Intro to Infectious Diseases Pharmacotherapy

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brittness
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72352
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Intro to Infectious Diseases Pharmacotherapy
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2011-03-13 16:48:43
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Intro Infectious Diseases Pharmacotherapy
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Intro to Infectious Diseases Pharmacotherapy- Abrahms
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  1. Prophylaxis
    • Prevention of an infection
    • ex. prior to intraabdominal surgery
  2. Empiric
    • Have idea of what causes but don't know for sure
    • Most antibiotic use
  3. Definitive
    • Know what you are treating
    • ex. PCN shot for syphilis
  4. 6 main steps to treat infectious disease
    • 1) Is infection present? What is evidence? (Epidemology, Pathophysiology, Clinical Presentation, Diagnostic workup)
    • 2) Obtain cultures for micro lab
    • 3) Start empirical antibiotics (Which pathogens likely to cause this infectious syndrome?)
    • 4) Review gram stain, organism(s) ID & susceptibility reports from lab
    • 5) Narrow your therapy bassed on culture results (monitoring parameters, watching for side effects, avoiding DDI, looking for clinical improvement)
    • 6) Stop therapy when appropriate
  5. Infection Present? (Time 0)
    • Fever
    • H&P
    • WBC w/ diff
    • S/s
  6. Fever
    • Controlled elevation in body temp above normal
    • Normal 98-98.6*
    • Rectal 0.6 higher, axilla 0.6 lower
    • Not harmless unless > 105*
  7. WBC w/ differential
    • Most infections assoc. w/ leukocytosis
    • Normal WBC 4.5-9.5
    • Bacterial infections- increase PMN % & presence of neutraphils (Left shift)
    • Viral, fungal, TB- Lymphocytosis
    • Parasites, allergies- eosinophilia
  8. Local S/S
    • Vary depending on infection
    • Ex- cellulitis: swelling, erythema of skin, tenderness, drainage
    • UTI- pain on urination ( dysuria)
    • Pneumonia- cough
  9. Radiographical studies
    • chest xray
    • MRI
    • CT
  10. Blood cultures
    • Taken in acutely ill, febrile (sick enough to be hospitialized)
    • 2 sets of blood culture, one hour apart from 2 different peripheral sites (anaerobic & aerobic)
  11. Host factors
    • Thorough H&P
    • Where infection acquired?
    • Immunocompetant vs. immunosuppressed
    • Pets? Sick contacts? Travel?
    • Drug allergies?
    • Age
    • Liver & renal fxn
    • Pregnancy & lactation
    • Metabolic abnormalities
    • Concomitant drugs and disease states
  12. Drug factors
    • Tissue penetration
    • efficacy
    • route, bioavailability
    • Bacteriocidal vs bacteriostatic
    • SE & DDI
    • Cost & insurance
  13. Patient improving
    • Monitor fever
    • Resolution of S/S of infection
    • Normalizing of WBC & vital signs
  14. MIC
    lowest antimicrobial concentration that prevents visible growth of an organism after approx 24 hours of incubation in a specified growth medium
  15. Skin normal flora
    • Streptococcus
    • Staphylococcus epidermidis
    • Corynebacterium
    • Propionibacterium
  16. Mouth normal flora
    • Viridans streptococcus
    • Peptococcus
    • Peptostreptococcus
    • Candida
  17. Upper airway normal flora
    • S. pneumoniae
    • S. pyogenes
    • Neisseria
    • H. influenzae
    • S. aureus (nose)
  18. Lower airway normal flora, blood, CSF, urine
    Should not have any
  19. Proximal small intestine normal flora
    • Enterococcus
    • Lactobacillus
    • Candida
  20. Distal Small intestine normal flora
    • Enterococcus
    • Lactobacillus
    • Bacteroides
    • Enterobacteriaceae
    • *more anaerobic environment further down
  21. Large intestine/ rectum
    • Enterococcus
    • Lactobacillus
    • Bacteroides
    • Enterobacteriaceae
    • Streptococcus
    • Clostridia
    • Candida
  22. Genito-urinary tract
    • Lactobacillus
    • Prevotella
    • Enterobacteriaceae
    • Group B strep
    • Staph
    • Candida
  23. Beta lactam antibiotics
    • Penicillins
    • Penicillinase Resistant Penicillins
    • Beta lactam/ beta lactamase inhibitor combinations
    • cephalosporins
    • carbapenems
    • monobactam
  24. Penicillin treats
    • Treponema pallidum (syphilis)- DOC
    • Strep (A, B, C, F, G)- 100% susceptible
    • Strep pneumoniae -65% susceptible
  25. Forms of penicillin
    • Penicillin G- IV
    • Penicillin VK- oral
    • Bi-cillin LA- IM
    • Procain penicillin- IM
    • Bi-cillin CR- IM
  26. Aminopenicillins
    • Amoxicillin
    • Ampicillin
    • Ticarcillin
    • Piperacillin
  27. Ampicillin
    • Enterococcus (most active)
    • Listeria monocytogenes (DOC)
  28. Piperacillin
    • Pseudomonas aeruginosa
    • Similar to PCN for gram (+)
  29. penicillinase resistant penicillins
    • Nafcillin
    • Oxacillin
  30. Nafcillin/ Oxacillin
    MSSA
  31. Beta lactam/ beta lactamase inhibitor combinations
    • Unasyn (Ampicillin/ sulbactam)
    • Augmentin (amoxicillin/ clavulanate)
    • Zosyn (piperacillin/ tazobactam)
  32. Unasyn/ Augmentin treats
    • MSSE
    • MSSA
    • Streptococcus
    • Enterococcus
    • Anaerobes (mouth, gut)
    • Some GNR- E. coli, klebsiella, proteus, haemophilus
  33. Zosyn treats
    • Strep
    • MSSA
    • MSSE
    • Enterococcus
    • Anaerobes (mouth, gut)
    • Excellent, broad gram (-) including Enterobacteriaceae
    • Pseudomonas
  34. Carbapenems
    • Imipenen/ cilastin (primaxin)
    • Meropenem (Merrem)
    • Doripenem (Doribax)
    • Ertapenem (Invanz)**
    • **Cannot be used interchangably with others
  35. Carbapenems
    • Most stable to Beta-lactamases
    • DOC ESBL- Klebsiella, E coli
    • High dose Imipenem/ cilastin--> seizures
    • Covers broad aerobic gram (+), aerobic gram (-), including:
    • -Acinetobacter
    • -Pseudomonas
    • -Anaerobes
  36. Ertapenem restrictions
    • Does not cover Acinetobacter or pseudomonas
    • Cannot be used interchangably with other carbapenems
  37. Monobactam
    • Aztreonam
    • (not a beta- lactam)
  38. Aztreonam treats
    • Only gram (-) activity
    • Pseudomonas
    • **Useful for severe beta lactam allergy
  39. Penicillins ADR
    • Allergic rxns (SJS)
    • Interstitial nephritis (Nephrotoxicity)
    • Seizures
    • Thrombocytopenia**
    • Adjust for renal dysfunction**
    • Back up oral contraception**
    • Clostidium difficile super infection**
    • **Can be applied to any antibiotic
  40. PCN allergy
    • PCN to Cephalosporin- 3-5%
    • PCN to Carbapenem- 11-50%
    • If IgE mediated or SJS hx AVOID!!
    • Desensitization protocols
  41. 1st generation Cephalosporins
    • Cephalexin
    • Cefazolin
  42. Cephalexin/ Cefazolin
    • Streptococcus
    • Staphylococcus
    • MRSA
  43. 2nd generation cephalosporins
    • Oral:
    • -Cefaclor
    • -Cefuroxime
    • Parenteral:
    • -Cefoxitin
    • -Cefuroxime
  44. Cefoxitin (IV)
    • Strep
    • MSSA
    • GNR
    • Bacteriodes (GI use)
  45. Respiratory use- 2nd generation cephalosporins
    • Cefuroxime (IV/PO)
    • Cefaclor (PO)
  46. Cefuroxime (IV/PO)/ Cefaclor (PO)
    • Strep
    • MSSA
    • some GNR
    • *Lack bacteroides
  47. 3rd generation cephalosporins
    • Oral:
    • -Cefdinir
    • Parenteral:
    • -Ceftazidime
    • -Ceftriaxone
  48. Ceftazidime
    • Enterobacteriaceae
    • Pseudomonas
  49. Ceftriaxone
    • Great strep
    • MSSA
    • Nisseria
    • Haemophilus
    • Moraxhella catarrhalis
    • Enterobacteriaceae
    • **No pseudomonas
  50. 4th generation cephalosporins
    Cefepime (IV)
  51. Cefepime
    • IV
    • Strep
    • MSSA, MSSE
    • Enterobacteriaceae
    • Pseudomonas
  52. 5th generation cephalosporins
    Ceftaroline
  53. Ceftaroline
    • IV
    • Streptococcus
    • MSSA
    • MRSA
    • Enterobacteriacese
    • H. Influenzae
    • **Only cephalosporin that covers MRSA
  54. Cephalosporin ADE
    • Allergy
    • **Neutropenia
    • Drug fever
    • **Biliary sludging (ceftriaxone)
    • **N-methylthiotetrazole (MTT) side chain found in cefotetan, cefamandole, inhibits vit K production, disulfiram reaction
  55. Glycopeptides
    • Vancomycin
    • Telavancin
  56. Vancomycin
    • IV, oral
    • MRSA- gold standard
    • MSSA
    • Strep
    • Enterococcus
    • **Clostridium difficile--> oral vancomycin only
    • No gram (-)
  57. Vancomycin side effects
    • Redman syndrome
    • Allergic rxn
    • Nephrotoxicity at higher doses
    • Ototoxicity
  58. Telavancin
    Contra-indicated in pregnancy
  59. Linezolid (Zyvox) treats
    • PO/ IV
    • Gram (+) specialist
    • MRSA
    • Staph
    • Strep
    • Enterococci
    • VRE
  60. Linezolid Pearls
    • Serotonin syndrome with SSRI's and other antidepressants
    • Myeloxuppression (Black box warning)
    • - Weekly CBC
    • Permanent peripheral neuropathy & optic neuropathy with prolonged use
  61. Aminoglycosides
    • Amikacin
    • Tobramycin
    • Gentamicin
    • Streptomycin (Parenteral, nebulized)
  62. Aminoglycoside treats
    • Enterobacteriaceae
    • Pseudomonas
    • Acinetobacter
    • (Gram (-) rod specialist)
    • *provides synergy with beta lactams
  63. Aminoglycoside toxicity
    • Nephrotoxicity
    • Ototoxicity
  64. Fluoroquinolones
    • Norfloxacin
    • Ofloxacin
    • Ciprofloxacin
    • Levofloxacin
    • Moxifloxican
  65. Ciprofloxacin treats
    • IV, PO, ophthalmic, otic
    • Excellent gram (-) activity
    • Pseudomonas
    • Not useful for most gram (+)
    • exception Bacillus anthracis (anthrax)- DOC
  66. Levofloxacin (levaquin)
    • Teriffic Strep pneumoniae
    • Same gram (-) as cipro
    • No anaerobic coverage
    • Atypicals
    • 2nd line in TB
  67. Moxifloxacin
    • Adds anaerobic coverage against bacteroides
    • strep pneumoniae
    • anaerobes
    • some gram (-)
    • mycoplasma
    • legionella
    • chlamydia
    • TB
    • **No pseudomonas activity
  68. Quinolone AE
    • Confusion (elderly)
    • Allergic rxn
    • QT prolongation
    • **Photosensitivity
    • **Tendon rupture
    • **Absolute CI- pregnancy, relative in pediatrics
    • Chelating agents (iron, Ca2+, Mg2+), dairy, tube feedings (**separate by a couple of hours)
  69. Macrolides
    • Erythromycin (PO/ IV)
    • Azithromycin (PO/IV)**
    • Clarithromycin (PO)**
    • **Advanced generation
  70. Erythromycin
    • Strep
    • Moraxella
    • H. influenzae
    • atypical bacteria
  71. Azithromycin/ Clarithromycin
    Better H. influenzae/ Legionella
  72. Macrolide ADE
    • N/V (erythromycin worst)
    • Bitter taste in mouth (Clarithromycin)
    • Inhibits CYP 3A4
    • QT prolongation
    • Prokinetic agent
  73. Clindamycin treats
    • IV, PO, topica, intravaginal
    • Strep
    • Staph
    • Anaerobes
    • MRSA
  74. Clindamycin ADE
    • diarrhea
    • Clostridium difficile (#1 associated w/)
  75. Daptomycin
    • IV only
    • Gram (+) activity only
    • MRSA
    • VRE
    • **Weekly CPK monitoring (rhabdomyolysis)
  76. Streptogramins
    Synercid (Quinupristin/ dalfopristin)
  77. Synercid
    • Gram (+) only
    • MRSA
    • VRE faecium
    • **Associated w/ severe myalgias
  78. Tetracyclines
    • Tetracycline (PO)
    • Doxycycline (IV/ PO)
    • Minocycline (PO)
  79. Tetracyclines ADE
    • Avoid use in children <9 yo (tooth discoloration)
    • Photosensitivity
    • Avoid iron, antacids, dairy
    • Empty stomach
  80. Tetracycline treats
    • MRSA skin infection
    • Lyme disease
    • Chlamydia
    • Atypicals
    • Malaria Prophylaxis
  81. Tigecycline
    • IV only
    • Broad coverage:
    • -Atypicals
    • -Enterococci
    • -Staph
    • -Strep
    • -Anaerobes
    • -Most enterobacteriaceae
    • VRE
    • MRSA
    • *N/V (30%)
  82. Bactrim (sulfamethoxazole/ Trimethoprim)
    • IV/ PO
    • **Dose based on TMP component only
    • Pneumocystis jiroveci (carinii)- DOC
    • MRSA
    • Enterobacteriaceae
    • Common uses: UTI, MRSA
  83. Bactrim ADE
    • Dermatological (SJS)**
    • Photosensitivity
    • Avoid us with warfarin
    • Do not give if G6PD deficient, pregnancy at term or to newborn
  84. Nitrofurantion treats
    • Use: Lower UTI only
    • E. coli
    • S. saprophyticus
    • Klebsiella
  85. Nitrofurantion ADE
    • CI Cr< 50 ml/min
    • Pulmonary fibrosis
    • peripheral neuropathy
  86. Nitroimidazoles
    • Metronidazole
    • Tinidazole
  87. Metronidazole
    • IV/ PO/ Vaginal gel
    • Anaerobic specialist
    • Great for gut anaerobes (Bacteriodes spp)
    • Trichomonas, Giardia (1st line)
    • C. difficile (1st line mild-mod)
  88. Metronidazole ADE
    • N/V
    • avoid w/ warfarin
    • Disulfiram reactions w/ alcohol
  89. Chloramphenicol
    • IV, Otic, Ophthalmic preps
    • Toxicities: gray syndrome
  90. Drugs w/ MRSA activity
    • Ceftaroline
    • Vancomycin
    • Linezolid
    • Daptomycin
    • Streptogramins (Synercid)
    • Tetracyclins
    • Tigecycline
    • Bactrim
    • Clindamycin
  91. Drugs with anti-pseudomonas activity
    • Carbapenems (except Ertapenem)
    • Aztreonam
    • Zosyn
    • Ceftazidime
    • Cefepime
    • Piperacillin
    • Aminoglycosides
    • Ciprofloxacin
    • Levofloxacin
    • Amikacin
  92. Drugs with atypical bacteria activity
    • Macrolides
    • Fluoroquinolones
    • Tetracyclines

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