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1
Q

Drugs only effective against gram positive bacteria

A

Penicillinase resistant penicillins (cloxacillin)
Vancomycin
Linezolid
Trimethoprim

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2
Q

Drugs only effective against gram negative bacteria

A

Aztreonam
Ciprofloxacin (mostly)

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3
Q

What drugs are effective against atypicals

A

Tetracyclines, macrolides
Levofloxacin

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4
Q

What drugs are effective against MRSA

A

Ceftaroline, ceftobiprole
Vancomycin
Macrolides, clindamycin, linezolid
Sulfonamides, trimethoprim, cotrimoxazole
Fluoroquinolones not used due to resistance

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5
Q

Drugs with oral bioavailability

A

NP V, PRP, aminopenicillins, 1st and 2nd gen cephalosporins
Vancomycin (CDAD)
Tetracyclines
Macrolides esp azithromycin
Clindamycin, linezolid
Neomycin for bowel prep
Fluoroquinolones, sulfonamides, trimethoprim, cotrimoxazole, nitrofurantoin
Amphotericin B, 5-flucytosine, metronidazole
NRTI, NNRTI, integrase inhibitors
Acyclovir, valacyclovir, ganciclovir, valganciclovir

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6
Q

Drugs that can be administered for pregnancy

A

Penicillins, cephalosporins, carbapenems, aztreonam
Oral vancomycin for CDAD
Azithromycin, erythromycin
Amphotericin B, itraconazole, voriconazole, terbinafine
Metronidazole (Avoid first trimester)
PEP - Tenofovir + emtricitabine
Integrase inhibitors (with folic acid)
Acyclovir, valacyclovir

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7
Q

Drugs effective against anaerobes

A

Aminopenicillins, piperacillin + tazobactam, carbapenems
Clindamycin
Levofloxacin, moxifloxacin
Metronidazole (first line)

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8
Q

Simple UTI drugs

A

Nitrofurantoin, cotrimoxazole are first line
Amoxicillin, cephalexin
Fluoroquinolones (but may have resistance)

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9
Q

Good CSF penetration

A

Penicillins
3-5th gen cephalosporins
Meropenem
Aztreonam
Vancomycin
Linezolid
Aminoglycosides
Fluconazole, voriconazole

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10
Q

MRSA orally

A

Clindamycin, linezolid, doxycycline
Sulfonamides, trimethoprim, cotrimoxazole

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11
Q

Pregnancy orally

A

NPV, PRP, aminopenicillins, 1-2 gen cephalosporins
Oral vancomycin for CDAD
Azithromycin, erythromycin
Amphotericin B, metronidazole (Avoid first trimester)
Tenofovir, emtricitabine, integrase inhibitors (with folic acid)
Acyclovir, valacyclovir

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12
Q

Anaerobes orally

A

Aminopenicillins
Clindamycin
Levofloxacin, moxifloxacin
Metronidazole (first line)

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13
Q

Atypicals pregnant

A

Azithromycin, erythromycin

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14
Q

MRSA pregnant

A

Ceftaroline, ceftobiprole

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15
Q

Anaerobes pregnant

A

Aminopenicillins, piperacillin + tazobactam, carbapenems
Metronidazole (AVoid first trimester)

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16
Q

UTI pregnant

A

Amoxicillin, cephalexin

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17
Q

Endocarditis

A

Gentamicin + penicillin first line
Streptomycin + penicilin

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18
Q

LA administered for procaine allergy

A

Bupivacaine
Lidocaine
Etidocaine
Mepivacaine
Prilocaine

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19
Q

Mechanisms of LAs

A

Bind to sodium channels to prevent opening and influx of Na+ causing depolarization
Prevents AP generation
Binds preferentially to small unmyelinated rapidly-firing and peripheral nerves
Binds more to nociceptive fibers to block noxious stimuli from generating pain signals

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20
Q

What local factors can affect LA action

A

Fiber positioning in nerve bundle, size and myelination, frequency of firing
Dosage
Site of injection (acidity, blood supply)
Acidity

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21
Q

What is a potential adverse effect when administering LA? How to prevent?

A

Systemic adverse effects like vasovagal syndrome, depressed CNS syndrome, restlessness, lightheadedness, dizziness, cyanosis, hypersensitivity, nausea, vomiting, liver damage

Administer with vasoconstrictor

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22
Q

Inhaled vs IV GA

A

Inhaled
- Maintenance, sometimes induction in children
- Surgical anesthesia, loss of consciousness
- Slower onset and offset
- Most excretion via lungs
- Can cause respiratory and cardiac depression (variable effect on heart rate but SV and systemic resistance typically fall)

IV
- Induction, adjunct to inhaled
- Cannot achieve surgical anesthesia (except ketamine) or loss of consciousness
- Faster onset and offset
- Dose controlled more accurately
- Does not require expensive vaporizer equipment or disposal equipment
- Most metabolism via liver and excretion via kidneys
- Respiratory and cardiac depression

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23
Q

Ester LAs

A

Procaine
Cocaine
Chloroprocaine
Tetracaine

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24
Q

PK of LA

A

PK does not affect onset

PK affects offset
- A and D into systemic bloodstream causes drop in [LA] to below MEC
- A and D into tissues slows excretion
- A depends on acidity –> more acidic = more charged, less penetration
- A and D depends on vasoconstrictor usage
- M via liver or butyrylcholinesterases
- E renally

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25
Isoflurane VS Nitrous oxide
Isoflurane - Inhaled GA - Liquid, has to be vapourized - Anxiolysis, amnesia, analgesia, sedation - Loss of consciousness, surgical anesthesia - Used for maintenance of GA - Metab in body - Excreted primarily via lungs - Higher solubility, slower onset and offset - Dose dependent respiratory depression - MOA via increasing brain Cl- opening times, hyperpolarization Nitrous oxide - Inhaled GA - Gaseous - Anxiolysis, amnesia, analgesia, sedation - Loss of consciousness, surgical anesthesia - Used as adjunct to labour pain and adjunct to other inhaled GAs - Metab in GI bacteria - Excreted primarily via lungs - Lower solubility, faster onset and offset - Lowest risk of increasing ICP - MOA via increasing brain Cl- opening times, hyperpolarization
26
LA for 1h long procedure
Procaine
27
LA administration
Infiltrative plexus block Topical
28
Advantages of using LA with adrenaline
Longer duration of action Lower risk of systemic side effects
29
MOA of IV GAs
Bind to GABA receptors and potentiate GABA in the brain Prolongs Cl- opening time and increases frequency of opening, hyperpolarizing the cell Prevents AP generation, block motor and autonomic responses to noxious stimuli Analgesic, amnesic, anxiolytic, sedative
30
Adverse effects of IV GAs
Generally decrease respiration, cardiac output and can cause hypotension, anterograde amnesia, increased ICP Excitement phase associated with amnesia but not delirium, vomiting + retching upon stimulation Ketamine causes post-op disorientation, illusions, dreams Post-op nausea Malignant hyperthermia (hyperthermia, muscle rigidity, tachycardia, hypertension, acidosis, death)
31
Balanced anesthesia?
IV induction Inhaled maintenance LA pre- and perioperative analgesia Muscle relaxants for tracheal intubation and efficiency of surgery CVS drugs to control transient autonomic responses to noxious stimuli
32
NSAID mechanism of action
COX enzyme inhibition COX1 constitutive, COX2 inducible (except kidneys, female repro tract, CNS, joints) COX1 produces TXA2, PGE2, PGI2 COX1 inhibition causes antiplatelet effect, cardioprotection, hypernatremia, hypertension, easy bruising, increased risk of hyperkalemia and acute liver failure, nausea, vomiting, abdominal discomfort, gastric ulcers, exacerbate existing wounds, contraindicated in pregnancy COX2 produces PGE2, PGI2 COX2 inhibition causes increased thrombosis, decreases inflammation and pain, hypernatremia, hypertension, increased risk of hyperkalemia and acute renal failure Inhibition of prostanoids reduces sensitization of nociceptive fibers, analgesic effect with analgesic ceiling Inhibition of COX2 prostaglandins reduces inflammation NSAIDs also associated with hypersensitivity, SJS, TEN
33
NSAIDs in 30 year old pregnant woman
Third trimester = premature closure of ductus arteriosus Gastric ulcer, hypertension, thrombosis, bleeding
34
NSAIDs in 75 year old woman with history if ischemic heart disease
Coxibs cause thrombosis, hypertension Aspirin is antiplatelet but gastric ulcer, hypertension and prolonged bleeding time
35
Paracetamol overdose
CYP450 conversion in minor pathway to NAPQI, reactive metabolite that causes damage to surrounding liver tissues and cells Depletes glutathione Exacerbated by alcohol Reversed by N-acetyl cysteine
36
Adverse effects of steroids
- Immunodeficiency - Moon face, buffalo hump, truncal obesity - Aseptic necrosis of femoral head - Osteoporosis - Muscle wasting - Myopathy - Diabetes, hyperglycemia - Hypokalemia, hyponatremia - Thin skin - Impaired wound healing - Hirsutism, hair growth - Impaired growth in children - Posterior subcapsular cataracts - Glaucoma - Easy bruising
37
Transcriptional MoA of corticosteroids
Enters cell, binds to nuclear receptors, inducing removal of inhibitory components, homodimerizes to enter nucleus, binds to specific DNA binding sites to induce transcriptional effects to reduce inflammation
38
How do corticosteroids achieve anti-inflammatory effects at different levels
○ Activation of antiinflammatory genes § Annexin A1 § Endonucleases § IL-1 antagonist § IkB-a (TNF-a antagonist) § Beta-2 adrenoceptor expression § IL-B1 antagonist ○ Suppression of proinflammatory genes § Cytokines(TNF-a, INF-y) § Chemokines (RANTES) § Inflammatory enzymes (COX2, PA2, 5-LOX) § Adhesion molecules (VCAM1) § Receptors (T cell receptors)
39
Why would triamcinolone be prescribed over hydrocortisone
More potent Used in situations where corticosteroids are needed for longer term More selectivity for glucocorticoid instead of mineralocorticoid action
40
Metformin MoA
Decrease hepatic glucose production Decrease intestinal glucose uptake Increase insulin receptor density at tissues
41
Precautions in scheduling appts for diabetics
Last mealtime Duration of insulin effect
42
Side effect of metformin, how to prevent it
Increased risk of lactic acidosis Dont use in pts with history of renal dysfunction
43
Side effect of short acting insulins, how to prevent it
Lipodystrophy Rotate site of injection
44
MoA of glibenclamide
Sulfonylureas bind to SU sites on Katp channels, prevent opening and cause depolarization, calcium channels open and cause insulin vesicle exocytosis
45
Adverse effects of glibenclamide
Weight gain, hypoglycemia (esp in pts with irregular eating habits, elderly, hepatic/renal dysfunction)
46
Extra benefits of metformin
Cardioprotective Weight loss
47
Chronic facial pain drugs
Antidepressants (amitriptyline) Anticonvulsants (phenytoin, carbamazepine) Anxiolytics/muscle relaxants (benzodiazepines)
48
Warfarin usage + anticonvulsants
Anticonvulsants (phenytoin and carbamazepine) induce CYP450 Less warfarin = thrombosis
49
Amitriptyline MoA
Inhibit 5HT and NET Increase serotonin and norepinephrine in synaptic cleft Interneurons modulate pain signaling
50
Amitriptyline adverse effects
Dry mouth, tachycardia, arrhythmia, blurring of vision, postural hypotension, constipation, sedation, serotonin syndrome if used with SSRIs or MAOs
51
Amox vs Azithromycin
Amox no effectiveness against atypicals, pseudomonas and klebsiella
52
Amox MoA
Transpeptidase inhibitor Blocks peptidoglycan cell wall synthesis Cell death
53
Azithromycin MoA
Macrolide, 50S ribosomal subunit inhibitor Prevents translocation of tRNA from A to P site Inhibits protein synthesis and cell division
54
Nystatin systemic effects
No, no systemic absorption via swish and swallow/spit
55
Nystatin MoA
Polyene Ergosterol, pores in cell wall Leakage of electrolytes and small molecules Cell swelling and death
56
Amoxicillin adverse effects
CDAD, hypersensitivity, neurotoxicity, hepatotoxicity, anosmia
57
Ciprofloxacin MoA
Fluoroquinolone DNA gyrase in gram neg, topoisomerase IV in gram pos Inhibits DNA synthesis Cell death
58
Ciprofloxacin PK
Administered orally Avoid taking with milk or antacids as heavy metal ions form chelates to reduce absorption Distributes well into bone, urine, kidneys, lungs, prostate Cleared renally
59
Effectiveness of ciprofloxacin
P aeruginosa Travellers diarrhoea Food poisoning Bacillus anthracis Typhoid fever Not first line for UTI and MRSA due to resistance
60
Adverse effects of ciprofloxacin
Phototoxicity Tendonitis QT prolongation GI disturbances Peripheral neuropathy Arthropathy Increased risk of CDAD Headaches, dizziness, lightheadedness Contraindicated in G6PD deficiency, children, breastfeeding and pregnancy May cause neuromuscular paralysis if given with myasthenia gravis drugs DDIs increase warfarin and cyclosporine
61
MoA of cotrimoxazole
Inhibits folic acid synthesis Dihydropteroate synthase and dihydrofolate reductase
62
PK of cotrimoxazole
Taken orally with full cup of water IV in severe infection Good CSF pen, crosses BBB well Excreted in urine
63
Adverse effects of cotrimoxazole
Glossitis Rash Photosensitivity Haematological disturbances like leukopenia, megaloblastic anemia, thrombocytopenia Contraindicated in pregnancy and G6PD deficency
64
Clindamycin for odontogenic infections
Good effectiveness against oral bacteria and anaerobes Good distribution into salivary gland fluids and bone
65
Adverse effects of clindamycin
CDAD, pseudomembranous colitis
66
Suspension > lozenge for pt with xerostomia
Lack of saliva to dissolve lozenge
67
Nystatin > fluconazole for oral candidiasis w/ kidney disease
Nystatin less side effects as not absorbed Nystatin targeted via swish and swallow Nystatin eliminated unchanged in faeces, fluconazole excreted renally so dose adjustment required
68
Adverse effects of nystatin
Skin irritation if administered topically
69
Precautions of fluconazole prescription
Kidney dysfunction Hepatic dysfunction (azoles cause hepatotoxicity) CYP450 drugs like warfarin (azoles inhibit CYP450)
70
Adverse effects of fluconazole
GI disturbances Hepatotoxicity QT prolongation
71
Azole resistance types
Efflux pumps Alterations to C-14-a-demethylase reducing affinity
72
Combination therapy?
Less drug needed due to synergism, less side effects, less resistance Broader spectrum of activity
73
Metronidazole DDIs?
Metronidazole inhibits CYP450, can affect drugs like warfarin
74
Adverse effects of metronidazole
Gastric disturbances, unpleasant metallic taste, oral moniliasis, peripheral neuropathy
75
Clindamycin MoA
Bind to 50s ribosomal subunit to inhibit protein synthesis, bacteriostatic
76
Macrolide suitability for odontogenic infections
Slightly broader activity than penicillins Can be used but may cause oral candidiasis or secondary infection, not selective
77
Adverse effects of macrolides
Ototoxicity Hepatotoxicity May cause QT prolongation GI distress
78
Patient related factors for antibiotic planning
Comorbidities - renal failure Concomitant drug usage - warfarin Pregnancy Age - children Genetics - G6PD deficiency Hypersensitivity - beta lactams
79
Antibiotic related factors for antibiotic planning
Side effects - penicillins? Resistance - clindamycin? Distribution - clindamycin?
80
Vancomycin adverse effects
Nephrotoxicity Ototoxicity Red man syndrome
81
Aminoglycoside adverse effects
Nephrotoxicity Ototoxicity Neuromuscular paralysis w myasthenia gravis Contraindicated in pregnancy

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