Infections Flashcards
(128 cards)
1
Q
Choosing antibacterial
A
Patient needs
Causative organisms - NOT for viral infections, avoid blind prescribing and national and local guidlines
Risk of resistance with repeated courses (higher risk of treatment failure)
2
Q
Patient factors to consider
A
Allergy - penicillin allergy or cross sensitivity
Renal and hepatic functions
Susceptibility to infection (immunocompromised)
Ability to tolerate drugs by mouth
Severity of illness
Ethnic origin
Age
Other medications
Female, pregnant or breastfeeding
Children
Taking oral contraception
3
Q
Allergy
A
Penicillin allergy
Cross sensitivity with cephalosporins and beta lactams
4
Q
Renal and hepatic function in patient factors
A
Renal - avoid Nitrofurantoin EGFR <45, Tetracyclines (except doxycyclines and minocyclines)
Hepatic - hepatoxicity (Rifampicin, tetracyclines), decrease metronidazole dose if severe impairment, cholestatic jaundice (flucloxacillin, co-amoxiclav)
5
Q
Age and gender in female risk factors
A
Elderly - increases risk of C.diff infection with clindamycin, renal/liver impairment consideration
Female; CI tetracyclines, trimethoprim, avoid; metronidazole, chloramphenicol, aminoglycosides, tetracyclines
Children - CI tetracyclines used <12 years, quinolones causes arthropathy avoid
6
Q
Antibacterial considerations
A
Viral - dont treat
Samples avoid blind treatment
Knowledge of prevalence organisms; narrow spectrum (less s.e) Vs broad spectrum (covers a range of organisms including the good)
Adjust dose based on patient factors; age, weight, hepatic, renal
Route of administration; depends on severity e.g IV severe, parenteral if vomiting (IM is painful in children)
Duration of treatment; depends on nature and infection and response to treatment - prolong use - resistance and s/e
7
Q
Broad spectrum examples
A
Aminoglycosides - gentamicin, neomycin
Macrolides - azithromycin, clarithromycin, erythromycin
Carbapenems
Cephalosporins - cephalexin
Tetracycline- lymecyclines and doxycyclines
Quinolones - ciprofloxacin
Ampicillins
Chloramphenicol
8
Q
Narrow spectrum antibiotics
A
Preferred choice except for serious infections where broad spec is needed
Penicillin G
Vancomycin
Teicoplarin
Clindamycin
9
Q
Sepsis
A
Life threatening medical emergency
Body’s reaction to severe infection
Affects whole body
10
Q
Septicaemia
A
Infection of the blood
Caused by bacteria, fungi or virus
11
Q
Symptoms of sepsis
A
Shivering fever/ very cold
Extreme pain or discomfort
Pale or discoloured skin
Sleepy, lethargic
Feeling like death
Shortness of breath
12
Q
Early management of sepsis
A
Give broad spectrum antibiotics at maximum recommended dose (ideally with 1 hour), to reduce risk of severe illness or death
Monitor patients at high risk regular, no less than every 30 mins
13
Q
Notifiable diseases
A
Public health risk diseases
Diseases where there could be a public health risk
Doctors must notify the proper officer, the local authority or local health protection unit
List of diseases on this
E.g anthrax, scar, whopping cough, small pox, TB, Thyroid, MMR
14
Q
Antibiotics before food, empty stomach
A
Demecyclines
Rifampicin
Oxytetracyclines
Phenoxymethylpenicillin
Flucloxacillin
Ampicillin
Tetracyclines
15
Q
Antibiotics to take with or after food
A
Metronidazole
Nitrofurantoin
16
Q
Antibiotic to use in pregnancy
A
Penicillins
Erythromycin
Cephalosporins
Clindamycin
17
Q
Antibiotic to AVOID in pregnancy
A
Tetracyclines
Aminoglycosides
Macrolide (exception is erythromycin)
Co-trimoxazole
Rifampicin
Metronidazole
Quinolones
Nitrofurantoin - esp last semester
Trimepthoprin - avoid in first trimester
18
Q
Antibiotics to avoid in sunlight
A
Doxycycline
Demeclocycline
19
Q
Contraindications of antibiotics
A
Penicillins - allergy
Tetracyclines - children under 12 years and pregnant
Quinolones - hx tendon disorders related to quinolone use
Aminoglycosides - myasthaenia gravis
20
Q
Antibiotics that discolour urine
A
Rifampicin - red discolouration or bodily too
Nitrofurantoin - brown and orange
21
Q
GI system infections
A
Clostridium- difficult infection
Diarrhoea
Elderly and women most at risk
Antibiotic - associated colitis
Clindamycin (the most), ampicillin, amoxicillin, 2nd or 3rd generation, quinolones
Treatment for 10 -14 days
1st episode mild-mod; oral metronidazole, subsequent episodes or severe infection is unresponsive to metronidazole
Oral vancomycin or findoxamicin
Loperamide is contra indicated
22
Q
Cardiovascular system
A
Endocarditis
Treat with amoxicillin +/- low dose gentamicin
Vancomycin in MRSA/penicillin allergy
Flucloxacillin in staphylococci
Benzylpenicillin in streprococi
23
Q
CAP
A
Community acquired pneumonia
Blood and sputum samples mod-high severity
IV - if severe and cant take oral
Mild to give amoxicillin alternative is doxycycline, clarithromycin, erythromycin (if pregnant)
CURB 65 score
- confusion, urea more than 7, respiratory rate is high, 65+, BP 90 systolic or 60 systolic or less
Cough at least; sputum, wheeze, breathlesssness or pleuritic pain
Focal chest signs present such as dullness to percussion, course crepitations, vocal Fremitus
At least one systemic feature present with or without temp above 38’ include sweats, fevers or myalgia
24
Q
Hospital acquired pneumonia
A
> 48 hours from admission
Higher risk; symptoms start over 5 post admission, recent, broad spec use, contact/health social setting
Non severe give oral
Severe or higher risk give IV
MRSA suspected add vancomycin or teicoplanin or linezolid
25
Nervous system infections
Meningitis/ meningococcal septicaemia
Causative agent; neisseria meningitis
Treatment; benzylpenicillin
Cefotaximine if penicillin allergy, chlorenphenicol (if immediate pen allergy)
26
Muskoskeltal infection
Osteomyelitis
Treat; flucloxacillin, clindamycin (if pen allergy), if MRSA suspected vancomycin
27
Skin infections
Staphylococci aureus
Impetigo - 1st line hydrogen peroxide, fusidic acid 7 days (if small areas affected can use mupirocin if fusidic resistance)
Cellulitis - flucloxacillin
Animal/human bites - co-amoxiclav, doxycycline and metronidazole
MRSA (skin + soft tissue) - tetracyclines or sodium fusidic and Rifampicin , clindamycin (alternative)
Mastitis - flucloxacillin or erythromycin
28
Otitis externa infections
Painful ear, swelling, itchy
Systemic antibiotic; infection spread, high risk (diabetic severe infection)
Treatment flucloxacillin (clarithromycin alternative)
29
Otitis media infection
Rapid onset, painful, swelling, effusion
Usual self limiting, 3-7 days
Oral antibiotic; discharge, feeling unwell at risk
Amoxicillin alternative is clarithromycin
30
Oral infections
Gingivitis - acute necrotising ulcerative periapical/periodontal abscess, periodontitis, pencoronitis
Treatment; dental infections; metronidazole 200 mg TDS 3 days, alternative amoxicillin/doxycycline
Change response if not better in 48 hours - may combine
31
Sinusitis
Usually viral but can be complicated by bacterial
Over 10 days; give high dose nasal corticosteroid for 14 days (mometasone/fluticasone - unlicensed)
No improvement after 7 days treatment - antibiotics
1st line - non-life threatening; phen V
Very unwell or high risk; co-amoxiclav
Alternative doxycycline alternative clarithromycin or erythromycin if pregnant
32
Sore throat infection
Symptoms or suggest strep
Fever pain
White tonsils, inflammed/severe
High risk give antibiotic
Phen v, clarithromycin (if allergic)
Benzylpenicillin if severe
33
Antibiotics and blood disorders
Blood disorders - sore throat, fever, malaise, rash, mouth ulcers, bruising or bleeding
E.g trimethoprim, co-trimoxazole, linezolid, gentamicin, vancomycin
34
Important safety information and advice
Flucloxacillin - hepatic disorder - liver toxicity (cholestatic jaundice, nausea vomiting abdo pain)
Co-amoxiclav - can cause cholestatic jaundice and hepatic disorders
Linezolid - optic neuropathy, blood disorders
Co-trimoxazole - CI in SJS
Quinolones - tendon rupture damage, convulsions, joint problems
35
Aminoglycosides
Broad spectrum bactericidal antibiotics
Inhibiting protein synthesis
Effective against aerobic, gram -ve (some +ve)
Bactericial - kills bacteria
Not given orally as its not absorbed from the gut
CI if myasthenia gravis (impaired neuromuscular transmission)
E.g gentamicin, neomycin, streptomycin, amikacin
Amikacin treat -ve bacteria resistant to gentamicin
Gentamicin - endocarditis, pneumonia, meningitis, septicaemia
Neomycin - oral-bowl sterilisation before surgery
Streptomycin - TB
36
Aminoglycosides monitoring
Monitored in elderly, obesity, cystic fibrosis, pregnant women and when high doses are given
37
Gentamicin ranges
Take blood samples approx 1 hour after administration (peak concentration) and also just before next dose (trough concentration)
If pre dose (trough conc’) is high - increased dose interval (increase interval in renal impairment)
If post dose (peak conc’) is high - decreased dose
IM or IV use for multiple daily regimen
Peak concentration = 5 - 10 mg/L
Trough concentration = < 2 mg/L
For multiple daily dose regimen in endocarditis
Peak concentration = 3-5 mg/L
Trough concentration = <1 mg /L
38
Aminoglycosides side effects
Dose related (narrow therapeutic index)
Parenteral treatment shouldn’t exceed 7 days - to avoid s/e
Renal excreted ( care elderly and those poor function)
Ototoxicity - tinnitus, hearing problems, diziness = irreversible
Nephrotoxicity - decreased urine output, oedema, sob, fatigue, avoid in renal impairment
Risk in pregnancy (auditory nerve damage in infants)
Antibiotic associated colitis
Skin reactions
Decreased; calcium, potassium and magnesium
39
Aminoglycosides interactions
Loop diuretics can increase ototoxicity risk
Nephrotoxicity with cephalosporin, vancomycin or ciclosporin
Only severe drug interaction is with ataluren and colistimethate
40
Aminoglycosides contraindication and caution
CI in myasthenia gravis
Care with dosage due to auditory disorders - irreversible
Avoid one daily regimes in patients with CrCl <20 ml/min, endocarditis, limb amputation, pregnancy
41
Carbapenems
Impermeable, meropenem, ertapenem, blapenem
Used for severe hospital acquired infection
Beta lactam antibiotic
Broad spectrum
Similar to penicillins and cephalosporins - CAUTION in pen allergies as cross sensitivity- increased risk allergic to these groups too
S/e; diarrhoea, headache, N/V
Avoid if history of immediate hypersensitivity reaction to beta lactam antibacterial
42
Cephalosporins
Cefazolin, cephalexin, cefuroxime, cefoxitin
5 generations
Broad spectrum bacterialcidal - interferes cell wall synthesis
1st gen more active than +ve the rest more against -ve
Excreted re ally
S/e; hypersensitivity, against pen allergic patients, antibiotic- associated colitis
Safe to use in pregnancy
Cefotoxamine and ceftriazome - treat meningitis as they cross BBB
Treat range conditions; pneumonia, septicaemia, UTI, peritonitis, meningitis,
43
Vancomycin
Glycopeptide
Narrow therapeutic spectrum antibiotic
Bactericidal activity against aerobic and anaerobic gram + bacteria
Colitis caused by C.diff infection
Red man syndrome - rapid infusion
Discontinue if tinnitus occurs (ototoxicity); monitor elderly (avoid loop diuretics; avoid concomitant use)
Higher nephrotoxicity then teicoplanin
S/e - blood disorder, dizziness, drug fever, hypersensitivity, neutropenia, skin reaction
44
Vancomycin monitoring
Initial dose is based on body weight
Subsequent doses based on serum vancomycin concentration
‘Trough concentration’ range 10- 20 mg/L
Monitor FBC, renal and hepatic function
Monitor vestibular and auditory function function
45
Clindamycin
Inhibits protein synthesis
Narrow therapeutic
Active against gram + bacteria
Bone and joint infections
Alternative to macrolides esp in penicillin sensitive patients
STOP IF DIAARHEOA occurs
S/e; antibiotic associated colitis
Monitor liver and renal function id treatment exceeds over 10 days
46
Macrolide
Erythromycin, azithromycin, clarithromycin
Bacteriostatic - stops bacterial cell growth
Broad spectrum
Similar to penicillin but not identical - good alternative
Active against many penicillin resistant staphylococci
Avoid clarithromycin in pregnancy, erythromycin not known to be harmful
47
Macrolide adverse effects
QT prolongation (prolongation when taken; antipsychotics, citalopram or lithium)
Taste disturbances
Antibiotic associated colitis
GI discomfort
Heparins impairment
Hypotension
Skin reaction
Nausea (common erythromycin)
48
Macrolide interactions
Risk rhadbdomylosis with statins (omit during therapy) - azithromycin safe to take alongside statins
QT prolongation; with Aminophylline, steroids, B2agonist and diuretics
Macrolides can increase exposure of ivabradine, diltiazem, digoxin, verapamil and warfarin
Erythromycin and clarithromycin are both enzyme inhibitors
Increase plasma concentration of other drugs
49
MHRA alerts and erythromycin
Erythromycin should not be given to patients with history of QT prolongation
Rivaroxaban and erythromycin can increase the risk of bleeding
50
Erythromycin
Can be used in pregnancy
Used to treat resp infections, legionella, skin and oral infections, early syphilis, chlamydia
Poor activity against H.influenza
Side effects; nausea and vomiting, diarrhoea (lower doses less effect)
May cause hepatoxicity
Ototoxicity in higher doses
Higher doses needed in more severe infection
51
Linezolid
Narrow spec
Bacteriostatic
Alternative to vancomycin in MRSA infection
S/e; blood disorders, optic neuropathy if >28 days use (counsel importance visual symptoms)
Interactions; hypertensive crises (SSRIs, TCAs, MAOIs, opioids)
Pneumonia and skin infections
52
Azithromycin
Less active than erythromycin over gram + but enhanced activity over some gram -
Long tissue half life and daily dosage recommended
Use if no other alternative if pregnant or breastfeeding
Can sell OTC in confirmed asymptomatic chlamydia infections in >16s and sexual partners
Max single dose 1 g
Not take food or indigestion remedies 2 hours before or after
53
Clarithromycin
Erythromycin derivative with slightly greater activity
More stable and causes fewer side effects
Tissue concentration higher than with erythromycin
Given BD
Treat H.pylori, Lyme disease
Avoid in 1st trimester and use only after if benefit outweighs risk
Avoid hepatic and renal impairment
Take with or just after food or meal, swallow whole, space evenly
54
Chloramphenicol
Inhibits protein synthesis
Broad spectrum
Bacteriostatic
Reserved for life threatening infections
Blood dyscrasia and grey baby syndrome (avoid in pregnancy)
55
Penicillins
Bactericidal and interfer with bacterial cell wall synthesis
Active against gram + and - bacteria
Different classes
Beta lactamase sensitive - benzylpenicillin G and pen v
Penicillinase resistant penicillins - flucloxacillin
Broad spectrum penicillins - amoxicillin, ampicillin co-amoxicillin
Antipseudomonal penicillins - piperacillin, ticarcillin
Mecillinam-type - pivmicilliam
Not known to be harmful in pregnancy
Empty stomach expect pivmeciliniam (amoxicillin can be taken before or after food)
56
Penicillin allergy
True allergy - immediate rash, hives, anaphylaxis; don’t use beta lactam
May not be allergic - minor rash, small, not itchy after 72 h
Hypersensitivity
Allergic reaction in 1-10% population (rash 7-10 days after 1st treatment)
Anaphylaxis occur in fewer 0.05%
Higher risk in patients with hx asthma, eczema or hayfever
Avoid in patients with history of anaphylaxis
Avoid cross sensitivity; cephalosporin and other beta lactams antibiotic - avoid use
57
Penicillin adverse reactions
Anaphylaxis
Angioedema
Dirrhoea (more common with broad spectrum)
Rash
Cholestatic jaundice - fluxloc up to 2 months after stopping
Increased c.diff risk (in particular co-amoxicillin and piperacillin-tozobactam)
58
Penicillin interactions
Reduce excretion of methotrexate which can increase its toxicity
Potentially alters the anticoagulant effect of warfarin (severe anectodal)
59
Penicillin contraindication and cautions
Avoid patients hx sensitivity or anaphylaxis
Avoid flucloxacillin in patients with hx hepatic dysfunction associated with flucloxacillin
Pivmicilliniam is CI in infants less than 3 months old and in GI obstruction
60
Benzylpenicillin
Penicillin G
Inactivated by beta lactamases
For otitis media, cellulitis, throat infection, pneumonia, anthrax and meningitis
Inactivated by gastric acid and absorption from GIT is low so must be given by an injection
S/e; fever
High doses may cause neurotoxicity (inc cerebral irritation, convulsions or coma) in renal impairment pts
61
Phenoxymethylpenicllin
Pen V
Similar activity to pen G but less active
Gastric acid stable so suitable for oral admin
Indicated principally for; respiratory infection in children, oral infections, tonsillitis, otitis media, cellulitis, strep infections, acute sinusitis
S/e; increase risk of infection, neurotoxic, oral disorders
62
Ampicillin
Abroad spectrum penicillin
Active against certain gram + and gram - organisms
Inactivated by penicillases
Many staphylococci are resistant so not used
Absorption decreased by food in stomach and half is only absorbed by oral route
S/e; maculopopular rashes
63
Amoxicillin
Broad spec penicillin
Derivative of ampicillin with similar anti-bacterial spectrum
Maculopapular rash commonly occurs with ampicillin and amoxicillin
Better absorbed by mouth ampicillin and not affected by food
Used; UTI, otitis media, sinusitis, uncomplicated CPA, oral infection, Lyme disease, h.pylori
S/e; cholestatic jaundice dont exceed 14 days
64
Co-amoxiclav
Broad spectrum with beta lactamase inhibitor (prevents breakdown of ring = more activity)
Amoxicillin and clauvulanic acid
Reserved for infections that are amoxicillin resistant beta lactamase
Caution cholestatic jaundice
65
Flucloxacillin
Penicillanse resistant penicillins
Acid stable therefore can be given orally as well as by injection
Absorbed by gut; take before food
Effective against infections caused by penicillin resistant staphylococci, impetigo, otitis media, pneumonia
Cholestatic jaundice and hepatitis may occur very rarely up to 2 months after use
Admin for >2 weeks and increase in age is risk factors
- not to use in patients with hepatic dysfunction associated with flucloxacillin, hepatic impairment caution
66
Nitrofurantoin
Narrow spectrum
Bactericidal
Used UTI
S/e; nausea risk peripheral neuropathy in renal impairment
Avoid at term can cause neonatal haemolysis
CI; infant less than 3 months old
Take with or after food
Urine discolouration yellow
67
Quinolones
Ciprofloxacin,levofloxacin, delafloxacin, ofloxacin, nalidixic acid
Activity against gram + and - bacteria, bactericidal and exerts effect via inhibition of bacterial DNA replication
Ciprofloxacin - resp tract and GI infection, UTI, gonorrhoea
Levofloxacin - skin infection, UTI, pneumonia
Ofloxacin - pelvic inflammatory disease, septicaemia, UTI
NOT recommended in children and growing adolescents as it can cause arthropathy
Discontinue drug is psychotic, neurological or hypersensitivity reactions occur
Avoid in pregnancy can cause arthropathy (joint disease)
NSAIDs can induce convulsions as drug lowers seizure threshold
68
Quinolone interactions
Severe interaction with NSAIDs- increase seizure risk
Prednisolone can increase risk of tendon damage
Drugs that prolong QT interval or cause arrhythmias e.g amiodarone, SSRIs, macrolides
Anticoagulant effect of warfarin increased
69
Quinolone cautions
Avoid exposure to excessive sunlight - discontinue if photosensitivity occurs
Can prolong QT interval - increasing arrhythmia risk
Pts with hx of epilepsy or seizure
70
Quinolone adverse effects
QT interval prolongation
Tendon rupture can occur within 48 hour of administration
DISCONTINUE and contact GP if serious adverse reaction occur e,g tendinitis or tendon rupture, muscle pain, muscle weakness, joint pain/swelling, peripheral neuropathy
Higher risk in patients over 60 or concomitant use corticosteroids
CI in hx of tendon damage
71
MHRA and quinolone
Tendon damage
Arthropathy in children hence not recommended
Risk aortic aneurysm and dissection - onset sudden severe abdominal chest or back pain
72
Tetracyclines
Lymecycline, doxycycline, minocycline
Broad spectrum antibiotic
Bacteriostatic and value decreased due to resistance
Acne, pneumonia, chlamydia, rickettsia, MRSA infections
Avoid in pregnancy and breastfeeding
Active against - and + gram bacteria
73
Minocycline
Only one of the tetracyclines that differs slightly
Has a broader spectrum
Active against neisseria meningitidis - Ve
Greater risk of lupus-erythematosis like syndrome
Sometimes causes irreversible pigmentation
Rarely used; vertigo and diziness
74
Tetracycline caution
Increase muscle weakness in patients with myasthenia gravis
Antacids can reduce absorption
Oxytetracyclines can exacerbate renal failure
Avoid in hepatic impairment
75
Children and tetracycline
Permanent staining of the teeth in children under 12 years
76
Milk and tetracyclines
Oxytetracyline, demeclocycline and tetracycline = NO milk
Doxycycline, lymecycline and Minocycline = CAN have with milk
Doxycline after food with skin protection
77
Tetracycline side effects
Discontinue intracranial hypertention - headache and visual distrubances
Nause and vomiting
Skin reaction
Photosensitivity reaction
Discolouration of tooth enamel in children
Angioedema
Systemic lupus erythrematosus exacerbation
78
What tetracycline has most photosensitivity
Demeclocycline
79
Tetracycline interactions
Isotretinoin can increase risk intracranial hypertension
80
Trimethoprim
Inhibits DNA synthesis
UTI and respiratory tract infections (chronic bronchitis, pneumonia)
Bacteriostatic, broad spectrum and folate antagonist
CI in blood disorders
S/e; diarrhoea, electrolyte imbalance, fungal overgrowth, headache, nausea, skin reactions, blood disorders
AVOID in 1st term pregnancy = teratogenic
Monitor FBC if on long term
Advice blood disorders; fever, sore throat, rash, mouth ulcers
81
Metronidazole
Inhibits DNA synthesis
High activity against anaerobic bacteria and Protozoa
Trachoma vaginitis, bacterial vaginitis and vaginosis
Orally to treat C.diff infection, topical used for microbial odours and in rosace
Alternative for oral infections in penicillin allergic patients
1st choice gingivitis 200mg TDS for 3 days
S/e; GI distrubances , dark urine, taste disturbance, furred tongue, mucositis is
Avoid alcohol during and 48 hours after last dose
Take WITH FOOD or just after meal or food
Interaction; alcohol (disulfiram like reaction), warfarin increase level
82
UTI
Common in women than men
Main caused E.coli
Collect urine specimen before treatment - start on broad spec abx until cause is known on sensitivity
Uncomplicated - trimethoprim, Nitrofurantoin
Women for 3 days and men for 7
83
TB treatment
2 phases
Initial phase of 4 drugs for 2 months
Continuous phase of 2 drugs for 4 months
Rifampicin, Isoniazid, Pyrazinamide, Ethambutol
84
TB treatment monitoring
Check renal and hepatic function before treatment
Pts with pre-existing liver disease and alcohol dependence should have frequent liver checks (particularly in 2 the first months)
If no liver disease, further checks necessary only if patient has fever, malaise, vomiting, jaundice or unexplained deterioration
Discontinue if signs of liver disease develop; jaundice, dark urine, vomiting
Isoniazid and pyrazinamide = hepatotoxic
85
Isoniazid
May cause peripheral neuropathy
Give pyridoxine prophylaxis - B6 from start of treatment to prevent neuropathy
Report hepatoxicity
86
Ethambutol
Can cause visual changes
Report visual distrubances
87
Rifampicin information for patient
Discolouration of urine orange / brown and soft contact lenses
Inducer - contraception decreased use IUD
Discontinue if; presistant nausea, vomiting, Maisie, jaundice signs
88
Rifampicin side effects
Blood disorders
Nausea and vomiting
Menstrual disorders
Thrombocytopenia
Tear and urine discolouration
Psychosis
IV use; bone pain, GI disorders, hyper bilirubin anemia, psychotic disorder
89
Rifampicin interactions
DOACs and warfarin
Ciclosprin
Sildenafil
Macrolide
Clozapine
Contraception- all
Mycophenolate
Verapamil
Is an inducer
90
Rifampicin monitoring
Renal function checked before treatment
FBC should be monitored in patients on prolonged therapy
Hepatic function should be checked before
If alcohol dependent check hepatic function and FBC frequently
91
Types of antifungals
Triazole - Fluconazole, itraconazole; prevention and systemic treatment of fungal infections
Imidazole - clotrimazole, ketoconazole, miconazole treatment vaginal candidiasis and dermatophyte infection
Polyene - nystatin, amohotericin
Other antifungals - griseofulvin and terbinafine
92
Amphotericin B
Polyene antifungals
Caution; avoid rapid infusion (risk of arrhythmias)
Side effect nephrotoxicity
Can cause anaphylaxis - test dose is done first
Manufacture advises against pregnancy
Plasma electrolyte, blood counts, hepatic and renal function - monitoring
93
Fluconazole
Triazole antifungals
Susceptibility to QT interval prolongation
Diarrhoea, GI, N/V and skin reactions
Discontinue if rash occurs or signs of hepatic disease
Age 16-60 years sold
Pack size 150 mg MAX OTC
94
Intraconazole
Can cause HF
Immediate medical attention if signs of liver disease (n/v, anorexia, dark urine, abdo pain)
Interact antacids - need acidic pH for it to work
95
Imidazole antifungals
Clotrimazole, econazole, ketoconazole, miconazole
Treatment vaginal candidiasis and dermatophye infections
Daktarin and canesten
Mostly topical
96
Nystatin
Oral
Oropharyngeal, pernoral infections and candidiasis albicans
Used on prescription
97
Dermatophyte infections
Infections; skin, hair, and nail
Risk factors; diabeties, immune compromised, poor circulation and peripheral arterial disease
Tinea pedis, tinea corpons, tinea capits, tinea uriguium
98
Systemic therapy of antifungals
If topical fails
Many areas infection
If site of infection is difficult to treat
Oral terbinafine and intraconazole (broader spec) preferred over griseofulvin
Tinea captis treated systemically
99
Helminth infections
Threadworms / pinworms
Combine with hygiene measures to break cycle of auto infection
Treat ALL family members
Single dose 100 mg mebendazole (ovex OTC or vermox POM) in 2 years in OTC or 6 months POM
Second dose after 2 weeks to prevent re infection
No more 8 tablets in a pack
100
Herpes simplex virus
2 tyopes
Herpes simplex 1 and 2
Varicella zoster virus
101
Herpes simplex
Mouth and lips, eye - normally herpes - herpes simplex 1
Genital infection - normally herpes - herpes simplex 2
Start treatment of herpes simplex within 5 days of infection appearance
102
Varicella zoster
Chicken pox
More severe in adolescent and adults than children
Antiviral treatment which is started within 24 hours of onset - only high risk
Those previously exposed to chickenpox and are at risk of complications may need varicella zoster immunoglobulin prophylaxis
103
Shingles; herpes zoster
Pain and rash along one side along the nerve line
Systemic antiviral treatment can reduce severity and pain duration
Treatment within 72 hours onset of rash (continue for 7 to 10 days)
Immunocompromised and higher risk patients - treatment with parental antiviral drug
Chronic pain which persist after rash has healed needs specific management (pros therapeutic neuralgia)
104
Treatment of herpes viruses
Aciclovir - treatment of choice, active against HSV but doesn’t eradicate them
Famcliclovir - prodrug of penciclovir used in herpes zoster ad genital herpes
Valaclovir - ester of Aciclovir, used in herpes zoster and simplex also cytomegalovirus disease after organ transplant
105
Types of malaria
Non falciparum - non fatal cased by plasmodium vivax
Falciparum malaria - malignant, fatal, caused by plasmodium falciparum (deadly), multiple rapidly in blood, very dangerous in pregnancy (especially in pregnancy)
106
Chloroquine (avloclor)
Used malaria
Prophylaxis and treatment of non falciparum malaria
Used with proguaril when resistance to chloroquine regimen may not give optimal protection (Paraguay/avloclor)
Ocular toxicity in adults if dose exceeds 4 mg/kg
Chloroquine no longer recommended for treatment of falciparum malaria but recommended for treatment of non falciparum malaria
P medicine
Once weekly
1 week before travel and 4 weeks after
Not for epileptic, severe renal impairment
MHRA alert - with Macrolide abx can increase cv events
107
Mefloquine
POM
Used malaria prophylaxis
Rarely used due to resistance
Neuropsychiatric reactions - CI in psychiatric disorders
ONCE WEEKLY
2-3 weeks before travel and 4 weeks after
Liecensed for up to 1 year
108
Proguanil
Praudrine
P medicine
Used with chloroquine or alone for malaria prophylaxis
Proguaril alone is not suitable for treatment
WITH atovaquone (=malarone) licensed for treatment of acute uncomplicated malaria
Once weekly
1 week before travel and 4 weeks after
109
Malarone
Used for both types positive
Falciparum malaria prophylaxis of uncomplicated falciparum and treatment of non falciparum malaria
Used as alternative to mefloquine or doxycycline
Suitable for short trips because only needs to be taken for 7 days after leaving endemic area
OD
1-2 days before travel and a week after
Avoid severe renal impairment
Can be used up to 1 year
110
Quinine
Standby treatment
Quinine sulphate, quinine bisulphate
Also used in leg cramps nocturnal
Used in treatment of non falciparum and falciparum malaria
Associated with QT prolongation
111
Doxycycline and malaria
Adults and children over 12
Prophylaxis in mefloquine and chloroquine resistant areas
Used as alternatuve
Once daily
Used 1-2 days before travel and up to 4 weeks after
Photosensitivity, oesophageal irritation, CI children/pregnant
112
Malaria prophylaxis
Not all drugs is 100% breaththrough infections can occur
Protect against bites - long sleeves avoiding going out after dusk
Mosquito nets impregnated with permethrin
Mats and vaporised insecticides useful
DEET 20-50% safe and effective when applied to skin of adults over 2 months
113
Returning from malaria region zone
Any illness within 1 year especially within 3 months of return may be malaria
Advise travellers to report any illness to their doctors immediately particular if its within 3 months of return
114
Malaria prophylaxis and epilepsy
Chloroquine and mefloquine unsuitable
Proguaril alone is recommended in areas without chloroquine resistance
Doxycycline or malarone recommended in areas with chloroquine resistance
115
Pregnancy and breastfeeding in malaria prophylaxis
Avoid travelling if possible
Chloroquine and proguaril given
Proguaril alone (give folic acid 1st trimester)
Avoid; malarone, doxycycline, and mefloquine unless no alternative and not use 1st trimester
116
Malaria prophylaxis and anticoagulants
Start chemo prophylaxis 2-3 weeks before travel
INR should be stable before travel
INR should be measured before starting prophylaxis 7 days after starting and completing the course
Check INR regular intervals for prolonged stages
117
Falciparum treatment
Quinine (together or followed by doxycycline or clindamycin), malarone, riamet
High doses of quinines are teratogenic; but in malaria the benefit outweighs the risk
118
Non falciparum treatment
Chloroquine
Quinine, riamet or malorone
In pregnancy give chloroquine weekly
119
Viral infections influenza at risk
Patients over 65 years
Chronic respiratory conditions
Chronic heart disease
Chronic renal disease
Chronic liver disease
Immunocompromised
Carers
Diabeties mellitus
Pregnant
Chronic neurological disease
120
Influenza treatment
Oseltamivir (tamiflu) and zanamivir (olenza) - effective started few hours before onset of symptoms
Reduce duration of symptoms by 1 to 1.5 days
Reduce risk of complications from influenza in elderly and patients with chronic diseases
Tamiflu - given 48 hours exposure
Olenza - given within 36 hours of exposure
Not recommended for seasonal prophylaxis against influenza. - give flu vaccine
Licensed for post exposure prophylaxis of influenza when influenza is circulating in the community (with at risk patient groups
121
Acute bronchitis
Cough, may/may not have sputum, wheeze breathlesssness
Systemic features with or without raised temperature
Sweat, fever, myalgia
Wheeze present but not other focal chest signs
122
What can you not take with milk?
Demeclocy line
Oxytettacycline
Tetracyclines
123
What can you not take with milk?
Demeclocy line
Oxytettacycline
Tetracyclines
124
What can be taken with milk?
Doxycycline
Lymecycline
Mini cyclone
125
Rare side effect on amoxicillin
Furred toungue
126
When to take second dose of mebenzadole
Take after 14 days
127
Where to report notifiable diseases?
Local protection team
128
How much maloff protect can you sell?
12 weeks max
