ANTIMICROBIAL AGENTS

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					NAPLEX

ANTIMICROBIAL
AGENTS
        Selecting Appropriate Antimicrobial Agents

       Empiric therapy
       Identify the causative organism
       Test the sensitivity of the organism to
        antimicrobial drugs
       Identify important host factors:
          Site of infection-CNS, bone, prostate, UTI

          Susceptibility to toxicity

          Patient allergies



PG 52
        Mechanisms of Action of Antimicrobial Agents

       Interference with cell wall synthesis
           penicillins, cephalosporins

       Inhibition of protein synthesis
           macrolides, clindamycin, tetracyclines, quinolones

   Interference       with enzyme unique to bacterial cell
           sulfonamides

   Interference       with the permeability of microbial cell
   membranes
           amphotericin B

PG 52
        Sulfonamides
   PABA            dihydrofolic acid (DHFA)   tetrahydrolfolic acid (THFA)


           Sulfa




PG 53
        General considerations - Sulfonamides
    Mechanism of action : competitive antagonism of PABA in enzyme
    system essential for bacteria growth.


    For ophthalmic use, sulfa sodium salt solutions are very alkaline (i.e.,
    pH 10+). The only sodium salt suitable for ophthalmic use is
    sulfacetamide sodium (solutions have pH of about 7.4).


    Sulfas are eliminated renally unchanged. Makes them good for UTIs.


    Sulfas are less soluble in acid urine. This is one cause of crystalluria.


    Stevens-Johnson syndrome is associated with sulfa use.



PG 53
  General considerations – Sulfonamides (cont’d)
   Combinations of sulfamethoxazole and trimethoprim (Bactrim, Septra, etc.)
   are less likely to result in bacterial resistance.


   Sulfasalazine (Azulfidine) is used in treating inflammatory bowel disease
   and RA. Watch for sulfa allergy, salicylate allergy, and urine discoloration.
   - GI side effects, dose is titrated upward slowly, monitor blood counts – dyscrasias
   If a patient cannot use sulfasalazine because of sulfa sensitivity, use
   mesalamine products, i.e., Asacol, Pentasa, Rowasa. – various dosage
   forms
   Remember that silver sulfadiazine (Silvadene) and mafenide (Sulfamylon)
   are used topically for treatment of serious burns.




PG 53
  Penicillins




PG 54
  General Considerations – Penicillins
    Mechanism of action: interfere with bacterial cell-wall
    synthesis (bactericidal)


    Note that all penicillins have a beta lactam ring and
    thiazolidine ring.


    Possible cross-sensitivity with other beta lactam
    antimicrobials (e.g., cephalosporins).
           - percent cross-sensitive ranges from 5-7%




PG 54
   Structure Activity Relationships:
             AMino penicillins – AMpicillin, AMoxicillin, bacAMpicillin
             NOX penicillins – penicillinase (beta lactamase) resistant
              penicillins: Nafcillin, OXacillin, clOXacillin (PO),
              diclOXacillin(PO)----MSSA (vanco alternative)
             MEZPCT penicillins – antipseudomonal penicillins: MEZlocillin,
              Piperacillin, Carbenicillin, Ticarcillin (combo with
              aminoglycosides, not in the same IV)

        Therapy problems with penicillins:
             Acid Resistance
             Beta-lactamase (penicillinase) resistance (combo products;
              Zosyn, Timentin, Augmentin)
             Hypersensitivity
PG 55
Which of the following is an adverse
effect associated with use of
aminopenicillins?
  a. polydipsia
  b. hemolytic anemia
  c. cholelithiasis
  d. tardive dyskinesia
  e. angina
Which of the following is an adverse
effect associated with use of
aminopenicillins?
  a. polydipsia
  b. hemolytic anemia
  c. cholelithiasis
  d. tardive dyskinesia
  e. angina
        Cephalosporins




PG 56
        General considerations
        Contains beta-lactam ring. Therefore, may have cross-sensitivity with
        penicillins.


        As you go from 1st generation to 4th generation, you get:
               increased gram-negative activity
               decreased gram-positive activity
               increased resistance to beta-lactamase destruction
               increased ability to enter cerebrospinal fluid




PG 56
Which of the following antimicrobial
agents has effective coverage of streptococcus
pneumoniae?
  I. amoxicillin
  II. doxycycline
  III. gentamicin


  a. I only
  b. III only
  c. I and II only
  d. II and III only
  e. I, II, and III
Which of the following antimicrobial
agents has effective coverage of streptococcus
pneumoniae?
  I. amoxicillin
  II. doxycycline
                           Gram +
  III. gentamicin
                           Non-DRSP

  a. I only
  b. III only
  c. I and II only
  d. II and III only
  e. I, II, and III
        General considerations (cont’d)
        First generation (generally start with CEPH):
               Good for surgical prophylaxis
        Second generation (generally start with CEF):
               Good for otitis, sinusitis and respiratory tract infections
        Third generation (generally end with IME or ONE):
            ●   Good for meningitis, CAP, gram-negative bacilli, gonorrhea,
                Proteus, Salmonella, Klebsiella
            ●   Cefixime (suprax), cefotaxime (claforan), ceftriaxone (rocephin)
        Fourth generation (cefepime) Maxipime:
            ●   Good antipseudomonal activity




PG 57
        Tetracyclines




PG 58
        General Considerations
        Products:

               Tetracycline HCI (Achromycin V, Sumycin, Robitet, Panmycin)
               Minocycline (Minocin)
               Doxycycline (Vibramycin, Doxy 100, Doxychel, Vibra-Tabs)


        These are bacteriostatic antimicrobials. They interfere with protein
        synthesis.
        Broad spectrum antimicrobials. Work against many gram-positive
        and gram-negative organisms.
                 - also effective against atypical organisms mycoplasma and
        chlamydia pneumoniae, useful for patients allergic to penicillin b/c gram +
        coverage



PG 58
        General Considerations
        Not for use in children under age 8. May cause discoloration of
        developing tooth enamel.

        Not for pregnant women. May adversely affect fetal
        development.

        Most have the potential for causing phototoxicity.

        Drug interaction with divalent (Mg, Ca, Fe) or trivalent (Al)
        compounds and tetracyclines may result in complexation and
        impaired absorption. Do not use together.

        Broad spectrum activity can lead to thrush or vaginal candidias




PG 58
    Macrolides
    General Considerations:
         Bacteriostatic – inhibit protein synthesis
         May be good for patients who are
          hypersensitive to beta-lactam
          antimicrobials.

         Good respiratory coverage.

             CAP caused by S.pneumo, M.cat, H.flu or atypicals
            (mycoplasma, legionella, and chlamydia)


PG 59
 Erythromycin
   Oral Products

   Erythromycin base (E-Mycin, Ery-Tab, PCE, Eryc)
      Coating used on most products
      Administer on an empty stomach

   Erythromycin stearate (Erythromycin Stearate,
   Wyamycin S)
      Better absorbed than erythromycin base




PG 59
   Erythromycin (cont’d)
    Erythromycin esolate (Ilosone)
    Associated with cholestatic hepatitis
     Better absorbed than erythromycin base


    Erythromycin ethylsuccinate (eryPed, E.E.S.)
        Most well absrobed
        Available in liquid form
        400 mg of EES = 250 mg of erythromycin base


    Parenteral Products
    Erythromycin lactobionate
    Erythromycin glucepate
    Drug Interactions: Mainly due to enzyme inhibition of erythromycin – (3A4)


PG 59
    Clarithromycin (Biaxin)


    Usually used BID. XL form used once daily.


    Prodrug: May be given with or without meals


    Used in combination with a proton pump inhibitor for H.
    pylori treatment.


    Metallic taste




PG 60
    Azithromycin (Zithromax)
    More gram-negative activity than erythromycin or
    clarithromycin
    Once-daily dosing, usually for five days after otitis media
    (e.g., Z-Pack)
    Available as suspension, tablets, IV
    Suspension should not be taken with food or antacids.


    Dirithromycin (Dynabac)
    Prodrug
    Once-daily dosing




PG 60
    Lincosamides
    General considerations
    Watch for pseudomembranous enterocolitis (Clostridium
    difficile).
           •Treat clostridium with metronidazole (Flagyl) or oral
           vancomycin.
    Good in gram positive (staph) and gram-negative infections,
    particularly anaerobes

        Lincomycin (Lincocin, Lincorex)
        Morbilliform rash possible; DC drug if it happens

        Clindamycin (Cleocin)
        Available in topical form for acne



PG 61
Which of the following antibiotics has
   bacteriostatic activity?
    a. amoxicillin
    b. ciprofloxacin
    c. erythromycin
    d. penicillin
    e. cephalexin
Which of the following antibiotics has
   bacteriostatic activity?
    a. amoxicillin (cell wall)
    b. ciprofloxacin (inhibits DNA gyrase)
    c. erythromycin (protein synthesis)
    d. penicillin (cell wall)
    e. cephalexin (cell wall)
    Aminoglycosides
    General Considerations
    Glycosides – poorly absorbed from the GI tract
    Bactericidal
    Good for serious gram-negative pathogens (pseudomonas,
    proteus, etc.)
    Frequently administered with extended-action penicillin (IV
    incompatible) - dosed q8h or q24h (conc. dependant kill)
    Eliminated by glomerular filtration; Watch for ototoxicity
    Monitor peaks and troughs – peaks 30 min after infusion, trough 30
    minutes before next dose. peak = 4-10ug/ml trough = 0.5-2, adjust
    dose if CrCl < 60ml/min. hearing test if prolonged therapy


PG 61
Which of the following antimicrobial
agents is available for parenteral use only?
  I. cefaclor
  II. tobramycin
  III. ticarcillin

  a. I only
  b. III only
  c. I and II only
  d. II and III only
  e. I, II, and III
Which of the following antimicrobial
agents is available for parenteral use only?
  I. cefaclor
  II. tobramycin
  III. ticarcillin

  a. I only
  b. III only
  c. I and II only
  d. II and III only
  e. I, II, and III
    Parenteral use

                                      Reference Peak Range

    Streptomycin sulfate
    Kanamycin sulfate (Kantrex)
    Gentamicin sulfate (Garamycin      (4mcg-10mcg/ml)

    Tobramycin sulfate (Nebcin)        (4mcg-10mcg/ml)

    Amikacin sulfate (Amikin)          (15mcg-25mcg/ml)

    Netilmicin sulfate (Netromycin)




PG 61
Which of the following antibiotics
requires monitoring of serum levels?

 a. penicillin
 b. ceftazidime
 c. azithromycin
 d. gentamicin
 e. cephalexin
Which of the following antibiotics
requires monitoring of serum levels?

 a. penicillin
 b. ceftazidime
 c. azithromycin
 d. gentamicin
 e. cephalexin
    Oral use
    Not for systemic action


    Neomycin sulfate (Mycifradin) - Used for bowel prep prior to
    surgery , treat diarrhea caused by e.coli, neomycin also binds
    ammonia, use in patients w/hepatic encephalopathy, watch for
    absorption interactions


    Tobramycin (TOBI) – inhaled product for CF patients




PG 62
    Fluoroquinolones
    General Considerations - Inhibits DNA-Gyrase
    May cause phototoxicity
    Not for patients under 18 – affects growth
    Do not use within 2-4 hours of antacids; iron – also inhibits
    CYP1A2 (increased levels of theophylline and caffeine)
    Generally useful for UTI, lower respiratory infections,
    gonorrhea, prostatitis – older agents have more gram -,
    less gram + coverage, newer agents have broader gram +
    [moxifloxacin, gatifloxacin]
    All end in -oxacin


PG 62
    Names
    Second generation
        Norfloxacin (Noroxin) – high urine levels - UTIs
        Ciprofloxacin (Cipro)- renal elimination: reduce dose
        Ofloxacin (Floxin)

    Third generation
        Levofloxacin (Levaquin) – renal elimination: reduce dose
        Sparfloxacin (Zagam) – reports of prolongation of QT interval (D/C)
        Gemifloxacin (Factive) – renal elimination: reduce dose, skin rash

    Fourth generation
        Moxifloxacin (Avelox) – Multi-drug resistant Streptococcus pneumonia
        (MDRSP)


PG 62
     MISCELLANEOUS ANTIMICROBIAL AGENTS
     Antibacterials


     Mupirocin (Bactroban) – topical use for impetigo, intranasal for staph


     Vancomycin (Vancocin) – associated with red man syndrome (must be
     infused slowly, over min of 30 minutes); reserved for serious/resistant
     gram + infections (MRSA, enterococcus)
             – rapid drop in BP accompanied by rash in neck or chest area
             - Monitoring – 1 hour before and 1 hour after
             - Peak – 25-40mcg/dl & Trough 5-12mcg/dl


     Metronidazole (Flagyl) – active against gram-negative organisms and
     protozoa, (anaerobes) Avoid alcohol. May darken urine.
PG 63
    MISCELLANEOUS ANTIMICROBIAL AGENTS (cont’d)
    Carbapenems
        •broad spectrum; used for resistant gram +/– organisms, pseudomonas,
        MRSA, enterococcus, anaerobes
        •similar to penicillins (cross-sensitivity) but b-lactamase resistant
        •Risk of seizures and renal adjustment

    Imipenem/cilastatin (Primaxin) – cilastatin is a renal dipeptidase
    inhibitor
    Meropenem (Merrem)---lacks good pseudomonas coverage
    Doripenem (Doribax)
    Ertapenem (Invanz)
    ----Aztreonam (Azactam)---monobactam, ok with PCN allergy



PG 63
Which of the following antibiotic is
classified as a macrolide?

 a. telithromycin
 b. tobramycin
 c. azithromycin
 d. doxycycline
 e. kanamycin
Which of the following antibiotic is
classified as a macrolide?

 a. telithromycin
 b. tobramycin
 c. azithromycin
 d. doxycycline
 e. kanamycin
     MISCELLANEOUS ANTIMICROBIAL AGENTS (cont’d)


     VRE and MRSA drugs
     Quinupristin / dalfopristin (Synercid) –
     Linezolid (Zyvox) –……oral dosing available
     Tigecycline (Tygacil) –




     Chloramphenicol (Chloromycetin) – for typhoid fever; may cause
     aplastic anemia and gray baby syndrome




PG 63-64
                 Pneumonia
   Organisms:




   Treatment:
                             --Comorbidities:
                             Chronic obstructive
                             pulmonary disease
                             (COPD), diabetes,
                             chronic renal failure,
                             chronic liver failure,
                             heart failure (HF),
                             cancer, asplenia,
                             immunosuppressed
                 Pneumonia
   Treatment:




                             --Risk factors for
                             MDR organisms:
                             recent antibiotic
                             therapy (in last 90
                             days), hospitalized ≥
                             5 days,  resistance
                             in environment,
                             nursing home
                             resident, chronic
                             dialysis, home
                             infusion therapy,
                             immunosuppressed
                 Meningitis
   Organisms:




   Treatment:
        Urinary Tract Infection
   Organisms:




   Treatment:
                 STDs
   Organisms:




   Treatment:
        Antitubercular Drugs


        R   rifampin
        I   isoniazid
        P   pyrazinamide
        E   ethambutol
        S   streptomycin


PG 64
   Antitubercular Drugs
   Isoniazid (Nydrazid, Laniazid)
        May cause B6 deficiency – supplement malnourished, alcoholics, kids
        Used for prophylaxis or in combo with other drugs for active disease
             6 months of prophylaxis if +PPD; For treatment used in combo with
               rifampin for at least 6 months
        Metabolized by acetylation (slow versus rapid acetylators)
             monitor for hepatoxicity
   Rifampin (Rifadin, Rimactane)
        Potent enzyme inducer (potential drug interactions with many drugs)
        Potentially hepatotoxic;
        Use may result in discoloration of virtually all body fluids (urine and
        tears----watch contact lenses)



PG 64
  Antitubercular Drugs (cont.)

  Ethambutol (Myambutal) – for treatment of MAC and drug-resistant Tb
  as part of combination therapy
         - optic neuritis is a rare but serious side effect
         - monitor with eye exams
  Pyrazinamide – used in combination therapy; potentially hepatotoxic

         - may increase uric acid levels
  Steptomycin- can be used as fourth drug in regimen instead of
  pyrazinamide




PG 65
   Antimalarials
   Quinine sulfate (Quinamm) – also used for muscle cramps;
   no longer used due to hematologic adverse effects


   Doxycycline – tetracycline; possible phototoxicity and
   binding interactions


   Melfoquine HCl (Lariam) – may cause neuropsychiatric
   adverse effects; once- weekly dosing


   Atovaquone/proguanil (Malarone) – newer product; once
   daily; do not use if renally impaired
PG 65
   Antimalarials
   Chloroquine (Aralen) – may worsen psoriasis symptoms


   Hydroxychloroquine sulfate (Plaquenil Sulfate) – may
   worsen psoriasis symptoms
         - also used as a DMARD for RA; phototoxicity,
          hematological side effects, ocular and ototoxicity
   Primaquine phosphate – take with food to reduce GI upset;
   may be used for PCP




PG 66
          HIV Antiretroviral Therapy
       Therapy initiated based on CD4 count,
        viral load and presence of symptoms
          Initial regimen in treatment naive patients:
           • NNRTI + 2 NRTIs
           • PI + 2 NRTIs


       Learn drug class representatives and
        major toxicities


PG 69
    Which HIV drug is correctly matched
      with its mechanism of action?

a. Lamivudine - nucleoside reverse
  transcriptase inhibitor
b. Enfuvirtide - protease inhibitor
c. Stavudine - binds to human CCR5
  receptor
d. Didanosine – protease inhibitor
e. Indinavir – blocks virus entry into human
  cells and subsequent viral replication
    Which HIV drug is correctly matched
      with its mechanism of action?

a. Lamivudine - nucleoside reverse
  transcriptase inhibitor
b. Enfuvirtide - protease inhibitor
c. Stavudine - binds to human CCR5
  receptor
d. Didanosine – protease inhibitor
e. Indinavir – blocks virus entry into human
  cells and subsequent viral replication
               NNRTIs
non-nucleoside reverse transcriptase
   inhibitors (vir in the middle)

   Delavirdine (rescriptor) (rash, LFTs)
   Efavirenz (Sustiva)
     Drug of choice

     Category X, vivid dreams

   Nevirapine (Viramune)
     Rash (Steven Johnson Syndrom)

     Liver metabolism
                 PIs
  Protease inhibitors (vir at the end)
   Exception – darunavir, tenofovir, raltegravir, abacavir

   Metabolized through the liver (commonly 3A4)
        • potential for significant drug interactions
   Low dose of ritonavir frequently used to enhance
   the concentrations of coadministered PIs
   Adverse effects: GI intolerance, hyperglycemia,
   dyslipidemia, lipodystrophy, LFT alterations


PG 72
                      NRTIs
        nucleoside reverse transcriptase
           inhibitors (all the others)
  Exception – maraviroc

  All NRTIs (except abacavir) are excreted renally; require
  dose adjustment but few drug interactions


  Most common ADRs – GI intolerance, typically subsides in
  first couple of weeks
          - High risk for perpheral neuropathy


  Black Box warning: Risk of lactic acidosis with hepatic
  steatosis
PG 69
        AIDS – Opportunistic Infections
       PCP / PJP (pneumocystis carninii pneumonia)
           trimethoprim-sulfamethoxazole
       CMV retinitis
           Ganciclovir
       MAC / MAI (mycobacterium avium complex)
           Macrolide + ethambutol
       Cryptococcus neuformans meningitis
           Amphotericin B +/- flucytosine
           Fluconazole used for maintenance


PG 74
   Drugs for influenza


   M2 inhibitors
           Amantadine, rimantidine
           Effective for influenza A virus only
           Begin within 48h of symptom onset; continue 2-5 days


   Neuroaminidase inhibitors
           Oseltamivir (Tamiflu)
           Zanamivir (Relenza)
           Effective for influenza A and B viruses
           Begin with 48h of symptoms onset; continue 5 days


PG 74
   Drugs for herpes simplex and herpes zoster (shingles)
   Acyclovir (Zovirax) – for herpes simplex types 1 and 2
   - dosed 5x/day for 10 days, 5 days if recurrence
   Penciclovir (Denavir) – topical treatment for herpes labialis
   (cold sores)
   Valacyclovir HCl (Valtrex) – for herpes simplex and herpes
   zoster; acyclovir prodrug
   Famcyclovir (Famvir) for herpes simplex and herpes zoster
   (shingles); penciclovir prodrug
   - begin therapy as soon as first sign of lesion
   Docosanol (OTC-Abreva) topical cream

PG 75
   Anthelmintic drugs of choice
   Nematodes (roundworm)
        Mebendazole (Vermox)—do not use in pregnancy – blocks glucose uptake
        Albendazole (Albenza) – degeneration of cytoplasmic microtubules intestinal cells
        of helminths

        Piperazine citrate Preg B – blocks affect of ACH
        Pyrantel pamoate (Antiminth)


   Trichuriasis (whipworm)
        Mebendazole (do not use in pregnancy)


   Hookworm – mebendazole (do not use in pregnancy)



PG 75
Which of the following medication(s) can cause
  nephrotoxicity?

I.     Ganciclovir
II.    Foscarnet
III.   Gentamicin

           a. I only
           b. III only
           c. I and II only
           d. II and III only
           e. I, II, and III
Which of the following medication(s) can cause
  nephrotoxicity?

I.     Ganciclovir
II.    Foscarnet
III.   Gentamicin

           a. I only
           b. III only
           c. I and II only
           d. II and III only
           e. I, II, and III
Which of the following agents inhibits the
   HIV enzyme reverse transcriptase?
     I. zanamivir
     II. ritonivir
     III. didanosine

     a. I only
     b. III only
     c. I and II only
     d. II and III only
     e. I, II, and III
Which of the following agents inhibits the
   HIV enzyme reverse transcriptase?
     I. zanamivir (Neuroaminidase inhibitors)
     II. ritonivir (protease inhibitor)
     III. didanosine (nucleoside reverse transcriptase inhibitors)

     a. I only
     b. III only
     c. I and II only
     d. II and III only
     e. I, II, and III
         DERMATOLOGIC STUDY OUTLINE
         Acne
         Pathophysiology— abnormal keratinization
         leads to obstruction of the follicle and
         accumulation of sebum to form a closed
         comedo or ―white-head‖


         Goal of therapy is to unblock follicles



PG 146
Normal Pore   Inflamed Pore
   Dermatologic Study Outline




PG 146
   Dermatologic Study Outline
         Isotretinoin (Accutane)
          Effective therapy option for the treatment of severe,
         inflammatory acne, or more moderate forms that have been
         refractory to other treatment options
          pregnancy category X
          two forms of contrception, iPLEDGE program


         Oral Antimicrobials
            • Tetracycline
            • Erythromycin
            • Clindamycin


PG 146
   Psoriasis
         Pathophysiology — exact mechanism unknown. May be due to
         defects in epidermal cell cycle, AA metabolism, immunologic
         mechanisms, environmental triggers
         Treatment modalities
            • Emollients (e.g., petrolatum)
            • Ultraviolet light
            • Coal tars (typically compounded)
            • Topical corticosteroids
            • Systemic corticosteroids (pulse dosing)
            • Antineoplastic agents (methotrexate, hydroxyurea)
            • Psoralens (pulse dosing)
            • Immunosuppressant agents (Etanercept, Efalizumab)
            • Retinoids (pulse dosing)
PG 146
  Which of the following psoriasis
medications is not pregnancy category
                  X?
I. Dovonex
II. Methotrexate
III. Soriatane

  A.   I only
  B.   III only
  C.   I and II only
  D.   II and III only
  E.   I, II and III
  Which of the following psoriasis
medications is not pregnancy category
                  X?
I. Dovonex
II. Methotrexate
III. Soriatane

  A.   I only
  B.   III only
  C.   I and II only
  D.   II and III only
  E.   I, II and III
 A patient presents to the pharmacy
with obvious mild acne, which of the
 following cannot be recommended
       without a prescription?

 a. Benzoyl peroxide 2.5% cream
 b. Sulfur soap
 c. Benzamycin gel
 d. Salicylic acid wash
 e. Benzoyl peroxide 10% lotion
 A patient presents to the pharmacy
with obvious mild acne, which of the
 following cannot be recommended
       without a prescription?

 a. Benzoyl peroxide 2.5% cream
 b. Sulfur soap
 c. Benzamycin gel
 d. Salicylic acid wash
 e. Benzoyl peroxide 10% lotion
                   Fungal Infections

       Tinea corporis – body surface
       Tinea capitis – scalp
       Tinea cruris – groin (―jock itch‖)
       Tinea pedis – feet (―athlete’s foot‖)
       Onychomycosis – nails




PG 67-68 and 147
   Therapy
         Prophylaxis. Keep skin dry; frequent changes and thorough cleaning of
         clothing; and avoid likely areas of contamination.
         Active:
         Dusting powders (medicated versus nonmedicated), wet compresses
         Topical drug therapy
             • Fatty acids (undecylenic acid)      • Tolnaftate (Tinactin, Aftate)
             • Haloprogin (Halotex)                • Miconazole (Micatin,Monistat)
             • Clotrimazole (Lotrimin)             • Oxiconazole (Oxistat)
             • Sulconazole (Exelderm)              • Butenafine (Mentax)
             Nystatin (Mycostatin, Nilstat) – good for superficial candida (thrush)


         Systemic drug therapy for topical fungal disorders
             • Griseofulvin (microsized versus ultramicrosized)
             • Terbinafine (Lamisil)
             • Avoid corticosteroids

PG 147
        Antifungal Drugs (cont’d)
        Miconazole (Monistat, Micatin) – broad-spectrum antifungal
        agent available as powder, aerosol, cream, and
        suppository; may be used topically or vaginally
        Clotrimazole (Lotrimin, Mycelex) – broad-spectrum
        antifungal available as cream, lotion, suppositories, and
        troches (OTC use for 2 weeks after infection clears)
        Ketoconazole (Nizoral) – for superficial and systemic fungal
        infections; also available as OTC shampoo for dandruff;
        enzyme inhibitor
        Itraconazole (Sporanox) – for oral or topical treatment of
        superficial or systemic fungal disorders; enzyme inhibitor.
              - hepatotoxicity; take w/ food and avoid antacids
PG 67
    Antifungal Drugs (cont’d)

       Terbinafine (Lamisil) – used orally for
        onychomycosis of fingernail or toenail. Used
        topically for superficial tinea infections (OTC
        use for 1 week). Monitor for hepatoxicity with
        oral use.

       Ciclopriox (Penlac) – applied topically once
        daily for treatment of onychomycosis. –
        requires long-term therapy


PG 67
    Antifungal Drugs (cont’d)

       Griseofulvin (Grisactin, Grifulvin V, Fulvicin)
         For tinea only

         Duration of therapy
             • depends on type: corporis: 2-4 wks.; capitis: 4-6 wks.,
               pedis: 4-8 wk
           Regular versus microsized versus
            ultramicrosized
             • ultra is better absorbed; take w/ fatty meal
             • causes induction interactions




PG 67
          Antifungal Drugs (cont’d)
       Other Azoles
         Posaconazole (Noxafil)

         Voriconazole (Vfend)
            • Reserved for severe invasive fungal infections (asperigillosis)
       Echinocandins (less DI, but monitor LFTs)
          Anidulafungin (Eraxis)

          Caspofungin (Cancidas)

          Micafungin (Mycamine)

       Ampho B and related Lipid products
          nephrotoxicity




PG 68
NAPLEX

Sample Questions
Which of the following antibiotics does
not have a significant drug interaction
            with warfarin?

  A.   ciprofloxacin
  B.   azithromycin
  C.   TMP-SMZ
  D.   Metronidazole
  E.   Nafcillin
Which of the following antibiotics does
not have a significant drug interaction
            with warfarin?

  A.   ciprofloxacin
  B.   azithromycin
  C.   TMP-SMZ
  D.   Metronidazole
  E.   Nafcillin
Which of the following medications is
   the best treatment option for an
uncomplicated urinary tract infection?
 A.   penicillin
 B.   cefuroxime
 C.   levofloxacin
 D.   gentamicin
 E.   clarithromycin
Which of the following medications is
   the best treatment option for an
uncomplicated urinary tract infection?
 A.   penicillin
 B.   cefuroxime
 C.   levofloxacin
 D.   gentamicin
 E.   clarithromycin
       Which of the following antimicrobial
       agents is available for parenteral use
                       only?
I.         piperacillin
II.        aztreonam
III.       rifampin
        A.     I only
        B.     III only
        C.     I and II only
        D.     II and III only
        E.     I, II and III
       Which of the following antimicrobial
       agents is available for parenteral use
                       only?
I.         piperacillin
II.        aztreonam
III.       rifampin
        A.     I only
        B.     III only
        C.     I and II only
        D.     II and III only
        E.     I, II and III
Which of the following agents is a
      non-nucleoside reverse
      transcriptase inhibitor?

  A.   didanosine
  B.   delavirdine
  C.   stavudine
  D.   zidovudine
  E.   lamivudine
Which of the following agents is a
      non-nucleoside reverse
      transcriptase inhibitor?

  A.   didanosine
  B.   delavirdine
  C.   stavudine
  D.   zidovudine
  E.   lamivudine
Which of the following agents may be
 utilized in combination with other
medications for H. pylori eradication?


 A.   tetracycline
 B.   azithromycin
 C.   penicillin
 D.   fluconazole
 E.   cefuroxime
Which of the following agents may be
 utilized in combination with other
medications for H. pylori eradication?


 A.   tetracycline
 B.   azithromycin
 C.   penicillin
 D.   fluconazole
 E.   cefuroxime
 Peripheral neuropathy is associated
with which one of the following agents:


  A.   nevirapine
  B.   delavirdine
  C.   Saquinavir
  D.   Stavudine
  E.   tenofovir
 Peripheral neuropathy is associated
with which one of the following agents:


  A.   Nevirapine (NNRTI)
  B.   Delavirdine (NNRTI)
  C.   Saquinavir (PI)
  D.   Stavudine (NRTI) do not use with AZT (zidovudine)
  E.   Tenofovir (NRTI)
Administration of calcium or iron must
  be separated by at least 2 hours if
   antibiotics in this category are
             prescribed:

   I.        Macrolides
   II.       Tetracyclines
   III.      Fluroquinolones
          A.    I only
          B.    III only
          C.    I and II only
          D.    II and III only
          E.    I, II and III
Administration of calcium or iron must
  be separated by at least 2 hours if
   antibiotics in this category are
             prescribed:

   I.        Macrolides
   II.       Tetracyclines
   III.      Fluroquinolones
          A.    I only
          B.    III only
          C.    I and II only
          D.    II and III only
          E.    I, II and III
Which of the following antimicrobial
  agents has effective coverage for
           M. pneumoniae?
A.   amoxicillin
B.   erythromycin
C.   metronidazole
D.   cefotriaxone
E.   clindamycin
Which of the following antimicrobial
  agents has effective coverage for
           M. pneumoniae?
A.   amoxicillin
B.   erythromycin
C.   metronidazole
D.   cefotriaxone
E.   clindamycin
Which of the following regimens is
 most appropriate for C. difficile
           eradication?

A.   Clarithromycin 500 mg PO q 12 hours
B.   Clindamycin 300 mg IV q 6 hours
C.   Vancomycin 125 mg PO q 6 hours
D.   Doxycycline 100 mg PO q 12 hours
E.   Vancomycin 1000 mg IV q 12 hours
Which of the following regimens is
 most appropriate for C. difficile
           eradication?

A.   Clarithromycin 500 mg PO q 12 hours
B.   Clindamycin 300 mg IV q 6 hours
C.   Vancomycin 125 mg PO q 6 hours
D.   Doxycycline 100 mg PO q 12 hours
E.   Vancomycin 1000 mg IV q 12 hours
       Which agent is available in both a
        topical and an oral product for the
                treatment of acne?
I.        clindamycin
II.       erythromycin
III.      doxycycline
       A.     I only
       B.     III only
       C.     I and II only
       D.     II and III only
       E.     I, II and III
       Which agent is available in both a
        topical and an oral product for the
                treatment of acne?
I.        clindamycin
II.       erythromycin
III.      doxycycline
       A.     I only
       B.     III only
       C.     I and II only
       D.     II and III only
       E.     I, II and III
     Which of the following drugs
represents first (primary) agents in the
          treatment of TB?

  A.   Ethambutol + PASA
  B.   Ciprofloxacin + PASA
  C.   Isoniazid + rifampin
  D.   Cycloserine + streptomycin
  E.   Penicillin + Benemid
     Which of the following drugs
represents first (primary) agents in the
          treatment of TB?

  A.   Ethambutol + PASA
  B.   Ciprofloxacin + PASA
  C.   Isoniazid + rifampin
  D.   Cycloserine + streptomycin
  E.   Penicillin + Benemid
Which of the following antibiotics is
considered first line treatment for a
      gonorrhea infection?

A.   Ampicillin
B.   Ciprofloxacin
C.   Doxycycline
D.   Penicillin
E.   Tetracycline
Which of the following antibiotics is
considered first line treatment for a
      gonorrhea infection?

A.   Ampicillin
B.   Ciprofloxacin (also..ceftriaxone, cefixime)
C.   Doxycycline (chlamydia)
D.   Penicillin
E.   Tetracycline
        Which of the following groups of
         antibiotics may be prescribed for a
           gravid patient with gonorrhea?
I.        cephalosporins
II.       fluoroquinolones
III.      tetracyclines
       A.     I only
       B.     III only
       C.     I and II only
       D.     II and III only
       E.     I, II and III
        Which of the following groups of
         antibiotics may be prescribed for a
           gravid patient with gonorrhea?
I.        cephalosporins
II.       fluoroquinolones
III.      tetracyclines
       A.     I only
       B.     III only
       C.     I and II only
       D.     II and III only
       E.     I, II and III
A gravid patient with a Chlamydia
infection is likely to be prescribed
which of the following antibiotics?

A.   Ampicillin
B.   Levofloxacin
C.   Doxycycline
D.   Erythromycin
E.   Penicillin
A gravid patient with a Chlamydia
infection is likely to be prescribed
which of the following antibiotics?

A.   Ampicillin
B.   Levofloxacin
C.   Doxycycline
D.   Erythromycin
E.   Penicillin
Which of the following is the BEST
treatment for a patient with herpes
              zoster?
  A.   Cidofovir
  B.   Famciclovir
  C.   Ganciclovir
  D.   Penciclovir
  E.   Tenofovir
Which of the following is the BEST
treatment for a patient with herpes
              zoster?
  A.   Cidofovir
  B.   Famciclovir
  C.   Ganciclovir
  D.   Penciclovir
  E.   Tenofovir
 Which of the following medications
would be appropriate for the treatment
   of Pseudomonas aeruginosa?
a.   Ampicillin
b.   Cefepime
c.   Ceftriaxone
d.   Erythromycin
e.   Clindamycin
 Which of the following medications
would be appropriate for the treatment
   of Pseudomonas aeruginosa?
a.   Ampicillin
b.   Cefepime
c.   Ceftriaxone
d.   Erythromycin
e.   Clindamycin

				
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