunistic Infections Mycobacterium avium complex infection
(Clarithromycin or azithromycin) + ethambutol Add a 3rd or 4th agent using rifabutin, amikacin or streptomycin, moxifloxacin or levofloxacin Secondary PPx: Same as treatment regimens ## Footnote Ethambutol - ototoxicity
73
BJ is on tobramycin IV every 8 hours for treating a gram-negative infection and his levels are reported as a peak of 8.3 mcg/mL and a trough of 2.5 mcg/mL. Which of the following recommendations should the pharmacist make to the medical team?  A. Increase the dose of tobramycin  B. Decrease the dose of tobramycin  C. Extend the dosing interval of tobramycin  D. Shorten the dosing interval of tobramycin  E. Continue the current regimen
Extend the dosing interval of tobramycin ## Footnote The peak of tobramycin is within range, but the trough level is above the goal level (it should be less than 2 mcg/mL and ideally less than 1.5 mcg/mL). By extending the dosing interval, the trough level will decrease and the toxicity risk is lowered without decreasing the peak for this concentration-dependent drug.
74
Protease Inhibitors Meds
**Atazanavir** (**Reyataz**) **Darunavir** (**Prezista**) Fosamprenavir Lopinavir/ritonavir (Kaletra) Tipranavir (Aptivus) | "navir"
75
All PIs
Rec w/ a PK booster (ritonavir or cobicistat) No renal dose adjustments
76
Which PIs do you take w/ food?
Darunavir (Prezista) Atazanavir (Reyataz) | Reduces GI upset
77
Which PI needs an acidic gut for absorption?
Atazanavir (Reyataz) ## Footnote Avoid PPIs w/ unboosted atazanavir Separate boosted atazanavir w/ PPI by 12 hours No more than 20 mg of omeprazole or equivalent
78
Which PI is used only for PK boosting?
Ritonavir | Low doses
79
PIs SE
Diarrhea, nausea Hyperglycemia/insulin resistance, dyslipidemia, lipodystrophy Hepatotoxicity (eg, ↑ LFTs, hepatitis) Hypersensitivity reactions (eg, rash, SJS/TEN)
80
Atazanvir SE
Hyperbilirubinemia (reversible) | Yellow appearance to the skin or scleral icterus (yellow eyes)
81
Which PIs should not be taken if the pt has a sulfa allergy?
**Darunavir** (**Prezista**) Fosamprenavir Tipranavir (Aptivus)
82
Which PI contatins alcohol?
Lopinavir/ritonavir (Kaletra) Sol | Disulfiram rxn w/ metronidazole
83
PK Boosters Med
Cobicistat (Tybost) Ritonavir (Norvir) | Take w/ food
84
Which PK Booster can artificially ↑ SCr?
Cobicistat (Tybost)
85
# PI & PK Booster Drug interactions CI or should be avoided
Alpha-1A blockers: alfuzosin, silodosin, tamsulosin Amiodarone, dronedarone Anticoagulants/antiplatelets: apixaban, rivaroxaban, ticagrelor Azole antifungals: voriconazole, posaconazole, itraconazole, isavuconazole Protease inhibitors for hepatitis C (eg, grazoprevir, glecaprevir) Lovastatin & simvastatin PDE-5 inhibitors used for pulmonary hypertension: sildenafil, tadalafil Strong CYP3A4 inducers (eg, carbamazepine, rifampin, St. John's wort) Systemic, inhaled & intranasal steroids (except beclomethasone)
86
Which of the following antimicrobials has a risk for additive QT prolongation when combined with amiodarone?  A. Zithromax  B. Penicillin V potassium  C. Invanz  D. Nitrofurantoin  E. Cleocin
Zithromax ## Footnote All macrolides have a risk for QT prolongation and should be used cautiously in patients with cardiovascular disease or those taking other QT prolonging drugs.
87
Macrolides Meds
Azithromycin (Zithromax) Clarithromycin (Biaxin) Erythromycin (E.E.S.)
88
Macrolides Coverage
Atypical pathogens (Legionella, Chlamydia, Mycoplasma, Mycobacterium avium) H. influenzae S. pneumoniae ## Footnote Azithromycin covers traveler's diarrhea
89
# Common Uses Macrolides
CAP, Strep throat
90
# Common Uses Azithromycin
COPD exacerbations Chlamydia Gonorrhea MAC PPx ## Footnote And Traverlers' diarrhea
91
# Common Uses Clarithromycin
H. pylori
92
# Common Uses Erythromycin
↑ gastric motility | e.g. gastroparesis
93
Macrolides Safety Issues
QT prolongation: caution w/ CVD ↓ K/Mg, use of other QT-prolong drugs Drug intxn: Clarithromnycin/erythromycin Strong 3A4 inhibitors CI w/ simvastatin/lovastatin
94
JP has a blood culture report showing Gram-positive cocci resembling Streptococci, Klebsiella pneumoniae and anaerobes. Which of the following medications would provide adequate coverage for these organisms?  A. Ertapenem  B. Rifaximin  C. Metronidazole  D. Fosfomycin  E. Ciprofloxacin
Ertapenem ## Footnote Carbapenems are very broad-spectrum antibiotics. They cover gram positives, gram negatives and anaerobes. Rifaximin, metronidazole and fosfomycin have a much narrower spectrum. Ciprofloxacin does not have reliable strep coverage, nor does it cover anaerobes. 
95
Carbapenem Meds
Doripenem Imipenem/Cilastatin (Primaxin I.V.) **Meropenem** Meropeneme/Vaborbactam (Vabomere) **Ertapenem** (**Invanz**)
96
Carbapenems Class Effects
All active against ESBL-producing organisms and (except ertapenem) Pseudomonas Do not use with penicillin allergy Seizure risk (with higher doses, failure to dose adjust in renal dysfunction, or use of imipenem/cilastatin)
97
Carbapenems Coverage
Broad coverage, so remember what is not covered: Atypicals, VRE, MRSA, C. difficile, Stenotrophomonas **E**rt**AP**enem does not cover PEA: Pseudomonas, Enterococcus, Acinetobacter
98
Carbapenems Common Uses
Polymicrobial infections (e.g., severe diabetic foot infection) Empiric therapy when resistant organisms are suspected ESBL-positive infections Resistant Pseudomonas or Acinetobacter infections (except ertapenem)
99
Carbapenems Form
IV only
100
Ertapenem must be diluted in?
NS

NAPLEX Review UWorld (17 decks)

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