most common microbial entry site?
mucosal surfaces
aspergillos is common in ______ patients.
immunocompromised
Streptococcus is gram ___ cocci and is ___ (aerobic/anearobic).
Enterococcus is gram ___ cocci and is ___ (aerobic/anearobic).
S. aureus is gram ___ cocci and is ___ (aerobic/anearobic).
Staph epidermidis is gram ___ cocci and is ___ (aerobic/anearobic).
Listeria is gram ___ bacilli and is ___ (aerobic/anearobic).
positive aerobic * sometimes causes meningitis * often present in patients <2yo, >50yo or pregnant
Corynebacterium is gram ___ bacilli and is ___ (aerobic/anearobic).
Peptococcus and peptostreptococcus are gram ___ cocci and is ___ (aerobic/anearobic).
Clostridium is gram __ bacilli and is (aerobic/anaerobic).
Tetani is is gram ___ bacilli and is ___ (aerobic/anearobic).
Nisseria (meningitis and gonorrhea) is gram ___ cocci and is ___ (aerobic/anearobic).
Moraxella is gram ___ cocci and is ___ (aerobic/anearobic).
Enterobacteraciae family is gram ___ bacilli and is ___ (aerobic/anearobic).
What are enterobacteraciae family members?
SPACE EK
Serratia Proteus Acinetobacter Citrobacter Enterobacter E. coli Klebsiella
Pseudomonas is gram ___ bacilli and is ___ (aerobic/anearobic).
Haemophilus influenzae is gram ___ bacilli and is ___ (aerobic/anearobic).
Is there Gram negative ANAerobe COCCI?
NONE
Bacteriodes fragilis is gram ___ bacilli and is ___ (aerobic/anearobic).
Melaninogenicus is gram ___ bacilli and is ___ (aerobic/anearobic).
Fusobacterium is gram ___ bacilli and is ___ (aerobic/anearobic).
Prevotella is gram ___ bacilli and is ___ (aerobic/anearobic).
Legionella is ___ bacteria.
atypical
Mycoplasma is ___ bacteria.
atypical
Chlamydia is ___ bacteria.
atypical
What are two kinds of mycobacteria?
Mycobacterium tuberculosis (MTB) Mycobacterium avium intracellulare (MAI) (for HIV patients)
Where do mycobacterium usually travel to, why?
Is virus curable?
No we either prevent or get them and self limit.
Where are these bacteria located?
mouth
Where are these bacteria located?
skin and soft tissue
Where are these bacteria located?
bones and joints
Where are these bacteria located?
abdomen
Where are these bacteria located?
Urinary tract
Where are these bacteria located?
upper respiratory tract
Where are these bacteria located?
lower respiratory tract
Where are these bacteria located?
lower respiratory tract in hospital
Where are these bacteria located?
meningitis
Four advantags of gram stain diagnostic tool
1) rapid diagnosis (meningitis) 2) identify organism difficult to grow (anaerobes) 3) evaluate specimen quality (sputum vs. saliva) 4) identify cell types indicative of infection (WBC)
What diagnostic tool should meningitis use?
gram stain
What diagnostic tool should mycobacteria use?
acid fast stain
What diagnostic tool should nocardia (G+, catalase +, bacilli bacteria) use?
acid fast stain
When do you use DNA probe and acid fast stain?
to diagnose what type of mycobacterium it is
When do you use PCR and acid fast stain?
TB only
Acid fast stain has ___ (low/high) sensitivity.
low
Influenza uses ___, which is an antigen test.
nasopharyngeal swab
RSV uses ____, which is an antigen test.
nasopharyngeal swab
Legionella's antigen test should be done using ____.
urine
Antigen tests are for the bacteria that takes ___ (short/long) time to grow as cultures.
long
Colonization means there is no infection. T or F?True False
True
Immunocompromised patients favor (cidal or static) agents.
cidal
Aminoglycosides are ____(concentration or time) dependent antibiotic.
concentration
Mechanism of aminoglycosides?
inhibit protein synthesis (irreversibly bind to 30s ribosome)
Aminoglycosides are bacteri___ (cidal or static).
cidal
Where is aminoglycoside's distribution?
primarily in extracellular and body fluids LOVES water some to fat
How is aminoglycoside eliminated?
renally (because it loves WATER)
Which is the ONLY aminoglycoside that can be used for Gram Positive Aerobe Synergy?
gentamicin (NOT tobra or amikacin)
Aminoglycoside must be combined with another agent to treat G(+) aerobe. T or F?True False
True (synergy only)
Which bacteria groups can aminoglycoside treat?
G(+) aerobe (synergy only - gentamicin) G(-) aerobe Mycobacteria
Can aminoglycoside cover pseudomonas?
YES!
What is the Aminoglycoside coverage for Pseudomonas?
amikacin tobramycin gentamycin
Which aminoglycoside do you use to cover mycobacterium tuberculosis? (MTB)
streptomycin
Which aminoglycoside do you use to cover mycobacterium avium intracellulare? (MAI)
amikacin
Which aminoglycoside can you use with B-LACTAM for synergy, enterococci, streptococci, MSSA, MRSA and listeria?
gentamicin
Which amionoglycoside do you use with synergy for Streptococcus viridans and Enterococcus faecalis?
streptomycin
aminoglycoside adverse effects
nephrotoxicity ototoxicity
Is nephorotoxicity of aminoglycoside reversible?
How do you check aminoglycoside nephrotoxicity? (clinical presentation)
low urine output increase in BUN and serum Cr
Which are older FQ?
norfloxacin ciprofloxacin
How is levofloxacin supplied?
How is moxifloxacin proided?
How is ciprofloxacin provided?
How is gemifloxacin provided?
PO
What are the dual mechanism of FQ?
DNA gyrase : removes excess positive supercoiling in the DNA helix Topoisomerase IV : essential for separation of interlinked daughter DNA molecules
What kind of bacteria does the DNA gyrase mechanism of FQ target?
gram negative
What kind of bacteria does topoisomerase IV inhibition mechanism of FQ target?
gram positive
FQ is bacteri___ (cidal or static).
cidal
Does FQ have a good oral bioavailability?
Yes
Where is FQ distributed?
extensive tissue distribution : prostate , liver, lung, skin/soft tissue, bone , urinary tract prostate and bone are important some CSF penetration
How is ciprofloxacin eliminated?
both
How is levofloxacin eliminated?
How is moxifloxacin eliminated?
hepatic thus moxifloxacin is NOT for prostatitis and UTI
Which of these can you NOT use for prostatis and UTI?
moxifloxacin because it is hepatically eliminated only
Which FQ is used for gram POSITIVE bugs?
newer agents : levo, moxi, gemi MSSA, strep pneumo including PRSP also CA MRSA
Which FQ is used for gram NEGATIVE bugs?
ALL have excellent activity enterobactericiae H influ, M catarrhalis, Neisseria Pseudo aeruginosa
Which FQ can you NOT use for pseudomonas aeruginosa?
moxifloxacin cipro and levo have FDA approved indications
Which 2 FQs can you use for pseudomonas aeruginosa?
ciprofloxacin levofloxacin
FQs do not cover oral anaerobes. T or F
Mycobacterium tuberculosis is covered by FQ. T or FTrue False
True
FQ causes QT prolongation. T or FTrue False
True. could lead to torsades check CV function, see if the patient is on other drugs that may cause QT prolongation as well.
You do not need to monitor LFT with FQ. T or FTrue False
false LFT can be elevated due to potential hepatoxity AE.
Phototoxicity caused by FQ is more common with ___ (older/newer) FQ agents.
older FQ : norfloxacin and ciprodue to halogen at position 8
BBW of FQ?
articular damage : arthropathy including articular cartilage damage, arthralgia, joint swellingtendon rupture
Can FQ cause dysglycemia?
Yes dysglycemia is hypo and hyperglycemia
FQ is associated with clostridium dificile. T or FTrue False
True
All FQ have drug interaction with ____ and ____ . What's the problem?
divalent and trivalent cations: zinc, iron, calcium, aluminum, mangesium, antacid, sucralfate, some enteral feeding impairs oral absorption warfarin : idiosyncratic
Divalent and trivalent should be avoided with ciprofloxacin _ _ hours prior and __ hours after.
2 hours prior 6 hours after
Divalent and trivalent should be avoided with moxifloxacin __ hours prior and __ hours after.
4 hours prior 8 hours after
Divalent and trivalent should be avoided with levofloxacin __ hours prior and __ hours after.
2 hours prior 2 hours after
Theophylline and cyclosporin should be avoided with which FQ?
ciprofloxacin inhibition of metabolism thus increases level then increases toxicity.
What are examples of lipopeptide?
what is the mechanism of action of lipopetide?
rapid depolarization of membrane potential doesnt rupture the cell wall so it may lessen the immune response from sudden release of exotoxin proteins
Lipopeptides have ____ (cidal/static) activity.
cidal
What bacteria does daptomycin cover?
gram positive : staph (MSSA, MRSA) enterococcus faecalis (VRE faecium and faecalis - not FDA approved but data available) strep (PRSP)
What is the drug of choice for enterococcus? Alternatives?
Drug of choice : ampicillin vancomycin daptomycin
Daptomycin has a great coverage for gram negative bugs. T or FTrue False
FALSE intrinsically inactive!
What three condition/disease does daptomycin cover?
cSSTI (complicated skin and soft tissue infection) bacteremia right sided endocarditis
What is the daptomycin dose used for SSTI?
4mg/kg/d
What is the daptomycin dose for endocarditis?
6mg/kd/d higher dose than cSSTI
What is the daptomycin dose for bacteremia?
6mg/kg/d higher dose than cSSTI same dose as endocarditis
Daptomycin is not excreted via kidney T or F?True False
False excreted via kidney
Should you dose adjust for daptomycin in case of CrCl<30, HD, CAPD?
Daptomycin is dosed by ___ body weight. (actual/ ideal)
actual body weight
Daptomycin is effective against pneumonia. T or FTrue False
FALSE NOT efficacious for treatment of pneumonia because daptomycin is inhibited by lung surfactant
Daptomycin interacts with commercially available _________ used in determining PT and INR. How does this affect PT and INR? So what should you do?
thromboplastin reagents Interaction leads to an erroneous prolongation of PT or elevated INR. so measure PT/INR before daptomycin dose (or daptomycin trough concentration)
Adverse effects of daptomycin
Mechanism of televancin?
inhibit bacterial cell wall synthesis inhibit cell membrane permeability
Telvancin has activity against _____.
staphylococcus streptococcus enterococcus corynebacterium spp
Televancin dose for SSTI? How long do you administer for?
10mg/kg/d administer over 60 min
What are side effects of televancin?
taste disturbance foamy urine nephrotoxicity QTc prolongation N/V coagulation test interference
Can you televancin for pregnant patients?
NOPE avoid in pregnant patients
Penicillinase resistant penicillin has a great coverage for _____.
G+ bacteria nafcillin so a great tip to memorize is naf for staph
What is an example of carboxypenicillin drug?
ticarcillin (Timentin)
What is an example of ureidopenicillin drug?
piperacillin (Zosyn)
How is benzathine penicillin different from Pen G and Pen VK? When is it used?
it is longer acting used for syphilis patients
What is the primary coverage of natural penicillins? (pen G, pen VK, benzathine penicillin)
Gram positive: staph, strep, enterococcus
Why was penicillinase resistant penicillin developed?
developed to overcome the penicillinase enzyme of S. aureus which inactivated natural penicillin
What do penicillinase resistant penicillin cover?
Gram positive: MSSA, streptococci
Penicillinase resistant penicillin can be used to treat MRSA. T or FTrue False
False
Why was aminopenicillin developed?
developed to increase activity against gram negative aerboes
What bacteria do aminopenicillins cover?
Gram positive : MSSA, streptococci, entercoccus sp, listeria monocytogenes Gram negative: proteus mirabilis, salmonella, shigella, E.coli, H. influ
Why was carboxypenicillin developed?
developed to further increase activity against resistant gram negative aerobes
What bacteria do carboxypenicillin cover?
ticarcillin gram positive : marginal gram negative : proteus mirabilis, salmonella, shigella, e.coli, h.influ, enterbacter sp, pseudomonas aeruginosa
Can carboxypenicillin treat pseudomonas aeruginosa?
Yes
Why was ureidopenicillin developed?
developed to further increase activity against resistant
What do ureidopenicillin cover?
piperacillin gram positive : strep, MSSA, enterococcus gram negative : proteus mirabilis, salmonella, shigella, e.coli, h.influ, enterbacter, pseudomonas aeruginosa, serratia marcescens, klebsiella anaerobes : fairly good activity
Can ticarcillin and piperacillin cover MRSA?
No
Can piperacillin and ticarcillin cover pseudomonas aeruginosa?
Yes
Do b-lactamase inhibitor contribute to antibacterial activity? What are some examples? What kind of substrate do they act as?
they have weak antibacterial activity clavulanic acid, sulbactam, tazobactam suicide substrate
Unasyn is ampicillin and ____.
sulbactam
Timentin is ticarcillin and ____.
clavulanic acid
Zosyn is piperacilin and ____.
tazobactam
Which cephalosporin generation has the best activity vs. gram + aerobes? What are the examples?
first generation cefazolin, cephalexin, cephalothin, cefaclor, cefadroxil
First generation cephalosporins have ___ (great, mediocre, limited) activity vs. gram negative aerobes.
limited
First generation cephalo covers pseudomonas. T or FTrue False
F
First generation cephalo covers MRSA. T or FTrue False
F
Cefazolin.
Cephalothin
1st generation
Cefaclor
Cephalexin
Cefadroxil
First generation cephalo covers H. Influenza. T or F
F second generation covers this
First generation cephalo does not cover M. catarrahlis. T or F
T second generation covers this
Nesseria can be treated with first generation cephalo. T or F
F covered by second generation
What are cephamycins? What is so special about them?
cefoxitin, cefotetan, cefmetazole the only 2nd generation cephalo that cover anaerobes. (bacteroides fragilis group)
Cefuroxime covers bacteroides fragilis. T or F
F only cephamycins cover them.
Cefoxitin covers bacteroides fragilis. T or F
Cefotetan covers bacteroides fragilis. T or F
Cefmetazole covers bacteroides fragilis. T or F
Cefprozil covers bacteroides fragilis. T or F
F this is not a cephamycin.
Cefuroxime
Cefotetan
Cefoxitin
Cefmetazole
Cefprozil
Loracarbef
3rd generation cephalo has ____ (more/less) activity against gram positive aerobes and has ___ (more/less) activity against gram negative aerobes.
LESS for positive MORE for negative
Unlike the other 3rd generation cephalo, ____ and ____ have good activity against gram positive aerobes, such as S. pneumoniae.
Cefdinir is a good choice for S. pneumoniae?
No 3rd generation cephalo generally do not have a good activity vs. gram positive aerobes, except ceftriaxone and cefotaxime
Cefotaxime is a good choice for S. pneumoniae?
Yes one of 2 exceptions for 3rd generation cephalo
Cefpodoxime is a good choice for S. pneumoniae?
No not one of 2 exceptions for 3rd generation cephalo that cover gram positive. ceftriaxome and cefotaxime
Several 3rd generation cephalo are strong inducers of _____.
extended spectrum beta lactamase
3rd generation cephalo covers enterobacter spp?
Yes
2nd generation cephalo covers enterobacter spp?
Nope
Which 2 cephalosporins cover pseudomonas aeruginosa?
ceftazidime (3rd generation) cefepime (4th generation)
Ceftriaxone
3rd
Ceftazidime
3rd
Cefotaxime
3rd
Cefixime
Cefpodoxime
Cefdinir
3rd
4th generation cephalo covers gram positive?
Yes~
4th generation cephalo covers gram negative? How about pseudomonas aeruginosa?
As opposed to the 3rd generation cephalo, 4th generation is a ___ (strong/poor) inducer of extended spectrum beta lactamases
poor inducer 4th generation has stability against b-lactamases
Which abx class has the most broad spectrum of activity?
carbapenems activity vs. gram positive and negative and aerobes and anaerobes
Generic name for Primaxin?
imipenem/cilastatin
Which carbapenem would you use for enterococcus, gram positive?
imipenem
Which carbapenem would you use for acinetobacter?
imipenem
Which carbapenem would you use for pseudomonas aeruginosa?
meropenem more active vs. gram negative
Which carbapenem can you NOT use for enterococcus?
ertapenem
Which carbapenem can you NOT use for pseudomonas?
ertapenem
Which carbapenem can you NOT use for acinetobacter?
ertapenem
Which carbapenem has more activity vs. gram positive?
imipenem
Which carbapenem has more activity vs. gram negative?
meropenem
Generic name for Invanz?
ertapenem
Doripenem seems to act similar to imipenem and meropenem. T or FTrue False
T
What is the benefit of ertapenem in terms of t/2?
it has a longer half life so daily dosing is possible but INvanz is INcomplete coverage!
Why is imipenem combined with cilastatin?
prevent hydrolysis by enzymes in the renal brush border by inhibiting dihydropeptidase 1
What effect does cilastatin have on half life of imipenem?
prolongs t/2
Does cilastatin add antibacterial effect on imipenem?
No
Does cilastatin help in maintaining therapeutic urinary concentration?
Yes maam
Cilastatin prevents ____ effects of imipenem and metabolites.
nephrotoxic
If beta lactam is given for more than 2 weeks, what adverse effect could happen?
hematologic: leukopenia, neutropenia, thrombocytopenia
Is there cross reactivity amongst beta lactams?
Yes all penicillins and even other b-lactams
Interstitial nephritis is a potential adverse effect for which drug? What kind of reaction is this?
nafcillin type IV hypersensitivity reaction
What does aztreonam cover?
gram NEGATIVE only
Aztreonam covers pseudomonas aeruginosa?
YES.
Aztreonam could have a cross-allergy with beta lactams?
No monobactam's structure makes cross allerginicity with b-lactam unlikely.
What does vancomycin cover?
gram POSITIVE only NO activity against gram negative aerobes also NONE against anaerobes.
What is a special issue with C.diff and vancomycin?
For C. difficile treatment, you can use ORAL ONLY
Does vancomycin cover enterococcus?
Yes
Vancomycin covers MSSA, MRSA and CoNS but which other agent might work faster against them?
Ancef (cefazolin) 1st generation cephalo
How is the vancomycin distribution? How do you dose it?
widely distributed into body tissues and fluids, including adipose tissue use TBW for dosing inconsistent peneration into CSF
Should you adjust vancomycin renally?
Yes eliminated via kidneys
When do you use vancomycin?
MRSA serious gram positive infections in B-lactam allergic patients surgical ppx MDR oral vanco for C. diff colitis
What is the target trough for vancomycin?
15-20mg/L
Red man syndrome is related to the ___ of vancomycin infusion. What is the goal then?
RATE infuse over 60 minutes (at least 15mg/min)
How commons is nephrotoxicity if vancomycin is used alone?
rare
Nephrotoxicity may occur if the dose of vancomycin is over _____.
4 g/day
Nephrotoxicity of vancomycin may be more common in following conditions...
dose >4g/day weight >101.4kg ClCr <86.6ml/min ICU stay
How is linezolid supplied?
PO and IV
What does linezolid cover?
resistant gram positives MRSA, GISA, VRE
What is the MoA of linezolid?
bind to 50S ribosomal subunit then inhibit protein synthesis
Linezolid is mostly bacteri___ (cidal/static).
static cidal against some like strep pneumo, streptococcus
To which bacteria does linezolid present bacteriostatic activity?
Enterococcus faecium AND faecalis including VRE
Which abx covers both enterococcus faecium and faecalis?
linezolid
For which indications can you use linezolid 600mg q12h?
For which indications can you use linezoild 400mg q12h?
uSSTI
What is the bioavailability of linezolid?
100%!
Should you adjust linezolid dose in case of renal issues?
Nope also not removed by HD
What are some adverse effects of linezolid?
myelosuppression (blood levels will drop after 2 weeks) peripheral and optic neuropathy lactic acidosis serotonin syndrome
Linezolid is not approved and should not be used for the treatment of patients with ____ bloodstream infection or ___ related infections.
cather related cather site
What is the benefit of tigecycline compared to tetracycline?
avoids the resistance mechanisms seen with tetracycline such as efflux and ribosomal protection mechanisms
Tigecycline is bactericidal or static?
bacteriostatic
Tigecycline's mechanism of action
binds 30S ribosome so prevent protein synthesis
Does tigecycline cover MRSA?
Yes
Does tigecycline cover VRE and GISA?
Yes
Does tigecycline cover gram negative?
Yes e.coli, klebsiella, enterbacter, acinetobacter
Does tigecycline cover anaerobes?
Does tigecycline cover pseudomonas?
NOPE
What are the indications of tigecycline?
What is a regular dosing for tigecycline?
Do you have to adjust tigecycline dose for renally impaired?
Nope
Do you have to adjust tigecycline dose for hepatically impaired?
Yes LD : 100mg (same) MD : 25mg q12h (half the dose)
What is child pugh? What are the parameters? How is the grade divided?
classification of severrity of liver disease ascites, bilirubin, albumin, prothrombin time, encephalopathy grade A, B, C : C is the worst
What are the most common SEs of tigecycline?
nausea, vomiting occur within the first 2 days of therapy yes dose related, more in female, more in younger (18-50yo) result from an excess release of serotonin ondansetron helps extending the infusion time does not help
tigecycline can be used in pregnant patient. T or F
In macrolides, what are benefits are the newer agents?
improved PK : better bioavailability, better tissue penetration, prolonged t/2 broader spectrum of activity : H.influ, M. catarr, neisseria improved tolerability
Macrolides cover MRSA?
No
Macrolides cover streptococcus pneumoniae?
yes
Do macrolides cover anaerobes?
Yes activity against upper airway anaerobes
Do macrolides cover atypical bacteria?
Yes : excellent activity legionella penumophila, chlamydia, mycoplasma, ureaplasma
Do macrolides cover pseudomonas?
No
What is the drug of choice for legionella pneumophila?
macrolides!
Do macrolides cover MAI?
yes
Do macrolides cover treponema pallidum?
Yes
How much azithromycin do you give for HIV patients with CD4 <50? Why?
1200mg weekly prophylaxis for disseminated MAC
How is the distribution of macrolides?
extensive tissue and cellular minimal CSF
Can macrolides be dialyzed?
Nope
What is the elimination of clarithromycin?
partially eliminated by kidney so must adjust dose when CrCl <30ml/min
How are all macrolides eliminated?
hepatically
What SE can happen if you use macrolides for a long time? When would such a time be?
hearing loss such as TB which takes at least 6 months of therapy
Can macrolides elevate LFT?
yes
Which macrolide inhibits CYP enzyme? which enzymes? how does this compare to other macrolides?
erythromycin CYP 3A4 and 1A2 clarithromycin silghtly less extent azithromycin few clinically significant DI
Which has activity against resistant strains?
telithromycin
MoA of telithromycin?
same as macrolides (inhibit protein synthesis) but activity against resistant strains
Generic name for Ketek?
telithromycin
What is telithromycin FDA-indicated for?
CAP
Telithromycin has many drug interactions. why?
strong 3A4 inhibitor
What are side effects of telithromycin?
hepatotoxicity QTC prolongation visual disturbance
