Disease Management

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Disease Management
2011-01-16 17:25:33
disease management pharmacy

Disease management 4th year lecture
Show Answers:

  1. What are the symptoms of asthma?

    Chronic cough (may be worse at night)


    Frequent ‘chest infections’

    Persistent cough

    Children: Recurrent ‘wheezy bronchitis’

    Chest tightness or shortness of breath

    ! regular scripts (or purchase) of antibiotics, cough mixtures
  2. Asthma: Aims of treatment
    Control symptoms, incl nocturnal & exercise-induced

    Prevent exacerbations

    No need for rescue medication

    Achieve best possible lung function (FEV1 &/or PEF > 80% predicted or best)

    Minimise side effects
  3. Asthma: Non pharmacological management
    Allergen avoidance e.g. pollen, house dust mite, pets

    Stop smoking

    Lose weight if obese

    Avoid exercise in cold air

    Minimise occupational stimuli

    Avoid NSAIDs & b-blockers

    Immunotherapy, Buteyko breathing technique

  4. Which b2-agonists are used in asthma and how do they have their effect?
    short-acting: salbutamol, terbutaline

    Onset 1-5 mins, duration 4-6 h

    Bronchial smooth muscle relaxation

    Enhance mucociliary clearance

    First-line, symptomatic relief

    long-acting (LABA):

    salmeterol: Onset 10-20mins, duration 12 h

    formoterol: Onset 1-3 mins, duration 12 h
  5. Which corticosteroids are used in asthma and when to use them?
    inhaled: e.g. beclomethasone, budesonide

    Ciclesonide (new inhaled steroid)

    oral: prednisolone

    IV: hydrocortisone

    Suppress inflammatory process

    Use if:

    –Exacerbation of asthma in last 2 yrs

    –Using inh ß2-agonist >3 times per wk

    –Symptomatic >3 times per wk

    –Waking 1 night per wk
  6. Corticosteroids: ADR's

    –hoarseness or dysphonia

    –oral candidiasis

    –adrenal suppression

    >1500mcg beclomethasone daily



    –adrenal suppression


    –skin thinning


    –moon face

  7. Which leukotriene antagonists are used in asthma and how do they work?
    Oral montelukast, zafirlukast

    Antagonise bronchoconstriction, oedema and mucous production by LTC4, D4, E4
  8. Which methylxanthines are used in asthma and how do they work?
    oral: theophylline

    iv/oral: aminophylline (salt of theophylline)



    –anti-inflammatory effects

    SR preparations used to give more predictable effect

    brand must remain constant
  9. Methylxanthines: ADRs/od
    Therapeutic range: 10-20mg/l

    <20mg/l: nausea, diarrhoea, nervousness, headache

    >20mg/l: vomiting, insomnia, arrhythmias

    >35mg/l: hyperglycaemia, arrhythmias, convulsions, death
  10. Methylxanthines: Factors affecting clearance
    Reduce clearance (Increased plasma levels)


    –liver disease


    –enzyme inhibition e.g. cimetidine, erythromycin, allopurinol, ciprofloxacin

    Increased clearance (Reduced plasma levels)



    –enzyme induction e.g. carbamazepine, rifampicin, phenytoin
  11. Which cromones are used in asthma and how do they work?

    What ADR's are associated with them?
    Nedocromil: Preventer in 5-12y olds

    Inhibits mediator release from mast cells



    –bitter taste

  12. Which immunosuppressants are used in asthma?
    methotrexate, ciclosporin, gold

    steroid-sparing agents

    specialist use, rarely
  13. Which anti Ig-E monoclonal antibodies are used in asthma and how is it used?

    Licensed as add-on therapy in adults and children > 12 for severe persistent allergic asthma

    S/C injection every 2 to 4 wks

    Only initiated by specialist centres

    Patients must fulfil specific criteria (NICE)

    Discontinue after 16 wks if inadequate response
  14. Adult asthma management (BTS/SIGN guideline) : Step 1
    Step 1: Mild, intermittent asthma

    Inhaled short acting b2 agonist as req’d
  15. What sort of information is included in an Asthma Action Plan?

    When is an action plan issued?
    Inhaler/PEF training

    Knowledge of drug types

    Recognition of worsening asthma

    Action points e.g.

    –­ inhaled steroids

    –start oral steroid

    –seek medical attention

    Consider for every asthmatic on an individual basis

    Written, personalised

    Describes PEF at which to:

    –Double dose of inhaled steroid

    –Start oral steroids

    –Telephone GP or call ambulance

    Evidence of improved health outcomes

    Mod – severe disease, i.e. BTS Step 3 or above &/or previous admission
  16. What is a PEF?

    How is one done?

    How do we use the information?
    Peak Expiratory Flow rate

    effort dependent

    best of 3

    available on FP10

    dependent on sex, age, ht

    % predicted normal or best

    –e.g. <50% acute severe asthma
  17. Acute severe asthma treatment: What do we immediately give to treat?
    Severe or life-threatening?

    Immediate Rx:

    –oxygen: highest possible conc. 40-60%

    –b-agonist: neb or multiple doses via spacer

    –Cxsteroid: prednisolone 40-50mg po or 100mg iv hydrocortisone


    –Ipratropium nebs

    –Single dose IV magnesium sulphate

    –iv aminophylline/iv salbutamol
  18. Monitoring of acute severe asthma

    O2 saturation

    arterial blood gases


    theophylline levels (if cont >24h)

    serum K+/glucose


  19. Monitoring of Asthma
    Are aims achieved?


    –b-agonist use



    Inhaler technique

    Review 3 monthly: step down if possible

    Self-management plan/Action plan?
  20. Treatment of acute severe asthma - non immediate

    When to transfer to ITU?

    How to treat during hospitalisation after acute attack?

    When to discharge patient?
    Transfer to ITU if

    -Deteriorating PEF

    –persistent hypoxia


    –exhaustion, drowsiness

    –coma, resp. arrest

    During hospitalisation

    –iv ® neb ® inhaler

    –oral steroid 1-3 wks

    –re-start steroid inhaler

    –discharge criteria

    –action plan

    –check inhaler technique

    Steroid inhaler probably started at higher dose than previously

    Discharge only with PEF >75% predicted/best

    diurnal variation <25%

    Been on discharge medication for at least 24 hours
  21. COPD

    How to diagnose?

    What are the stages of COPD and how are they characterised?
    Airflow obstruction – usually progressive, not fully reversible and does not change markedly over several months

    Diagnosis: symptoms + spirometry (FEV1 < 80% predicted and post bronchodilator FEV1/FVC < 0.7

    Emphysema, chronic bronchitis, COAD

    FEV1 ≥ 80% predicted = stage 1/mild

    FEV1 50-79% predicted = stage 2/moderate (mild 2004)

    FEV1 30-49% predicted = stage 3/severe (moderate 2004)

    FEV1 < 30% predicted = stage 4/very severe (severe 2004)
  22. COPD risk factors



    Alpha-1 antitrypsin deficiency


    Existing impaired lung function
  23. Aims of COPD treatment
    Stop smoking (only intervention shown to reduce lung function decline)

    Improve symptoms

    Prevent acute infective exacerbations

    Reduce rate of disease progression

    Maintain nutritional intake

    Inc QoL
  24. Which bronchodilators are used in COPD?
    Continuous bronchodilation important

    Short-acting ß2 agonists e.g. salbutamol

    –Onset 15mins, duration 4-6h

    –Most commonly used b’dilator in COPD

    LABAs e.g. salmeterol

    – Duration 12h

    - Modest inc in FEV1, but symptoms, exercise capacity, health status improved


    –ß vagal airway tone & reflex bronchoconstriction

    –Short-acting: Ipratropium, oxitropium

    –Long-acting: Tiotropium

    –Use alone or add to ß2 agonists if inadequate relief

    –ADRs: dry mouth, occ urinary retention
  25. Which methylxanthines are used in COPD?

    What is their mode of action?

    When are they used?

    Which route are they given by?
    Methylxanthines (see Asthma)

    Mode of action

    -strengthen diaphragm

    -mucociliary clearance

    -improve CNS response to hypoxaemia

    Place in therapy

    -Inadequate control with short- and long-acting bronchodilators

    -Inhalers unsuitable

    Caution: elderly


    –Theophylline or aminophylline


    –Aminophylline: Loading dose (if no previous use) then continuous infusion

    –Monitor levels

    Interactions important
  26. Which corticosteroids are used in COPD?

    When are they used?
    Inhaled beclomethasone, fluticasone, budesonide

    Use for pts with

    –FEV1 <50% predicted + 2 or more exacerbations requiring antibiotics or po steroids a year

    –Higher doses required

    –None licensed for use alone in COPD

    Oral: only when oral steroids cannot be withdrawn after exacerbation
  27. Oxygen in COPD: How does it work?

    When is it used?

    Criteria for LTOT

    –Improves hypoxia & ß work of breathing


    –Used for acute exacerbations

    –Long Term O2Therapy (>15h daily) prolongs life

    24 - 28% O2 to prevent decrease in respiratory drive (O2 is stimulus for breathing due to chronic retention of CO2 - danger! High O2 concentrations)


    –criteria for use (NICE)

    –hazard = smoking

    –cylinders or concentrator

    Assess people who have: very severe airflow obstruction FEV1 ≤ 30% predicted



    peripheral oedema

    ↑ JVP

    O2 sat ≤ 92% on air
  28. Vaccinations in COPD
    Annual influenza vaccine

    Pneumococcal vaccine
  29. Antibiotics in COPD: When are they used and which ones?
    Exacerbations only

    Choice dependent on

    –local policy

    –lab sensitivity patterns

    –previous Rx

    Common brands are adequate, newer ones rarely appropriate
  30. Which mucolytics are used in COPD?

    How do they work?

    Who should they be used for?
    e.g. Carbocisteine, Mecysteine

    Facilitate expectoration by reducing sputum viscosity

    Consider in pts with chronic productive cough

    Continue if improvement (stop after 4 wk trial if no benefit)

    Shouldn't be used routinely to prevent exacerbations in people with stable COPD
  31. Treatment of stable COPD
    1. Short-acting bronchodilator as needed (ß2-agonist or anticholinergic)

    2. Still symptomatic: Combined short-acting ß2-agonist with a short-acting anticholinergic

    3. Still symptomatic: Long-acting bronchodilator (ß2-agonist or anticholinergic)

    4. In mod - severe COPD, consider combination of long-acting bronchodilator & inhaled Cxsteroid (Discontinue if no benefit after 4/52)

    5. If still symptomatic, consider adding theophylline

    Use inhaled Cxsteroids if criteria apply

    Assess need for oxygen

    Stop smoking, encourage exercise, nutrition, flu vaccine
  32. Treatment of acute COPD exacerbations

    Which pathogens are usually involved and which antibiotics to treat?

    When to give antibiotics?

    Other medication?

    –Haemophilus influenzae

    –Streptococcus pneumoniae

    –Moraxella catarrhalis

    1st choice - Amoxycillin/tetracycline

    2nd choice - broad spectrum cephalosporin/macrolide

    Home 7d Hospital 7-14d

    Antibiotics if 2 or more of

    –Inc breathlessness

    –Inc sputum volume

    –Inc sputum purulence

    Prednisolone 30mg for 7-14 days

    Add or inc bronchodilator
  33. Complications of COPD, symptoms of the complications and how to treat them?
    Cor pulmonale

    –Right heart failure - 90% due to COPD

    –Symptoms: peripheral oedema, hepatomegaly

    –Rx: diuretics reduce oedema

    –O2 reduces hypoxia


    –↓ O2 → ↑ RBC → ↑ haematocrit → ↑ Blood viscosity

    –Prescribe O2 to ↓ hypoxia


    Acute respiratory failure

    Type 1 (emphysema)

    –↓ O2 ↓ CO2 ↑ or N pH

    –i.e. ventilation ↑ to compensate for ↓ O2

    –DO NOT use doxapram (resp stimulant)

    Type 2 (chronic bronchitis)

    –↓ O2 ↑ CO2 ↓ pH

    -i.e. ventilation insufficient to prevent ↑ CO2

    –Assess need for NIV, consider respiratory stimulant: doxapram
  34. COPD monitoring in community and hospital

    Inhaler technique

    Adverse effects

    Blood gases


    Annual flu vaccine


    -Theophylline levels

    -blood gases

    -U & E's


    -o2 sats

  35. COPD symptoms
    Current or ex-smoker with:

    –Persistent cough

    –Recurrent ‘bronchitis’ in winter

    –Breathlessness on exertion

  36. Smoking cessation
    Ask about smoking status

    Advise all smokers to stop

    ?Referral to smoking cessation service


    –Set a stop date

    –Get family support

    –Recommend NRT (pharmacist role)/Zyban (Rx only) - doubles chance of successfully stopping

    –Arrange follow-up
  37. Pharmacists responsibilities towards newly diagnosed pts
    Ensure understanding of disease, education

    Assess prescriptions:

    –appropriate doses




    –Check pts have been shown how to use inhalers/take medicines
  38. Spacer devices: Advantages and how to use
    E.g. aerochamber, nebuhaler, volumatic

    Avoid need for coordination with MDI

    Inc lung deposition

    Reduce deposition in mouth/throat

    Caution! Dry in air after washing

    Replace every 6-12 months
  39. Factors affecting choice of inhaler
    Depends on

    –pt preference

    –assessment of correct use


    –manual dexterity



    No evidence for correct order of use

    Choice of drug may determine inhaler

    Cost, e.g. Seretide 500 Accuhaler £40.92
  40. How to obtain a nebuliser?

    How to use?
    Determine local policy:

    –borrow from surgery/hospital?

    –Purchase from pharmacy?


    –Caution - over reliance (asthma)

    –Mixing drugs

    –Increased s/e compared with inhalers

    –Servicing once/yr
  41. Non specific monitoring for respiratory illness

    –Changes in Rx

    –Symptoms, incl exercise limitation

    –Inhaler technique


    –Drug/disease interactions e.g. b-blockers

    –Adverse effects, e.g.

    - b-agonists - tremor

    - inh steroids - thrush, hoarse voice
  42. Oxygen therapy for respiratory disease: Who is it supplied by and how to order?
    Supplied by commercial company for different parts of England, e.g. Air Products for NW

    GP/hospital uses HOOF form to order

    Provision of advice for pt &/or carer

    Help monitor pts using O2
  43. Reasons for treatment failures in respiratory illness

    –Failure to take medicines as Rx’d

    - peer pressure, ADRs

    –Failure to use devices correctly

    –Failure to use peak flow meter regularly

    –No Action Plan

    –Drug causes e.g. sedative use in COPD

    –Worsening of underlying disease or acute exacerbation

  44. Asthma - counselling points


    Avoid NSAIDs, b-blockers

    PEF + diary
  45. COPD counselling points


    Avoid NSAIDs, b-blockers + sedatives
  46. b-agonists in respiratory illness - counselling
    Time to effect

    ADRs – tremor



    –Use prn or regularly




  47. Inhaled C-steroids in respiratory illness - counselling points

    For inflammation

    Use regularly, even if well

    Rinse mouth


  48. Oral steroids in respiratory illness - counselling points
    Usually short course

    Carry steroid card if maintenance Rx

    Continue with inh steroids

    Take all tablets in morning

    With/after food

    ADRs - inc appetite, acne

    Long-term ADRs – osteoporosis (consider prophylaxis) etc
  49. Theophylline in respiratory illness - counselling points
    Same brand

    Take regularly but don’t inc dose if breathing worsens

    Avoid OTC preps incl theophylline

    ADRs – headache, irritability, nausea
  50. Antibiotics in COPD - counselling points
    Complete course

    Take regularly

    Drink plenty of fluids
  51. Leukotriene antagonists in respiratory illness - counselling points
    Take regularly
  52. Combined hormonal contraception (CHC):

    How effective?

    What does it contain?

    Mode of action?
    Over 99% effective

    Combined synthetic hormones

    Ethinylestradiol and progestogenic agent

    No corpora lutea development

    Endometrium doesn’t develop

    Cervical mucus ­increase viscosity
  53. CHC formulations
    Oral tablets (COC)

    Transdermal patch (Evra®) - see FFPRHC site

    Vaginal delivery system (NuvaRing®)
  54. CHC classifications and strengths
    Monophasic - fixed amounts of oestrogen and progesterone

    • Phasic - varying amounts over cycle
    • Biphasic
    • Triphasic

    Low strength: ethinylestradiol 20mcg

    Standard strength: ethinylestradiol 30 or 35 mcg or 30/40 mcg in phased preparations
  55. CHC types of hormone
    • Oestrogen
    • - Ethinylestradiol

    - Mestranol


    - Norethisterone

    - Ethynodiol

    - Levonorgestrel

    - Gestodene

    - Desogestrel
  56. Advantages of CHC
    Reliable (nearly 100% effective) and reversible

    Often reduces period pain and pre menstrual symptoms

    Protects against some pelvic infections

    Protects against cancer of the womb and ovary

    Reduces risk of benign breast disease

    Decreases the risk of iron deficiency anaemia
  57. CHC disadvantages/when to stop treatment
    Painful swelling in the calf of one leg

    Sudden, severe pain in the chest or abdomen

    Sudden breathlessness or coughing blood


    Unusual headaches, difficulty with speech/sight

    More severe migraines than usual

    Numbness or weakness of a limb
  58. Risk of thromboembolism with CHC
    Healthy, no COC, not pregnant

    l5 cases per 100,000 women

    COC 2nd Generation

    l15 per 100,000

    COC 3rd Generation

    125 per 100,000


    l60 per 100,000
  59. Contraindications with CHC
    Cardio vascular + / or thrombosis risk or history

    Certain migraines

    migraine with focal aura

    severe migraine lasting more than 72 hours despite treatment

    migraine treated with ergot derivatives

    Liver disease


    Carcinoma of breast or genital tract

    Undiagnosed vaginal bleeding

    Breast feeding
  60. CHC - missed pills
    "missed pill’ is one that is ≥24 hours late

    • If a woman misses only one pill:
    • take an active pill as soon as she remembers & next one at the normal time

    No additional precautions necessary

    If she misses two or more pills

    take an active pill as soon as she remembers & next one at the normal time

    Also additional method of contraception (e.g. condom) or abstain from sex, for next 7 days

    If these 7 days run beyond end of packet

    Start next packet at once (omit pill-free interval)

    Or for everyday (ED) pills, omit inactive tablets

    Seek advice about EHC if

    2 or more CHC tablets missed from first seven tablets in the packet and unprotected sex has occurred since finishing the last packet
  61. CHC patch - delayed or detached patch
    See BNF
  62. Nuvaring - deviation from normal regimen
    If outside vagina for less than 3 hours, may rinse and reinsert

    If over 3 hours then see advice in SPC www.medicines.org
  63. CHC link with cancer
    contraceptive pill use is associated with a 12% decrease in the risk of developing cancer overall

    statistically significant reduction in the rates of large bowel or rectal cancer and cancer of the uterine body or ovaries

    no differences between ever and never users in their risk of breast cancer

    no increase in the risk of cancers of the lung, cervix, central nervous system overall

    there was a very small increased risk in cervical cancer in women using OC for 8 or more years (rate 38 per 100 000 woman years)
  64. What reduces the effectiveness of CHC?
    Broad spectrum antibiotics

    - If short course additional precautions during and for 7 days after stopping

    - If in pill free period start next pack straight away

    - If longer than 3 week course additional precautions not needed

    Diarrhoea and vomiting

    - Up to 3 hours after taking pill

    - Additional precautions for 7 days after recovery

    - If in pill free period start next pack straight away

    Liver enzyme inducers

    - Carbamazepine, griseofulvin, phenytoin, phenobarbitone, rifampicin, rifabutin

    - Reduce effectiveness of COC

    - Short term course

    - Additional precautions during course and for 7 days after stopping

    - If in pill free period start next pack straight away

    - Long or short term course of rifampicin & rifabutin

    - Additional precautions during course and for at least four weeks after stopping
  65. Oral progesterone only contraception (POP):


    Mode of action?
    99% effective

    Contains a type of progestogen only

    Cervical mucus inc­ viscosity

    Changes in the endometrium

    Prevents ovulation in 40% of cycles
  66. POP advantages
    Useful for women who cannot take oestrogens (with caution)

    Including those at risk/with history of DVT

    Heavy smokers

    Older women



  67. POP disadvantages/when to stop treatment
    Few serious side effects with POP

    Main problem – irregular bleeding (tends to resolve on long term treatment)
  68. POP contraindications

    Undiagnosed vaginal bleeding

    Severe arterial disease

    Active liver disease or carcinoma

    Breast carcinoma (evidence uncertain)
  69. POP - missed pills
    If a woman misses a pill

    - Take as soon as she remembers and carry on with next one at the right time

    Protection may be lost if it is > 3 hours late (> 12 hours for Cerazette®)

    - Continue normal pill-taking

    - Also use additional method e.g. condom for the next two days

    • Faculty of Sexual and Reproductive Health Care
    • www.ffprhc.org.uk recommends emergency contraception if

    - one or more POP tablets missed or taken > 3 hours late (> 12 hours for Cerazette®) and

    - there has been unprotected sex before a further two tablets have taken
  70. What reduces the effectiveness of POP?
    Broad spectrum antibiotics

    - POP not affected by broad spectrum antibiotics

    Diarrhoea and vomiting

    - Up to 3 hours after taking pill

    - Additional precautions for 2 days after recovery

    Liver inducing enzymes

    - As for COC
  71. EHC

    Ulipristal acetate

    Intra-uterine device (IUD)

    - NON HORMONAL emergency contraception
  72. Levonorgestrel: Strengths available and how to take?

    Levonorgestrel 1.5 mg

    - Levonelle 1500 ® [POM],

    Levonorgestrel 1.5mg

    - Levonelle One Step® [P]

    Dose 1.5mg as single dose

    Within 72 hours (3 days)

    Vomit within 3 hours, extra dose

    If taking enzyme inducer give one single 3mg dose (unlicensed dose)

    Levonelle One Step® [P]

    - Can be sold to women over 16 years
  73. What does a pharmacist need to know before supplying EHC?
    Unprotected sex within the last 72 hours?

    Is EHC needed?

    Client present in the pharmacy?

    Client over 16 years?

    Is client likely to be pregnant already?

    Is client taking any medicines that may interact with Levonelle®?

    Does client have any medical condition?

    Does the client have liver problems?

    Has the client had any previous allergic reactions to levonorgestrol?

    Advice about how to take and side effects
  74. ellaOne (EHC)
    Ulipristal acetate 30mg tablet (POM)

    Synthetic progesterone receptor modulator

    May use up to 120 hours (5 days) of unprotected sexual intercourse or contraceptive failure

    If vomiting occurs within 3 hours, repeat dose
  75. EHC counselling
    Next period early or late

    Barrier method for 7 days or until next period

    Lower abdominal pain see GP

    - Possible ectopic pregnancy

    Period could be different than usual
  76. Types of parenteral progesterone only contraceptives, how to use and contraindications?
    Medroxyprogesterone acetate (Depo Provera®)

    - Intramuscular injection

    - Every 3 months

    - Long and short term use

    - Delayed fertility and irregular cycles

    - Reduction in bone mineral density, rare cases of osteoporosis and osteoporotic fractures

    - CSM advice

    - Adolescents - only if other methods inappropriate

    - In all women review risks/benefits beyond 2 years

    - Consider alternatives in women with risk factors for osteoporosis


    - Norethisterone Enantate (Noristerat®)

    - Intramuscular injection

    - Every 8 weeks

    - Short term

    - Same cautions and contraindications as oral POP


    - Etonogestrel (Implanon®)

    - Flexible, single rod, subdermal

    - 3 years

    - Same cautions and contraindications as oral POP
  77. Intra-uterine progesterone only contraceptive

    Mode of action?

    - Mirena® system

    - Releases hormone directly into the uterine cavity

    - Good if heavy periods

    - Fertility returns rapidly
  78. Non hormonal contraception - intra-uterine device


    Mode of action?

    Side effects?
    Plastic frame wound with copper wire

    98 - 99% effective

    IUD stimulates foreign body reaction

    Reduces chance successful implantation

    Not an abortion

    Side effects

    - Bleeding

    - Dysmenorrhoea

    - Pelvic Inflammation

    - Expulsion

    - Perforation

    - Pregnancy (greater risk of ectopic)
  79. Non hormonal contraceptive devices
    Diaphragms and Caps

    - Barrier method

    - Effectiveness influenced by experience, age, length of use

    - Up to 96% effective

    - Fit by trained family planning professional

    - Always used with spermicide

    - Left in-situ for 6-30 hours after intercourse
  80. What is cystitis?

    Inflammation of the (urinary) bladder and urethra

    Either non bacterial cystitis or bacterial cystitis

    Most common lower urinary tract problem experienced by women

    Rare in men

    Usually acute onset

    Most attacks short, however can be severe and may suffer frequent episodes
  81. Causes of cystitis
    Bacterial cystitis

    - Mainly E Coli

    - Possibly Klebsiella, Proteus, Enterococci

    Non bacterial cystitis

    - Dehydration

    - Perfumed toiletries

    - Sexual intercourse (minor trauma)

    - Synthetic underwear

    - Oestrogen deficiency in postmenopausal women
  82. Cystitis symptoms
    The same for both bacterial and non bacterial

    Lower urinary tract symptoms

    - Frequency

    - Urgency

    - Dysuria (often reported as burning sensation when passing urine)

    - Haematuria

    - Suprapubic discomfort (possibly spreading to back)

    Specific to bacterial cystitis more general symptoms such as nausea, vomiting and malaise
  83. OTC treatment for cystitis and how to use them?

    When to refer?
    Alkalising agents;

    - Sodium citrate - Canestan Oasis®, Cymalon®, Cystemme®

    - One sachet three times daily for 48 hours

    - Potassium citrate mixture

    - 10mls, diluted with water three times daily

    - Potassium citrate sachets Cystopurin®

    - One sachet three times daily for 48 hours

    Only for mild symptoms

    Refer if no improvement after 2 days
  84. Potassium citrate cautions - cystitis treatment
    Renal impairment

    Cardiac disease

    Those predisposed to high potassium levels

    - Potassium sparing diuretics

    - ACE inhibitors

    - Aldosterone antagonists

    (see BNF for further information)
  85. Sodium citrate cautions - cystitis treatment

    Renal impairment

    Cardiac disease

  86. Cystitis treatment options
    Alkalising agents (sodium and potassium citrate)

    Herbal products ü (alkalinizing effect)

    - Uva ursi tea

    - Equisetum herb

    - Lovage

    Cranberry juice or capsulesü (thought to inhibit microbial adherence to urinary epithelium if taken regularly)

    Antibiotics – GP referral & investigation

    (see BNF section on antibiotics)
  87. Cystitis - non pharmacological advice
    Drink plenty of fluids & empty bladder regularly (flushing effect)

    Avoid alcohol and coffee (possible bladder irritants)

    Pay attention to toilet hygiene!

    Wear cotton underwear & avoid tight fitting clothes

    Always empty bladder (fully) when need to

    Analgesics – paracetamol / aspirin / ibuprofen
  88. Cystitis: Who to refer?
    Girls under 16 years

    - To exclude UTI and kidney damage


    - Bacteruria in pregnancy can lead to kidney infection

    Males presenting with symptoms

    - Possibility of kidney/bladder stones or prostrate problems

    Diabetics with recurrent cystitis

    Haematuria (blood in urine)

    - Excessive inflammation of the bladder lining, kidney stones, tumour (if haematuria and no pain)

    Moderate to severe symptoms including fever and malaise

    Duration longer than 2 days and failed OTC treatment
  89. Thrush - causative organism?
    Most common cause of vaginal infection in women of child bearing age

    Caused by yeast - Candida albicans

    Opportunistic organism

    - Low levels in mouth, gut, skin

    - Becomes pathogenic when natural balance of flora is upset
  90. Thrush symptoms



    - Usually creamy-coloured and thick

    - No odour

    Dysuria (pain on urination) may occur

    Partner’s symptoms?
  91. Thrush risk factors

    - Occurs in 15-20% of pregnant women

    - Linked to hormonal changes


    - Higher levels of glucose in tissue and blood may favour occurrence of Candida

    Broad spectrum antibiotics

    - Disrupt normal flora

    - Steroid / immunosuppressant therapy

    Oral contraceptives

    Vitamin B and zinc deficiencies

    Tight clothing, hot weather, strong scented bath foams
  92. Thrush OTC products
    Antifungals – Imidazoles

    Clotrimazole (Canesten® - range of products)

    Pessaries, internal and external creams for topical application

    Antifungals – Triazoles

    - Fluconazole - 150mg oral as single dose

    - Peak plasma levels achieved after a few hours

    - Long half life

    - Liver enzyme inhibitors

    - Anticoagulants

    - Oral sulphonylureas

    - Ciclosporin

    - Phenytoin

    - Theophylline

    - C/I in pregnancy and breast feeding

    - 16 – 60 years
  93. Thrush - non pharmacology interventions
    Decrease sugar in diet

    Avoid using bubble bath / vaginal deodorants

    Use K Y Jelly or Replens

    Avoid tights, nylon underwear and tight fitting jeans

    Use of live yogurt

    Contains Lactobacilli that create and environment in which it is difficult for Candida to grow

    Treatment of partner
  94. Thrush - when to refer?
    First occurrence of symptoms

    More than 2 attacks in 6 months?

    Under 16 or over 60

    Pregnancy or suspected pregnancy

    Abnormal bleeding

    Dysuria / lower abdominal pain

    Previous history of sexually transmitted disease

    Any previous treatment failure
  95. Dysmenorrhoea: Types and when they typically present?
    2 types


    • - No underlying pathology
    • - First occurs 6-12 months from onset of menarche
    • - More common in women late teens to early twenties
    • - Pain starts shortly before or during menstruation or both
    • - Lasts for up to 72 hours


    • - Presents in women in 30’s / 40’s
    • - Presents after several years of painless periods
    • - Most often due to underlying pelvic pathology
    • - Pelvic inflammatory disease (PID)
    • - Endometriosis
    • - Fibroids
  96. Dysmenorrhoea symptoms

    - Lower abdominal pain – congestive or spasmodic

    - Bloating

    - Nausea, vomiting, constipation and/or diarrhoea

    - Headache


    - Pain persisting after period ends

    - Intermenstrual bleeding
  97. Dysmenorrhoea treatment
    NSAIDs - decrease prostaglandin synthesis


    Hot water bottle

    Bed rest

    Moderate exercise

    Secondary dysmenorrhoea;

    - NSAIDs may help
  98. PMS
    A combination of distressing physical, psychological, and behavioural changes

    Can start up to14 days before menstruation

    Reports suggest that up to 95% of women will experience symptoms at some time!
  99. PMS symptoms

    - Depression, mood swings or anxiety


    - Abdominal bloating

    - Breast tenderness

    - Abdominal pain

    -Water retention

    - Headaches


    - Reduced spatial awareness
  100. PMS treatment
    OTC treatments

    - Vitamin B6 supplements

    - 50-100mg daily

    - Magnesium and Zinc supplements

    - Menopace®

    - Evening primrose oil supplements

    - NSAIDs for pain relief

    Consider referral if no response after 3 months

    - Hormonal treatment – for moderate symptoms

    - Combined oral contraception

    - Antidepressant – for severe symptoms

    - SSRI

    - CBT
  101. PMS - general advice
    Talking with friends, family

    Increased education can decrease anxiety

    Maintain a menstrual diary


    Alter diet – regular, small, balanced meals rich in complex carbohydrates

    Stop smoking

    Restrict alcohol

    Reduce stress
  102. Osteoporosis: causes and characterisation
    Low bone mass

    Disruption of bone microarchitecture

    Increased skeletal fragility and fracture risk

    OP caused by: reduced osteoblast activity

    increased osteoclast activity

    low peak bone mass
  103. Osteoporosis: signs and symptoms

    Reduced bone density


    Reduced mobility


    Reduction in height
  104. Osteoporosis risk factors
    Hx of fracture

    Hx of fracture in 1st degree relative


    Low body weight


    Oestrogen deficiency

    Corticosteroid use

    White race

    Increase age

    Low calcium intake

    XS alcohol

    Lack of exercise

    Recurrent falls


    Impaired eyesight

    Poor health/ frailty
  105. Osteoporosis: Primary prevention
    Adequate Ca and Vit D

    Weight bearing exercise

    Reduced alcohol intake

    Stop smoking

    Reduce risk of falls esp in elderly
  106. Osteoporosis: Secondary prevention
    Pharmacological management:


    Vit D









    In addition to lifestyle changes
  107. Calcium in osteoporosis
    Adequate dietary calcium(400mg-700mg/d)can prevent bone loss and risk of OP

    Need extra if risk factors (500mg-1g)

    Should only be used as adjunct to other Tx in at risk ps

    Choice of preparation
  108. Vitamin D in osteoporosis
    Vit D helps control serum Ca levels

    Obtained from diet (10%) or action of sunlight on skin (90%)

    Metabolised to active form by liver and kidneys

    800 units/day recommended supplement

    Combined with Ca can increase bone mass and reduce fracture rate

    Regular plasma Ca checks needed
  109. Calcitriol
    Vitamin D analogue

    Licensed for use in PM women

    May reduce vertebral fracture risk

    250ng bd

    Regular plasma Ca checks needed
  110. Oral bisphosphonates: when and how to use?
    Reduce bone resoprtion

    To treat PM OP

    To prevent and treat steroid-induced OP

    Should be used as 1st line Tx

    Alongside Ca+/- Vit D

    Take 30-60mins away from food/ meds

    Take while sitting/standing with full glass of water

    Stay upright for 30-60mins after

    Alendronate (Fosamax)- once weekly

    Risedronate (Actonel)- once weekly

    Ibandronate ( Bonviva)- once monthly
  111. Parenteral bisphosphonates: When and how to use?
    Zolendronate- first choice iv bisphosphonate

    - Tx of postmenopausal osteoporosis

    - Pts unresponsive / intolerant to oral

    - Short iv infusion every 12 months


    - Tx of postmenopausal OP

    - Pts unresponsive / intolerant to oral

    - iv. bolus every 3 months


    - For men with established osteoporosis resistant to oral treatment

    - Iv infusion every 3 months for 12 months
  112. Denosumab in osteoporosis: when and how to use?
    Monoclonal antibody

    Just licensed / approved by NICE

    For treatment / prevention of postmenopausal OP in women resistant / intolerant to oral bisphosphonates

    Given by sc injection 2 / year
  113. HRT in osteoporosis: When and how to use?
    Oestrogens reduce bone resorption and increase Ca absorption

    Prevention of PM OP in women intolerant/unresponsive to other treatments

    Should be started early in menopause

    Can continue for up to 5 yrs

    Bone loss increases soon after stopping

    Should not be used as 1st line treatment due to increased risk of breast Ca

    Should not be used as long term prevention at >50yrs
  114. HRT risks
    Oestrogen only

    - Increases risk of breast and endometrial Ca

    - Increased risk of DVT,PE & stroke

    Oestrogen and progestogen combined

    - Increased risk of breast Ca compared to oestrogen only

    - Reduced risk of endometrial Ca

    - Increased risk of DVT, PE and stroke
  115. SERM's in osteoporosis: When to use?

    Mode of action?
    Selective agonist and antagonist activity on oestrogen receptors

    Reduce bone resorption

    Treatment and prevention of OP

    Used in women intolerant/unresponsive to bisphosphonates

    Reduced risk of breast and endometrial Ca compared with traditional HRT

    Does not redcue vasomotor menopausal symptoms

    Still risk of DVT, PE , stroke
  116. Calcitonin in osteoporosis: Mode of action and when to use?
    Reduces bone resorption

    Option if failed other treatments

    Nasal spray

  117. Strontium in osteoporosis: Mode of action
    Increases bone production and reduces resorption

    Licensed for treatment of PM OP

    Awaiting NICE review
  118. Parathyroid hormone in osteoporosis: Mode of action?

    When and how to use?

    Side effects?
    Increases bone formation and reduces fracture rate

    Restrictions as per NICE:

    Women > 65yrs unresponsive/intolerant to bisphosphonate with either:

    - vv low bone density

    - v low bone density with more than 2 fractures and other risk factors

    Daily s.c. injection

    Max 18 mth course

    Approx. £5,000/ course

    Side effects

    - Dizziness

    - Leg cramps

    - Antibody production
  119. Types of influenza treatment

    Zanamivir (Relenza) & Oseltamir (Tamiflu)


  120. Who should have the influenza vaccine?
    Over 65

    Chronic respiratory disease

    Chronic heart disease

    Chronic renal disease

    Chronic liver disease

    Diabetes mellitus


  121. Influenza symptoms
    Rapid onset

    7 - 10 day duration

    High fever

    Aches and pains

    Severe malaise

    Severe sweating

    Severe headache

    Slight nasal symptoms

    Sore throat infrequent

    Cough infrequent

    Bacterial infection common and severe
  122. Cold symptoms
    Slow onset

    4 - 7 days duration

    Slight fever

    No aches and pains

    Slight malaise

    Slight sweating

    Slight headache

    Pronounced nasal symptoms

    Frequent sore throat

    Frequent cough

    Bacterial infection uncommon and mild
  123. Cold treatment
    Self-limiting (1 to 2 weeks)


    Maintaining an adequate fluid intake


    Analgesics and antipyretics


    Steam inhalation
  124. Decongestants: types and examples of each
    Systemic V.s Topical

    Sympathomimetics (alpha adrenergic agonists)










  125. Decongestant side effects

    –Little systemic effect

    –Local irritation

    –Rebound congestion (rhinitis medicamentosa)


    Use caution



    –Raised interocular pressure

    –Prostatic hypertrophy

  126. Antihistamines - use in colds: examples?

    Mode of action?

    Side effects?





    Intrinsic anticholinergic properties

    Decrease mucus production

    Side effects

    Antihistamines - 1st generation - reduce rhinorrhoea, sneezing and weight of nasal secretions

    Mainly due to anticholinergic effect

    Drowsiness - side effect - benefit in sleep disturbance?
  127. Anticholinergic cold preparations: mode of action
    Ipratropium bromide intranasal spray

    significantly reduced nasal drainage and sneezing
  128. Echinacea for colds
    Not enough evidence to recommend
  129. Zinc for colds
    No clear evidence
  130. Vitamin C for colds
    Reduces symptoms of URTI's but benefit is small
  131. Sore throat: Symptoms and causes
    Hoarseness – children –croup


    More than 1 week

    Medication- steroid inhalers, carbimazole (agranulocytosis)
  132. Bacterial sore throat symptoms
    Rapid onset

    Marked soreness

    URTI and LRTI symptoms not always present

    Large tender lymph nodes
  133. Viral sore throat symptoms
    Slower onset

    Less marked soreness

    URTI and LRTI symptoms usually present

    Slight enlargement of lymph nodes, not usually tender
  134. Sore throat treatments

    Mouth washes and sprays



    -Local anaesthetics

    Lozenges and pastilles



    -Local anaesthetics
  135. Types of mouthwashes and sprays for sore throats

    –Chlorhexidine, hexedine, providone-iodine, cetylpyridinium

    –Effective antimicrobial action


    –Numbness and stinging

    –Spray from 6 years, mouthwash from 12 years
  136. Lozenges and pastilles for sore throat
    Antifungal & antibacterial – dequalinium, tyrothricin

    Local anaesthetics- benzocaine

    –Insoluble in water

    –action for 5-10 minutes
  137. External ear conditions: types
    Boil (furuncles)



    Impacted cerumen

    Foreign Objects

    External otitis

    Swimmer’s ear

  138. Middle ear conditions: types
    Otitis media (infection – many virus)

    Otitis Media With effusion (OME) – Glue ear

    Tympanic membrane perforation


    Vertigo (meniere’s disease)

  139. Ear condition treatments
    Boil – antibiotics

    External otitis

    –Antibiotics and hydrocortisone drops

    –5% aluminium acetate

    Impacted wax

    –Cerumen-softening agents – olive, aracis oil, urea, DDSS, hydrogen peroxide, sodium bicarbonate

    Foreign objects

    Otitis media – antibiotics?

    –80% clear in 3 to 4 days

    Barotrauma – sympathomimetics, amtihistamines, Valsalva’s maneuver
  140. Factors in choosing an antibiotic
    Sensitivity: active and no resistance (hospital microbiology departments will advise)

    Get to site of infection?

    Will patient tolerate drug: allergies, renal or liver function

    Most appropriate route of administration?

    Dose: affected by age, renal, hepatic function

    Length of treatment

    Side effects

  141. Pneumonia: signs and symptoms
    Purulent sputum

    deterioration in blood gases

    radiological changes

    shortness of breath

    Inc WBC count

    pyrexia and fever

    Lowered blood pressure

    myalgia, arthralgia
  142. Pneumonia diagnosis
    sputum gram stain


    sputum & blood culture
  143. Community Acquired Pneumonia: causative organisms
    Influenza virus

    Strep. pneumoniae (60-75%): lobar and broncho-pneumonia

    Haemophilus influenzae (commonest cause in COPD): broncho-pneumonia

    Mycoplasma pneumoniae (not so common in older patients)

    Pneumococcus pneumoniae

    Also less commonly Staph. aureus (in COPD or as super-infection), Legionella pneumophila
  144. Community acquired pneumonia: treatment

    Which drugs to use, when and for how long?
    If patient is in high risk group, sputum sample should be collected

    Viral: Relenza® (zanamivir), Tamiflu® (oseltamivir) Influenza A and B vaccines

    Bacterial: Need to treat empirically (i.e. without knowing what the causative organism is)

    amoxicillin 500mg tds po & clarithromycin 500mg bd po

    COPD patients: Gram-ve & Staph infections:

    → add quinolone if organism sensitive

    ß-lactamase-producing Haemophilus: → co-amoxiclav

    If seriously ill → iv antibiotics (amoxicillin or co-amoxiclav plus clarithromycin)

    Use CURB65 score to determine severity (3-5 = severe)

    If allergic to penicillins → clarithromycin

    Treatment should be continued for 10 – 14 days

    Alternative drugs: clindamycin: for gram+ve cocci, eg penicillin resistant staph, or metronidazole: for anaerobes

    Tetracyclines can also be used for H inf and Mycoplasma
  145. Community acquired pneumonia: When to admit infants?
    Oxygen saturations < 92% air

    Respiratory rate > 70 breaths/min

    Difficulty breathing

    Intermittent apnoea/grunting

    Not feeding

    Family not able to support the infant at home
  146. Treatment of CAP in children
    Treatment of children who are admitted

    Oral and IV treatment are equivalent for CAP, so oral amoxicillin should be used

    Oral group spend significantly less time in hospital and require less oxygen

    Time to resolution of symptoms is the same in both groups

    Use iv antibiotics when the child is severely ill or unable to absorb (e.g. co-amoxiclav, cefuroxime, cefotaxime)
  147. Hospital acquired pneumonia: high risk pts
    Mechanical ventilation

    Recent surgery


    Recent broad spectrum antibiotics
  148. Hospital acquired pneumonia: causative organisms
    Gram negative – E coli, Klebsiella, Pseudomonas spp

    Gram positive – Strep pneumoniae, Staph aureus

    Occasionally fungi – Candida, Aspergillus spp
  149. Hospital acquired pneumonia: treatment

    Which drugs and when, and how long to treat
    Empiric intravenous antibiotics – penicillin with beta-lactamase inhibitor:




    Cephalosporins, carbapenems, aminoglycosides, quinolones in penicillin allergy

    Sputum culture and sensitivity determine further treatment; antibiotic resistance

    Treat for 14 days

    Broad spectrum antibiotics used ***risk of Clostridium difficile high***
  150. Aspiration pneumonia: Who's at risk?

    Which organisms?

    How to treat?
    Hospital or community acquired

    High risk patients

    Impaired swallowing – e.g. stroke, Parkinson’s disease, Myasthenia gravis, other neurological conditions

    Mechanical ventilation

    Recent surgery

    Organisms – from GI tract

    Gram negative – E coli, Klebsiella spp


    Treatment – as for community or hospital acquired but cover anaerobes in addition

    - metronidazole (IV, rectal or oral)
  151. Non gonococcal urethritis - causative organisms
    Chlamydia trachomatis 30-50%

    Ureaplasma urealyticum 10-30%

    Mycoplasma genitalum 20%

    Not known 30%
  152. Non gonococcal urethritis - symptoms
    Pain on passing urine (dysuria), penile tip irritation

    Discharge from penis: clear, creamy, yellow

    Sometimes symptom-free
  153. Non-gonococcal urethritis - treatment
    Azithromycin 1g as a single dose or doxycycline 100mg bd 7 days

    Alternative: treat with eythromycin 500mg qds 14 days

    Contact tracing recommended
  154. Gonorrhoea: signs and symptoms
    Can get rectal or throat infection as well as genital; usually symptom-free


    - Urethritis, or infection of testicles and epididymides causes swelling and pain in the testicles


    - Infection of cervix ®vaginal discharge (not always)

    - Infection in uterus and Fallopian tubes® abdomen pain
  155. Gonorrhoea - treatment
    Some resistance to penicillins (β-lactamase gene), tetracyclines (plasmid-mediated), and 4-quinolones.

    Uncomplicated: ciprofloxacin 500mg single dose

    Oropharyngeal: ciprofloxacin (5/7) or IV ceftriaxone (5/7)

    Again, contact tracing recommended
  156. Thrush: causative organism, symptoms and treatment
    Candida albicans

    White itchy discharge, soreness

    Topical vaginal application of an imidazole (clotrimazole, econazole, ketoconazole or miconazole) as vaginal tablets, ovules or creams

    SR preparations, requiring single insertion e.g. clotrimazole 500mg

    In vulvitis, creams should also be applied

    Single dose oral fluconazole 150mg or itraconazole 200mg is as effective as topical treatment
  157. Bacterial vaginosis: casuative organisms, symptoms and treatment
    Many, often caused by: Gardnerella vaginalis

    Signs and symptoms

    - Sometimes symptom-free

    - Discharge: grey-white, malodorous

    - Sometimes painful or sore vagina


    Oral metronidazole 400mg bd for one week

    Recurrence is common
  158. Trichomonas vaginalis: causative organism, symptoms and treatment
    Causative organism: Trichomonas vaginalis (protozoan)

    Much more common in women

    Transmitted during sexual intercourse

    Can be spread through sharing towels

    Can cause urethritis in men

    Signs and symptoms

    - Yellow frothy discharge, often malodorous

    - Itching and sore vulva

    - Pain on passing urine and during sex


    Metronidazole 2g single dose

    Treatment failure is common
  159. Genital herpes: causative organism, symptoms and treatment
    Herpes simplex virus (HSV): 2 forms: HSV1 and HSV2

    Sexually transmitted infections are predominantly HSV2

    The virus is spread by direct contact with an infected person

    Recurrence is common

    Signs and symptoms

    -Tingling sensation followed by small fluid-filled blisters

    - Blisters burst to reveal ulcers

    - Sometimes flu-like symptoms


    - Oral aciclovir 200mg 5 times a day for 5 days, started as soon as prodromal symptoms become apparent

    - Topical 5% aciclovir cream applied 5 times a day for 5 days

    - First bout may take 2-4 weeks to heal: highly infectious during this time
  160. Syphilis: causative organism and symptoms
    Causative organism: Treponema pallidum

    Signs and symptoms

    Primary syphilis presents as a painless but highly infectious, ulcer (chancre) at the site of infection

    - Heal without treatment in 2-6 weeks, remain infected, with some lymphadenopathy

    Secondary syphilis

    - Non-irritating rash on the chest, back, palms and soles of the feet

    - Hoarseness, lymph node enlargement

    - Sometimes wart-like growths around the genitals

    - Can resolve without treatment

    Tertiary syphilis: neurological, cardiovascular disease, gummas, congenital syphilis
  161. Syphilis treatment
    Intramuscular procaine penicillin (= benzathine benzylpenicillin), single dose

    Standard treatment of syphilis more than two years after infection will not prevent neurological involvement, so 1200mg procaine penicillin i.m. is given weekly for 2 weeks

    In case of allergy, use doxycycline 100mg bd for 14 days in early syphilis and for 28 days for syphilis of more than two year’s duration
  162. Genital warts: causative organism, symptoms and treatment
    Causative organism: Human papilloma virus (HPV)

    Signs and symptoms

    - Painless but itchy


    - Podophyllotoxin 0.5% applied twice daily for three days

    - Application of trichloroacetic acid

    - Scissor excision

    - Freezing or electrocautery, surgery (rare)

    - May be associated with precancerous changes in the cervix

    - High recurrence rate
  163. HPV vaccine: Who to use it in?

    Which types do they prevent against?

    Which one is used in the UK, why?
    Cervarix® and Gardasil® – licensed for use in girls and young women aged 9 – 26

    Protection against HPV types 16, 18 / 6, 11, 16 and 18

    90% of all genital warts caused by HPV types 6 and 11

    70% of all cervical cancers caused by HPV types 16 and 18

    Routine vaccination to be given to 12-13 year-old girls from September 2008; two-year catch up for girls up to 18

    In UK concerns about effect of increasing promiscuity; only country to use Cervarix® vaccine

    Safety and potential use in boys and young men?
  164. Chlamydia: causative organism, symptoms and treatment
    Chlamydia trachomatis

    Signs and symptoms in women

    - Some vaginal discharge, itching and sore vulva

    - Pain on passing urine, abdominal pain

    - Irregular menstrual bleeding

    - Swollen, red eyes

    Asymptomatic in 80% of women and 50% men


    - Single dose azithromycin. 7 days of doxycycline or 14 days erythromycin can also be used

    - No sex (of any sort) until drugs taken
  165. Common causative agents of UTI's
    E coli

    Strep faecalis

    Proteus spp

    Pseudomonas spp

    Klebsiella spp
  166. Antibiotics used in cystitis
    Trimethoprim (70% effective)

    Nitrofurantoin, cephalosporins, co-amoxiclav, 4-quinolones, gentamicin

    Not amoxicillin

    Duration: 3-5 days
  167. Antibiotics used for recurrent UTI's
    Prophylactic trimethoprim

    3-6 months
  168. Antibiotics used in acute pyelonephritis
    2nd generation cephalosporin, 4-quinolone, gentamicin

    10-14 days

    2nd generation cephalosporin, 4-quinolone, gentamicin
  169. Antibiotics used in asymptomatic bacteruia
    treat in pregnancy with amoxicillin

    often needlessly treated (esp in hospitalised patients with catheters)

    7 days
  170. UTI features
    UTIs are common in healthy adults, particularly women

    cystitis produces symptoms of frequency, dysuria, urgency

    ascending infection causes pyelonephritis (loin pain, fever, malaise)

    UTI less common in men due to extra urethral length

    Repeated episodes need to be investigated

    - possibility of kidney stones needs to be eliminated

    - midstream urine test done

    - local obstruction must be treated
  171. Management of UTI in women: prevention, when to treat and in pregnancy
    Prevent by

    - maintaining adequate fluid intake

    - ensure bladder is fully empty

    - empty bladder after sexual intercourse

    Treat only

    - when woman is symptomatic

    - and urine tests positive for signs of infection (nitrites, WBCs)

    In pregnancy

    - UTI is common

    - may lead to acute pyelonephritis

    - screen for bacteruria at first visit and treat with antibiotics even if no symptoms
  172. Management of UTI in children
    1% boys <11 develop a UTI, 3x in girls, most infections <12 months of age

    risk of upper tract infection and scarring

    vesicoureteric reflux present in 25-50% infections

    Most infections only need 3-5 days antibiotics
  173. Trimethoprim side effects
    Blood disorders long term
  174. Nitrofurantoin side effects
    Nausea, GI disturbance

    Rarely, pulmonary reactions, peripheral neuropathy

    Contraindicated in renal impairment
  175. Cephalosporin/penicillin side effects
    GI disturbance (allergy, C diff)
  176. 4-quinolones side effects
    GI disturbance, N&V

    Rarely arthralgia, tendon damage
  177. Gentamycin side effects
    Nephro , ototoxic
  178. Meningitis risk factors
    Age; under 5s and teenagers / young adults (14-24)

    In neonates, maternal infection at birth

    Children with facial cellulitis, sinusitis

    Head trauma

    Chronic disease

    Splenectomy (vaccinations, prophylactic penicillin)
  179. How can organisms enter the CNS to cause meningitis?
    Spread via the blood (haematogenous) from another site in the body - most common

    Direct spread from sinuses or middle ear – less common

    Defects in skull or spinal column

    - Congenital or acquired
  180. Causative organisms for meningitis in neonates
    E coli

    other G negative; Β haemolytic Strep from mother
  181. Causative organisms for meningitis in 6month-5year age group
    Neisseria meningitidis

    Strep pneumoniae

    H influenzae in developing countries (no vaccination)
  182. Causative organisms for meningitis in 5-40 year age group
    Neisseria meningiditis,

    Strep pneumoniae
  183. Causative organisms for meningitis in the over 40 age group
    Strep pneumoniae,

    Staph aureus,

    Neisseria meningitidis; Listeria in the elderly
  184. Causative organisms for meningitis in those with a skull injury/defect
    Staph aureus
  185. Viral causes of meningitis
    Viral causes include Herpes simplex, Varicella zoster, mumps virus
  186. Meningitis: signs and symptoms in adults and older children
    Headache (80%)

    Neck stiffness (70%)

    High temperature, confusion

    Also photophobia and/or phonophobia

    Petechial rash

    –Usually only associated with meningococcal disease
  187. Meningitis symptoms in small children
    Often only irritable (inconsolable crying or when picked up/held)

    Poor feeding, bulging fontanelle in babies

    Cold extremities, abnormal skin colour (septicaemia)

    Petechial rash

    –Usually only associated with meningococcal disease
  188. Tests to confirm meningitis
    Analysis of cerebrospinal fluid obtained through lumbar puncture

    –Protein – increased in bacterial meningitis

    –WBCs – greater risk of meningitis if increased

    –Glucose – less than 50% → bacterial meningitis

    –Bacterial culture (can take 48hrs for result)

    Lumbar puncture must not delay treatment (30 mins max wait)

    FBC (markers of infection / inflammation) e.g. CRP, ESR, WBCs

    Blood culture (septicaemia)
  189. Meningitis complications
    Seizures and neurological sequalae e.g. hearing loss, visual field defects, palsies

    Low blood pressure → under-perfused organs

    Disseminated intravascular coagulation (DIC) due to activation of clotting cascade

    Adrenal failure caused by haemorrhage


    - Meningococcal

    –Gangrene of limbs
  190. Meningitis treatment
    Empirical antibiotics

    - Benzylpenicillin: i.v. 2.4g every 4h in adults

    - Cefotaxime: i.v. 2g every 6h in adults or ceftriaxone

    - Chloramphenicol in true penicillin and cephalosporin allergy

    Course length: 10-14 days

    Review antibiotic when culture and sensitivities return

    Eradicate nasopharangeal carriage - oral rifampicin additional 2-4 day course
  191. Supportive treatment for meningitis
    In addition to antibiotics, patient may require

    –Hydration therapy (to increase BP, treat septic shock)

    –Paracetamol to reduce fever

    –Dexamethasone to reduce cerebral inflammation (hence neurological complications)

    –Oxygen or ventilation if breathing difficulties

    –Anti-epileptic medication if seizures

    –Dialysis if kidney failure
  192. Consequences of meningitis treatment
    Risk of C difficile overgrowth with broad-spectrum cephalosporins

    Chloramphenicol – blood disorders; FBC must be monitored

    Antibiotics cause paradoxical increase in cerebral oedema due to bacterial death

    Blood flow decreased, harder to obtain therapeutic antibiotic concentrations
  193. Meningitis: treatment of contacts
    Close contacts given 2-4 days rifampicin in meningococcal or H influenzae disease

    Single dose ciprofloxacin (unlicenced) can be used in meningococcal disease

    Rifampicin prophylaxis indicated in epidemics
  194. Meningitis vaccines
  195. What does PEG tube stand for?
    Percutaneous endoscopic gastrostomy tube
  196. What types of drug should never be crushed to administer down an enteral feeding tube?
    Enteric coated

    Modified release

    Cytotoxics and hormones
  197. Which specific drugs can be a problem for administration down an enteral feeding tube and why? What can be done to improve the situation?
    Penicillin: the feed may reduce absorption of penicillin - increased dose may be needed, if poss stop feed for one hour before and two hours after administration

    Antacids: metal ions bind to protein in the feed and may block the tube - consider alternative drugs

    Phenytoin, digoxin, carbamazepine: blood levels may be affected by feeds - check regularly, dose may need to be increased

    Other antibiotics: levels of cipro, tetracyclines and rifampicin etc can be reduced by the feed - consider other drugs or increase dose
  198. What are the consequences of malnutrition?
    Poor wound healing

    Weakness and loss of muscle mass

    Apathy and depression

    Reduced immune response

    Increased morbidity and mortality
  199. What are the benefits of enteral nutrition?
    More physiological

    Less risk of infection

    Maintain GI tract

    Gut bacterial translocation?

    Costs less

    Easier for home patients
  200. How can EN be administered?
    Orally - sip feed

    Naso-gastric tube

    Percutaneous Endoscopic Gastrostomy tube
  201. What problems can develop with EN?


    Abdominal distention

    Blocked feeding tube

    Problems with the pump
  202. What questions should be asked before administering medication down a feeding tube?
    Can the patient take the meds orally?

    Are all the drugs necessary?

    Can alternative routes be used?

    Can another drug from the same class be used?

    Is the drug available in a more appropriate formulation?
  203. What ADR's are associated with b-agonists?
    fine tremor

    nervous tension


    peripheral vasodilatation


  204. What ADR's are associated with leukotriene antagonists?
    GI upset

    abdo pain

  205. Adult BTS guidelines for asthma: Step 2
    Step 2: Regular preventer therapy

    Add inhaled steroid, dose appropriate to severity
  206. Adult BTS guidelines for asthma: Step 3
    Step 3: Add-on therapy

    Add LABA

    Assess control & continue if good

    If inadequate, continue LABA & inc inhaled steroid dose

    No response to LABA - stop & inc inhaled steroid dose
  207. Adult BTS guidelines for asthma: Step 4
    Step 4: Persistent poor control

    Consider trials of:

    –Inc inhaled steroid

    –add another drug, eg leukotriene antagonist, SR theophylline, b2 agonist tablet
  208. Adult BTS guidelines for asthma: Step 5
    Step 5: Continuous or frequent use of oral steroids

    Use daily steroid tablet in lowest dose to give control

    Maintain high dose inhaled steroid
  209. When to use TPN?
    When EN is not an option;

    - cannot take anything by mouth or GI tract

    - "gut failure" - unable to digest or absorb food

    - the GI tract may be unavailable or unable to absorb nutrients

    - may be short or long term
  210. Indications for short term TPN?
    Awaiting feeding tubes

    Bowel obstruction

    Following major excisional surgery

    ICU pts with MOSF

    Minority of pts with IBD

    Severe pancreatitis
  211. Indications for long term TPN?
    Radiation enteritis

    Crohn's disease following multiple resections

    Motility disorders e.g. scleroderma

    Bowel infarction

    Cancer surgery
  212. How can TPN be administered?
    Peripheral line via venflon - short term use

    Peripherally inserted central catheter (PICC) - likely to be over two weeks or more use

    A central line - long term or when suitable veins cant be found - infection dangerous
  213. Basic contents of a TPN bag
    Nitrogen (protein)

    Glucose (carbohydrates)

    Fat (not in all)




    Trace elements
  214. Monitoring for a patient on TPN?
    Clinical history



    FBC including folate and vitamin B12

    Trace elements


    Fluid balance
  215. U&E monitoring frequency and rationale for a patient on TPN
    Daily - 3/7

    Fluid and electrolyte balance
  216. PO4, Mg, Ca monitoring frequency and rationale for a patient on TPN
    Daily - 2/7

    Refeeding - adequacy of the regimen
  217. LFTs and CRP monitoring frequency and rationale for a patient on TPN

    Liver and acute phase response
  218. FBC monitoring frequency and rationale for a patient on TPN

  219. Blood glucose monitoring frequency and rationale for a patient on TPN
    4hrly - weekly

  220. Trace elements monitoring frequency and rationale for a patient on TPN

    Adequacy of regimen
  221. Weight monitoring frequency and rationale for a patient on TPN
    Daily - weekly

    Nutritional status/fluid balance
  222. Anthropometry monitoring frequency and rationale for a patient on TPN

    Nutritional status
  223. Temperature monitoring frequency and rationale for a patient on TPN

  224. Line site monitoring frequency and rationale for a patient on TPN

  225. Fluid balance monitoring frequency and rationale for a patient on TPN

    Fluid and electrolyte requirement
  226. Complications of TPN
    Air embolism

    Catheter blockage

    Central line infection

    Metabolic problems e.g. hypoglycaemia, impaired liver function

    Bone disease
  227. Signs and symptoms of anaemia






    Palpitations, tachycardia, systolic murmurs


    Pins and needles

  228. Anaemia classifications
    Macrocytic - large cells

    Microcytic - small cells

    Normocytic - normal sized cells
  229. Causes of anaemia
    Reduced red cell production

    - iron deficiency

    - megaloblastic anaemia

    - sideroblastic anaemia

    - aplastic anaemia

    Increased requirements

    - pregnancy/lactation

    Excessive red cell destruction

    - G6PD deficiency

    Blood loss

    - acute trauma

    - chronic e.g. GI bleed
  230. Causes of iron deficiency anaemia
    (Microcytic anaemia)

    Reduced intake: poor diet

    Increased requirements: pregnancy, lactation

    Blood loss: trauma, GI bleed, menstruation
  231. Treatment or iron deficiency anaemia
    Find and treat underlying cause


    Iron therapy

    Oral Fe - 1st line

    - Avoid OTC sales without investigation

    - 100-200mg for deficiency

    - 60-130mg for prophylaxis

    - Haemoglobin should rise by 2g/100ml over 3-4 weeks

    - Treat for a further 3 months after normal levels reached
  232. Oral iron products: salts, combination products, modified release
    Different salts have different amounts of elemental iron

    - Ferrous sulphate 300mg = 60mg

    - Ferrous gluconate 300mg = 35mg

    Combo products - only one recommended - with folic acid for prophylaxis in pregnancy

    Modified release

    - e.g. Ferrograd

    - fewer side effects as have less iron

    - poor absorption due to max absorption occurring in duodenum

    - BNF - no therapeutic advantage, don't use
  233. Oral iron side effects

    Epigastric pain


    Dark stools

    Manage by;

    - taking with food

    - change salt
  234. Parenteral iron therapy: When to use? Formulations? Problems?
    Use only if oral is not possible

    - not any quicker than oral in most cases


    - malabsorption

    - unable to tolerate oral iron

    - continuing blood loss

    - chronic renal failure

    Iron dextran (i.v. and i.m.)

    Iron sucrose (i.v.)


    - painful

    - stains skin

    - risk of anaphylaxis
  235. Megaloblastic anaemia: type of anaemia, causes and treatment
    Macrocytic anaemia

    Due to;

    • - folic acid deficiency
    • - poor diet
    • - alcoholism
    • - malabsorption
    • - pregnancy
    • - drugs

    • - vitamin B12 deficiency
    • - lack of intrinsic factor
    • - GI surgery
    • - Bacterial overgrowth
    • - Tape worm
    • - Strict veganism
    • - may cause peripheral neuropathy as a symptom


    - oral folic acid 5mg daily for 4 months

    • - hydrocoxobalamin i.m.
    • - 1mg alternate days
    • - then 1 mg every 3 months
    • - lifelong treatment
  236. Production of red blood cells
    In bone marrow

    - erythroblasts

    - normoblasts

    In circulation

    - reticulocytes

    - erythrocytes

    Lifespan typically 120 days
  237. Microcytic anaemia - lab test characteristics
    RBC - reduced

    MCV - reduced

    HB - reduced

    MCHC - unchanged

    Serum Fe - reduced

    TIBC - Increased

    Reticulocyte count - variable
  238. Macrocytic anaemia - lab test characteristics
    RBC - reduced

    MCV - increased

    HB - decreased

    MCHC - unchanged

    Serum Fe - unchanged

    TIBC - unchanged

    Reticulocyte count - reduced
  239. Normocytic anaemia - lab test characteristics
    RBC - reduced

    MCV - unchanged

    HB - reduced

    MCHC - reduced

    Serum Fe - reduced

    TIBC - unchanged or reduced

    Reticulocyte count - increased or decreased
  240. Types of short acting insulin
    Human Actarapid

    Humulin S

    Onset: 1/2 - 1 hr

    Peak: 2-3 hr

    Duration: 8-10 hr
  241. Types of rapid acting insulin analogues
    Humalog (insulin lispro)

    Novorapid (insulin aspart)

    Onset: 15-30 min

    Peak: 30-90 min

    Duration: 4-6 hr
  242. Types of intermediate insulin
    Human insulatard

    Humulin I

    Onset: 2-4 hr

    Peak: 4-10 hr

    Duration: 12-18 hr
  243. Types of long acting insulin
    Insulin zinc suspension - Hypurine Bovine Lente

    Protamine zinc - Hypurin Bovine Protamine Zinc

    Onset: 2-10 hr

    Peak: 4-16 hr

    Duration: up to 24 hr
  244. Types of long acting insulin analogues
    Insulin glargine (Lantus)

    Detemir (Levemir)

    Flat profile (no peak)

    Onset: 2-4 hr

    Duration: 20-24
  245. Types of biphasic insulin
    Human mixtard 30

    Humulin M3

    Humalog Mix 25, 50

    Novomix 30

    Onset: 1/2 hr

    Peak: 1-12 hr

    Duration up to 12 hr
  246. Metformin in type 2 diabetes: When to use?

    Mode of action?

    First line choice if overweight

    Reduces hepatic gluconeogenesis

    Inc peripheral utilisation of glucose

    Doesn't cause weight gain or hypos
  247. Metformin side effects
    Serious GI disturbances

    - anorexia

    - nausea

    - diarrhoea

    Lactic acidosis (rare)

    - renal impairment major risk factor (also hepatic or cardiac failure)
  248. How to take metformin
    Start with low dose (500mg daily)

    Take during or after food

    Increase slowly

    Take in divided doses 2-3 times daily
  249. Sulphonylureas: examples

    When to use?

    Mode of action?



    Use first line in non obese type 2's

    Stimulates insulin production by the pancreas (needs residual pancreatic function)

    Can cause hypo's if meals missed

    Avoid long acting in elderly
  250. Gliclazide dose and side effects
    Starting dose 40-80 mg od

    Usual dose 80-160 mg bd


    Weight gain

    Mild GI disturbances
  251. Glitazones (pioglitazone):

    Mode of action?

    When used?
    Enhanced insulin sensitivity

    Reduces hepatic glucose production

    Used in combination therapy if pt unable to take metformin and sulphonylurea combo
  252. Monitoring needed for pioglitazone
    LFT's before starting and yearly
  253. Pioglitzone: side effects and contraindications

    Weight gain

    C/I in heart failure

    15mg initially then up to 45 mg OD
  254. Prandial glucose regulators: examples

    Mode of action

    When to use?



    Stimulate insulin secretion

    Less likely to cause hypo

    Use to control post prandial hyperglycaemia in combo

    Take immediately before food - omit dose if meal missed
  255. Acarbose: Mode of action?


    Side effects?
    Intestinal alpha glucosidase inhibitor that inhibits absorption of starch and sugars

    Can lower blood glucose

    Start at 50 mg increase slowly to 100-200 mg tds

    GI side effects problematic - flatulence

    Must be chewed with first mouthful of food to be swallowed

    Useful for post prandial hyperglycaemia
  256. Incretin mimetics: examples

    Mode of action

    When to use?



    Inhibits gastric emptying and reduces appetite

    Licensed for pts not achieving control with metformin and sulphonyls

    s/c injections

    GI side effects, transient

    Pancreatitis risk
  257. Incretin enhancers: examples




    Blocks rapid degredation of GLP-1

    Well tolerated but concerns about immune system
  258. Treatment of painful diabetic neuropathy
    1st line: Amitriptylline/nortriptylline 10-75mg unlicensed

    2nd line: Gabapentin, pregabalin, duloxetine licensed

    3rd line: topical capsacin cream, lidocaine patches, tramodol or accupuncture