NAPLEX Study Guide

Beta-1 receptor MOA

Bind mainly on heart, causing increasing heart rate and contractility

Selective beta-1 agonist

Dobutamine, Isoproterenol, Dopamine

Selective beta-1 antagonist

Metoprolol, Atenolol, Bisoprolol, Esomolol

Beta-2 receptor MOA

Bind mainly on lung, causing bronchodilation & bronchial muscle relaxation

Selective beta-2 agonist

SABA: Albuterol, Levalbuterol, Terbutaline

LABA: Salmeterol, Formoterol, Indacterol

Non-selective beta antagonist

Propranolol, Nadolol, Timolol

Alpha -2 MOA

Mainly on brain. Agonist cause decrease in Epi & NE and decrease in HR & BP)

Selective alpha-2 agonist

Clonidine, Guanfacine, Dexmedetomidine, Brimonidine (for glaucoma)

Alpha-1 MOA

Mainly on peripheral smooth muscle & vasoconstriction. Agonist cause increase in BP. Antagonist cause decrease in BP

Selective alpha-1 agonist

Phenylephrine, Midodrine (for low BP), Oxymetazolin (for congestion)

Non-selective alpha & beta agonist

Epinephrine

• NE is more alpha in MOA (more peripheral BP impact for shock)

Non-selective alpha & beta antagonist

Carvedilol, Labetalol

Dopamine agonist

Levodopa, Pramipexole (for depression, parkinson, RLS)

Dopamine antagonist

First-gen antipsychotics

• Haloperidol, Fluphenazine, Chlorpromazine, Perphenazine

Partial dopamine agonist

Aripiprazole, Brexpiprazole, Cariprazine

Serotonin agonist

Triptans

• Sumatriptan

Buspirone, Lorcaserin (for weight loss)

Serotonin antagonist

Ondansetron, Palonosetron

Second-gen antipsychotics

• Aripiprazole, Olanzapine, Risperidone, Quetiapine, Ziprasidone, Lurasidone, Paliperidone

MAO inhibitor

Phenelzine, Isocarboxazid, Tranycypromine, Selegiline, Rasagiline

• Blocking MAO will increase catecholamine level—> excessive catecholamine level can cause hypertension crisis or serotonin syndrome

MAO additive effect

MAO inhibitor MOA:

• Hypertension crisis: inhibit MAO enzyme which blocks the breakdown of neurotransmitters that cause increase in Epi & NE & dopamine

  • Symptoms: HTN, tachycardia, agitation, death

  • DDI: bupropion, SNRI, TCA, stimulants, levodopa, linezolid, methylene blue, tyramine (from food)

• Serotonin syndrome: inhibit MAO enzyme which blocks the breakdown of 5-HT, causing 5-HT increase in serum

  • Symptoms: tremor, akathisia, clonus, hyperthermia, sweating

  • DDI: SSRI, SNRI, TCA, mirtazapine, trazodone, triptans, opioids, tramadol, buspirone, lithium, dextromethorphan, St. John’s wart

Benzodiazepine additive effects

Agonist to different receptors: BZD bind and enhance the effect of GABA (inhibitory neurotransmitter), causing relaxing, hypnotic and anticonvulsant effect on muscle

• Side effect associated: respiratory suppression (especially with the co-use of opioids)— BBW

Chelation effect

Definition: chelation happen when a drug bind to polyvalent cations (Mg2+, Ca2+, Fe2+), resulting in an indissoluble complex in the gut fluid. The medication efficacy will significantly decrease

• Quinolone antibiotics & Ca2+

• Azithromycin & Mg+ & Al3+

• Levothyroxine & antacids, multivitamine, sucralfate, Mg2+, Al3+, zinc

  • Itraconazole & PPI

CYP450 metabolism used by manufacture

• Increase bioavailability

  • Valacyclovir metabolize to acyclovir by CYP450

• Percent drug abuse

  • Lisdexamfetamine is lysine + amphetamine to prevent crushing or snorting of the drug

Common CYP inhibitors

G ♥ PACMAN

G: grapefuit

P: protease inhibitor (PIs)

• especially ritonavir

A: azoles

C: cyclosporine, cobicistat

M: macrolides

A: amiodarone & dronedarone

N: non-DHP CCBs

• diltiazem, verapamil

Common CYP inducers

PS PORCS

P: phenytoin (anti-seizure class), phenobarbital

S: smoking

O: oxcarbazepine

R: rifampin, rifabutin, rifapentine

C: carbamazepine

S: St. John’s wort

Pgp efflux pumps

MOA: located in GI

• With Pgp blocker, dry will have increased absorption, resulting in increased serum drug cons

• At the mean time, OATP1B1/3 pumps drug from blood to the liver

Pgp inducers

Carbamazepine

Dexamethasone

Phenobarbital

Phenytoin

Rifampin

St.John’s wort

Tipranavir

Pgp inhibitors

Anti-infection (clarithromycin, itraconazole, posaconazole)

Cardiovascular drug (amiodarone, carvedilol, conivaptan, diltiazem, dronedarone)

HIV drug (ledipasvir)

HIV drug (cobicistat, ritonavir)

Other (cyclosporine, fibanserin, ticagrelor)

Common DDI

Amiodarone + Warfarin

• Amiodarone is CYP2C9 inhibitor

• Start warfarin at lower dose <5 mg or decrease warfarin dose by 30-50%

Amiodarone + Digoxin

• Amiodarone is Pgp inhibitor and digoxin is Pgp substrate

  • Effect: decrease digoxin excretion, increase risk of bradycardia

• Start oral digoxin dose at 0.125 mg QD or decrease digoxin dose by 50%

Digoxin + Loop diuretics

• Loop will decrease conc of K, Mg, Ca, Na, and decrease in these electrolytes will increase digoxin toxicity (arrhythmia, nausea, vomiting, vision changes, bradycardia)

Statin + strong CYP3A4 inhibitors

Valproate + Lamotrigine

• Valproate will decrease lamotrigine metabolism, causing SE like SJS/TEN

• Start lamotrigine with starter kit and titrate Q2wks

Smoking + Antipsychotics, Hypnotics, Antidepressants, Warfarin, Anxiolytics, Caffeine

• CYP1A2 inducer

QTC prolonging drug

Antiarrhythmics

Anti-infections

• Antimalarials: hydroxychloroquine

• Azoles (except isavuconazonium)

• Lefamulin

• Macrolides

• Quinolones

Antidepressants (highest risk with citalopram & escitalopram)

Antipsychotics

• First gen: haloperidol, thioridone, etc

• Second gen (highest risk with ziprasidone)

Antiemetics: ondansetron

Oncology medication

• Androgen deprivation therapy: leuprolide

• Tyrosine kinase inhibitors: nilotinib

• Arsenic trioxide

Other: Donepazil, Hydroxyzine, Loperamide, Ranolazine, Methadone, Cilostazol, Fingolimod, Solifenacin

Ototoxicity causing drug

Aminoglycosides

• Gentamicin, Tobramycin, Almikacin

Cisplatin

Loop diuretics (especially in rapid IV)

• FUrosemide, Bumetanide, Ethacrynic acid

Salicylates

• ASA, Salsalate, Mg salicylate

Vancomycin

Nephrotoxic drug

Anti-infections

• Aminoglycosides, Amphotericin B, Polymyxins, Vancomycin

Cisplatin

Calcineurin inhibitors

• Cyclosporine, Tacrolimus

Loop diuretics

• Furosemide, Torsemide, bumetanide, ethacrynic acid

NSAIDs

Radioactive dye

Anticholinergic drug

Antidepressant/ Antipsychotics

• Paroxetine, TCAs, First-gen antipsychotics

Sedating antihistamine

• Diphenhydramine, Brompheniramine, Chlorpheniramine, Doxylamine, Hydroxyzine, Meclizine, Cyproheptadine

Centrally-acting anticholinergics

• Benztropine, Trihexyphenidyl

Muscle relaxant

• Baclofen, Carisoprodol, Cyclobenzaprine

Antimuscarinics (for urinary incontinence)

• Oxybutynin, Darfenacin, Tolterodine

Other

• Atropine, Belladonna, Dicyclomine

Drugs that affect potassium lvl

Increase lvl due to:

• ACE/ ARB-i, Spirololactone, Canagliflozin, Cyclosporine, Tacrolimus, Bactrim, Drospirenone, Aliskiren, Potassium supplement

Decrease lvl due to:

• Beta-2 agonist, Diuretics, Insulin, Sodium polystyrene sulfonate

Drugs that affect folic acid lvl

Decreased lvl due to:

• Phenytoin, Fosphenytoin, Phenobarbital, Primidone, MTX

Drugs that affect G6PD

Dapsone, Methylene blue, Nitrofurantoin, Pegloticase, Primaquine, Rasburicase, Quinidine, Quinine, Sulfonamide

Common vesicant

Vasopressors (e.g., dopamine, norepinephrine, vasopressin, phenylephrine, etc)

Anthracycline (e.g., doxorubicin)

Vinca alkaloids (e.g., vincristine)

Digoxin

Foscarnet

Mannitol

Mitomycin

Nafcillin

PromethazineCVP

PVC compatibility

Drug that requires NON-PVC containers: LATTIN (leach absorbs to take in nutrients)

• Lorazepam

• Amiodarone

• Tacrolimus

• Taxanes

• Insulin

• Nitroglycerin

Dextrose compatibility

Drugs that can only be mixed in dextrose: Only Sugar Always

• Oxaliplatin

• Sulfamethoxazole/ trimethoprim

• Amphotericin B

Saline Compatibility

Drugs thats can only be mixed in saline: A DIAbetic Cant Eat Pie

• Ampicillin

• Daptomycin

• Infliximab

• Ampicillin/ sulbactam

• Caspofungin

  • Ertapenem

• Phenytoin

Fatal precipitation

Calcium + Ceftriaxone

Calcium + Phosphate

* Warning: LR contains calcium

Common filter needle size

Most common filer needle size: 0.22 micron filter

Parental nutrition often use 1.2 micron filter needles for lipids and calcium-phosphate particulate

Drugs that can't be refrigerated

Trick: Dear Sweet Pharmacist, Freezing Makes Me Edgy

• Dexmedetomidine (Percedex)

• Sulfamethoxazole/ trimethoprim

• Phenytoin- crystalize*

• Furosemide- crystalize*

• Metronidazole

• Moxifloxacin

• Enoxaparin

• Acetaminophen

• Acyclovir- crystalize*

• Deferoxamine- crystalize*

• Pentamidine- crystalize*

• Levetiracetam

• Valproate

Drugs that should be protected from the light

Trick: Protect Every Necessary Med from Daylight

• Phytonadine (vitamine K)

• Epoprostenol

• Nitroprusside

• Micafungin

• Doxycycline

Discoloration caused by drugs

Red

• Anthracyclines

• Rifampin- urine, saliva, sweat, tears

Blue

• Mitoxantrone

Yellow

• MTX

• Multivitamin Infusion

Yellow/ Orange

• Tigecycline- teeth

Brown

• IV iron- urine

Component of social determinants of health

• Education access and quality

• Health care access and quality

• Economic stability

• Social and community context

• Neighborhood and built environment

CrCl contradiction in CKD

CrCl <60

nitrofurantoin

CrCl contradiction in CKD

CrCl <50

TDF (Complera, Delstrigo, Stribild)

Voriconazole IV

CrCl contradiction in CKD

CrCl <30

TAF (Biktarvy, Descovy, Genvoya, Odefsey, Symtuza)

NSAIDs

Dabigatran

Potassium-sparing diuretics

eGFR contradiction in CKD

eGFR <30

Metformin

Phosphate binders

Aluminum hydroxide (Al³⁺ based)

• SE: aluminum toxicity (CNS effect), osteomalacia, constipation

• Max duration 4 wks

Calcium acetate (Ca²⁺ based)

• SE: hypercalcemia, constipation

Sucroferric oxyhydroxide, ferric citrate (metal based)

• SE: iron toxicity, discolored feces, constipation (ferric citrate)

Lanthanum carbonate (metal based)

• Warning & contradiction: GI perforation, GI obstruction, fecal impaction, ileus

• SE: nausea, diarrhea, constipation

• Chew tablet thoroughly to avoid GI effect

Sevelamer (non-calcium, non-metal based)

• Warning

  • Reduce absorption of vitamin D, E, K, and folic acid

  • Tablet form cause dysphagia (caution of pt who has trouble swallowing)

• Contradiction: bowel obstruction

• SE: n/v, diarrhea, metabolic acidosis (sevelamer hydrochloride)

• Lower cholesterol & LDL

Phosphate binders DDI

Polyvalent ion (Al³⁺, Fe³⁺, Ca²⁺)

Levothyroxine

Quinolone

Tetracyclines

Vitamin D analogs & calcimimetics

Calcitriol, calcifediol, doxercalciferol, paricalcitol (vitamin D analog)

• Warning & contradiction: hypercalcemia, vitamin D toxicity

• SE: hyperphosphatemia, n/v/d

• Take with food to decrease GI upset

Cinacalcet, etecalcetide (Calcimimetics)

• Warning: hypocalcemia (QTc prolongation, seizure), GI bleed, decreased bone turn over

• SE: n/v/d, anorexia, myalgia

Erythropoiesis stimulating agent

Epoetin alfa, darbepoetin alfa

• SE: HTN, DVT/PE/stroke

• ONLY initiate when Hgb <10 g/dL

• D/c if Hgb >11

• Assess iron panel & give IV iron as ESA ONLY works with adequate iron

Vadadustat

• PO ESA for dialysis >3 mon pts

Drugs that increase potassium level

Canagliflozin

Calcineurin inhibitors (cyclosporine, tacrolimus)

Drospirenone- containing OC

Potassium-sparing diuretics

ACE/ARB

Bactrim

Hyperkalemia treatment

1. Stabilize the heart→ calcium (gluconate > chloride)

2. Move K

   • → insulin + dextrose

   • → sodium bicarb (for metabolic acidosis)

   • → albuterol (SE: tachycardia, chest pain)

3. Remove K

   • → loop diuretics (monitor volume)

   • → sodium polystyrene sulfonate

   • → patiromer

   • → sodium zirconium cyclosilicate (fastest onset)

   • → hemodialysis

Potassium binders

Sodium polystyrene sulfonate

• Warning: GI necrosis, electrolyte disturbance

• SE: n/v/d

• Monitor K, Mg, Na, Ca

• Space out for 3 hrs

Patiromer

• Warning: GI motility, hypomagnesemia

• SE: constipation

• Monitor K, Mg

• Space out for 3 hrs

Sodium zirconium cyclosillicate

• Warning: GI motility, edema,

• SE: peripheral edema

• Space out for 2 hrs

HBV triple panel tests

HBsAg

• Positive during acute or chronic infection

anti-HBs

• Positive with HBV immunity (surface antibody)

anti-HBc

• Positive with previous or active infection (total antibody core)

Treatment naive HCV

8 wks- Mavyret (glecaprevir/ pibrentasvir)

• Take with food

• DO NOT use w/ statin (atorvastatin, lovastatin, simvastatin), cyclosporin >100 mg/d, ethinyl estradiol >20 mcg/d

12 wks- Epclusa (solosbuvir/ velpatasvir)

• SE: bradycardia

• DO NOT used w/ amiodarone

• No PPI; Space out from antacids (4 hrs), H2RA (12 hrs)

  • famotidine <40 mg BID

HCV treatment MOA & examples

NS3/4A protease inhibitor (-previr)

• Glecaprevir

• Grazoprevir

• Voxilaprevir

NS5A replication complex inhibitor (-asvir)

• Elbasvir

• Ledipasvir

  • DDI with acid suppressing drug

• Pibrentasvir

• Velpatasvir

  • DDI with acid suppressing drug

NS5B polymerase inhibitor (-buvir)

• Sofosbuvir

  • Induce bradycardia

  • DDI with amiodarone

DAA add-on therapy

Ribavirin (RNA/DNA replication inhibitor)

• BBW:

  • AVOID in pregnancy (teratogenic event): take 2 types of contraceptives→ 6-8 months after the therapy

  • Hemolytic anemia: 1-2 wks after initiation

• Combination therapy ONLY

• SE: fatigue, headache, insomnia, n/v/d, anorexia, hypothyroidism

HBV first-line (w/o HIV)

NRTIs

• TDF (Viread), TAF (Vemildy)

  • TDF > TAF: more renal toxicity (Fanconi syndrome) & bone density issue

  • SE: n/v/d, lipid abnormality (TAF)

  • Dispense in the original container only

• Entacavir (Baraclude)

  • SE: hematuria, glycosuria

  • TAKE ON EMPTY STOMACH

Interferons (SubQ)

• Pegylated INF alfa-2a (Pegasus)

  • Finite treatment duration of 48 wks

  • BBW: neuropsychiatric, autoimmune, ischemic, infectious disorder

  • Contradiction: autoimmune hepatitis, decompensated LF

  • SE: myelosupression, CNS effect, GI upset, elevated LFT, flu-like symptoms

    • Flu-like symptoms: pretreat with APAP & antihistamine

Hepatotoxic drug

• APAP

• Amiodarone

• Bosentan

• Isoniazid

• Ketoconazole

• Leflunomide/ teriflunomide

• MTX

• Nevirapine

• Propylthiouracil

• Valproic acid

• Zidovudine

Acute vertical bleed treatment

1. Supportive mechanism (mechanical ventilation, anticoagulation, transfusion)

2. Octreotide/ terlipressin

   • Octreotide

     • IV bolus→ con’t for 2-5 days

     • SE: bradycardia, cholelithiasis, biliary sludge, glucose disorder, hypothyroidism

   • Terlipressin

     • BBW: respiratory failure

     • Contradictionn: respiratory issue, ischemia

     • SE: hyponatremia, hypervolemia

3. Surgery

   • Redirection

     • Band ligation

     • Sclerotherapy

   • Enlargement

     • Balloon tamponade

     • TIPS

4. Ceftriaxone ppx 2-5 days

Portal HTN management

Nonselective beta-blocker

• BBW: taper over 1-2 wks

• Warning:

  • May mask hypoglycemia, hypothyroidism

    • Bronchospasm

    • Raynaud’s disease

  • SE: bradycardia, HoTN

Carvedilol

• 6.25 mg QD

• SE: floppy iris syndrome

Propranolol

Nadolol

Hepatic encephalopathy

First line

• Lactose

  • Titration goal: 2-3 BM per day

  • SE: flatulence, diarrhea, dyspepsia, abdominal pain

  • Monitor: mental status, BM, ammonia level

• Rifaximin

Ascites therapy

Spironolactone ± furosemide

• Ratio of 40 mg furosemide : 100 mg spironolactone (2:5 ratio) for potassium lvl

Paracentesis

• + albumin administration 6-8 g/L

Spontaneous bacterial peritonitis

Acute infection, which is revealed by ascitic leukocytes counts of ≥250 cell/mm³

• Ceftriaxone 5-7 days

• Secondary ppx: + Cipro / Bactrim

Gram stains

Gram-positive: thick cell wall— purple

Gram-negative: thin cell wall— pink

Atypical: non-stain

PCN

ALL PCN increase seizure risk & rash (SJS)

Natural PCN

• PCN GA: IV

• PCN GB: IM

  • 1^st line for syphilis

• PCN K

  • 1^st line for pharyngitis

Antistaphylococcal PCN— MSSA

• Nafcillin: IV/IM

  • Vesicant: extravasation risk

    • Cold pack + hyaluronidase

• Dicloxacillin

• Oxacillin

AminoPCN

• Amoxicillin

  • 1^st line for acute otitis media & endocarditis ppx d/c dental surgery

• Amoxicillin/ Clav (Augmentin)— MSSA

  • DO NOT use ER or 875 mg in CrCl <30

  • 1^st line for acute otitis media & bacterial sinusitis

• Ampicillin

• Ampicillin/ Sulb (Unasyn)— MSSA

Extended-spectrum PCN

• Pipera/ Tazo (Zosyn): IV— Pseudo

  • Prolonged infusion over 4 hrs for T > MIC

PCN DDI

Probenecid

• Increase PCN conc

Cephlosporins

1^st gen:

• Cefazolin: IV/IM

• Cephalexin: 250-500 mg PO Q6-12H

  • for MSSA, strep throat

2^nd gen

• Cefuroxime: PO/IV/IM

  • for acute otitis, CAP

• Cefotetan: IV/IM

• Cefoxitin: IV/IM

3^rd gen G1:

• Cefdinir: PO

  • for acute otitis

• Ceftriaxone: IV/IM

  • for CAP, meningitis, bacterial peritonitis, pyelonephritis

3^rd gen G2:

• Ceftazidime: IV/IM

4^th gen:

• Cefepime: IV/IM

  • for pseudomonas

5^th gen:

• Ceftaroline: IV

  • for MRSA

Cephalosporin warning & monitoring

Contraindication:

• Neonate:

  • Hyperbilirubine

  • W/ calcium

    • Especially w/ ceftriaxone→ precipitation

Monitoring:

• Renal function

  • No renal adj for ceftriaxone

Aminoglycosides dosing

Traditional dosing

• Gentamicin & tobramycin: 1 - 2.5 mg/kg/dose

  • CrCl ≥60: Q8H

  • Trough before the 4^th dose + peak after the 4^th dose

Extended interval dosing

• Gentamicin & tobramycin: 4 - 7 mg/kg/dose

  • Frequency: Hartford Dosing Nomogram

  • Random lvl after the 1^st dose

    • 6-14 hrs after the infusion

AG side effect & monitoring

BBW:

• Nephrotoxicity

• Ototoxicity

• Neuromuscular block

Monitoring:

• Drug lvl, renal impairment

Quinolone side effect & warning

BBW:

• Tendon rupture

• Peripheral neuropathy

• Seizure

Warning:

• QTc prolongation

  • Moxifloxacin > levofloxacin > ciprofloxacin

• Hypo/hyperglycemia

• AVOID in pregnancy

• Photosensitivity

DDI:

• Antacids

• Lanthanum & sevelamer

• QTc prolonging drugs (azoles, antipsychotics, methadone, macrolides)

• Cipro: Strong CYP1A2 inhibitor→ interact w/ caffeine, theophylline, tizanidine

Macrolides

Azithromycin

• Z-pak: 500 mg D1→ 250 mg D2-5

• Tri-pak: 500 mg QD x3d

Clarithromycin

• DO NOT use w/ lovastatin & simvastatin

Erythromycin

• DO NOT use w/ lovastatin & simvastatin

Macrolides warning

• QTc prolongation (erythromycin > azithromycin > clarithromycin)

• Hepatotoxicity

• Clarithromycin & CAD→ major mortality risk

Tetracycline

Doxycycline

• No renal adj

• Take w/ food & sit upright for 30 mins (avoid stomach irritation)

• DO NOT use in kid <8, pregnant/lactating

Minocycline

• SE: drug-induced lupus erythema

Bactrim

Single strength:

• 400/80 mg

Double strength:

• 800/160 mg

Dosing vs indication

• Uncomplicated UTI

  • 1DS PO BID x3d

• PCP ppx

  • 1DS or SS PO QD

Bactrim side effect & warning

Skin condition

• SJS, TEN, TTP

Hemolytic anemia→ G6PD deficiency

Sulfa allergy

Photosensitivity

K elevation & crystalluria→ drink w/ 8oz of H_²O

• IV Bactrim can ONLY be mixed in dextrose

CYP2C9 inhibitors→ interact w/ Warfarin

Vancomycin dosing

Indication	Loading Dose	Maintenance Dose
Sepsis	25 mg/kg	15-20 mg/kg
Suspected/confirmed meningitis
Pneumonia
Bone/joint infection
Endocarditis
Staphylococcus aureus bacteremia
Cellulitis	20 mg/kg	15 mg/kg
Febrile neutropenia
Coagulase negative Staphylococcus bacteremia

Usual interval: Q8-12H

• CrCl 20-49: Q24H

C.Diff dosing: 125 mg PO QD

Vancomycin side effect & warning

Ototoxicity

Nephrotoxicity

Vancomycin infusion reaction (rash, flushing, hypotension, etc)

AUC/MIC goal: 400-600

trough goal: 10-15 or 15-20

Daptomycin side effect & warning

Myopathy, rhbdomyolysis

False PT/INR elevation

CPK elevation

Compatible w/ NS/LR

Linezolide side effect & warning

Myelosupression

Optic neuropathy

Serotonin syndrome

• AVOID MAOI (2wks +) & tyramine-containing food

Hypoglycemia

DO NOT shake linezolide suspension

Clindamycin side effect & warning

BBW: C.diff

SE: n/v/d

Induction test (D-test) should be performed on S. aureus

• Flattened zone = clindamycin resistence

Metronidazole side effect & contraindication

Contraindication:

• Pregnancy (1^st trimeter)

• Alcohol within 3 days of treatment completion→ disulfur reaction

Side effects:

• Metallic tastes

Nitrofurantoin dosing & warning

Macrobid: 100 mg BID x 5 d

Mancrodantin: QID dosing (treatment dose); QHS (ppx dosing)

Contraindication

• Renal impairment (CrCl <60)

Warning

• G6PD deficiency

• Brown urine reP

PreOP abx selection

Cefazolin or Cefuroxime for MSSA coverage

• Alternative: clindamycin

Acute otitis media

First line

• Amoxicillin 90/mg/d in 2 divided dose

• Augmentin

→ If treatment failed, Ceftriaxone 50mg/kg IM for 3 days

COPD exacerbation antibiotics options

• Augmentin

• Azithromycin

• Doxycycline

• Respiratory quinolones

TB treatment

Latent TB (3HR-3HR-4R-9H)

• 12 weeks of weekly isoniazid & rifapentine

• 3 mons of QD isoniazid & rifampin

• 4 mons of QD rifampin

• 6-9 mons of QD isoniazid

  • Preferred regimen in HIV pts (9 mons recc)

Acute TB (6 mons total)

• 2RIPE→ 4RI

Rifampin DDI

Inducer for CYP3A4, PgP

• DDI w/ protease inhibitor (“-navir”), warfarin, OC

• DO NOT use w/ apixaban, rivaroxaban, edoxaban, dabigatran

Endocartidis dental ppx

Amoxicillin 2g PO 30-60 mins b/c procedure

• Alternative: macrolides 500 mg or doxy 100 mg

Systemic SSTI sign

Temp >100.4

HR >90

WBC >12000 or <4000

SSTI vs treatment

Impetigo (MSSA→ honey-colored crust)

• Warm, wet compress

• Local lesion: mupirocin

• Extended lesion: cephalexin

Folliculitis (MRSA→ red pimple like)

• Warm compress + incision & drainage

• Bactrim or Doxy

Mild cellulitis (MSSA & strep→ localized, unilateral, red, warm)

• Cephalexin

Mild abscess (MRSA→ localized fluid collection)

• Bactrim or Doxy

Severe purlulent (MRSA)

• Vanc, dapto, linezolide for 7-14 days

Necrotizing fasciitis (MRSA, broad negative, anaerobes)

• Vanc + Zosyn/ meropenem + clindamycin

Diabetic foot treatment duration

• No bone involvement: 2-4 wks

• Osteomyelitis: 4-6 wks

• Amputation with no residue: 2-5 days

Acute cystitis treatment

• Nitrofurantoin 100 mg BID x 5d

  • AVOID CrCl <60

• Bactrim DS 1 tab BID x 3d

  • Ppx dose: SS QD

• Fosfomycin x 1 dose

• Augmentin, cefuroxime, cephalexin, cipro or levo as alternative

Acute pyelonephritis

Moderately ill OP

If local quinolone resistance <10%

• Cipro or Levo 5-7 d

If local quinolone resistance <10%

• Ceftriaxone or ertapenem or AG→ quinolone 5-7 d

• Quinolone ADR→ Bactrim, Augmentin, Cefdinir… 7-10 d

Severe ill IP

• Ceftriaxone or quinolone 5-10 d

• If resistance concerned, Zosyn, carbapenem

Asymptomatic bacteriuria in pregnancy

Preferred:

• Augmentin

• Oral cephalosporin (e.g. cephalexin)

Alternative:

• Nitrofu, Bactrim, fosfomycin

STD post exposure ppx

DoxyPEP

• One dose of doxycycline 200 mg