ID 1 Introduction/Everything about the Drugs (NAPLEX)

Thick cell wall (stain purple)

A. Gram +

B. Gram -

A. Gram +

Thin cell well (stain pink)

A. Gram +

B. Gram -

B. Gram -

Gram - anaerobes

B frag

Common Resistant Pathogens (6 mnemonic)

Concentration dependent drugs (3)

• Aminoglycosides

• FQ

• Daptomycin

Exposure dependent drugs (4)

• Vancomycin

• Macrolides

• Tetracyclines

• Polymyxins

Time dependent drugs (1)

• Beta lactams (PCN, cephs, carbapenems)

Hydrophilic agents (5)

Lipophilic agents (6)

What classes are considered beta-lactam ABX? (3)

• Penicillins

• Cephalosporins

• Carbapenems

Beta-lactam MOA

inhibit bacterial cell wall synthesis by binding to PBPs

Natural PCN drugs & coverage **

• Pen VK, Pen G

• Strep & enterococci (but not staph)

Anti-staph PCN drugs & coverage **

• Naficillin, oxacillin, dicloxacillin

• Strep, MSSA (but not enterococci)

Amino-PCN drugs & coverage **

• Amoxil, Augmentin, Ampicillin, Unasyn

• Strep, enterococci, anaerobes, gram-

Not for IV use because it can cause cardio-respiratory arrest & death

A. Penicillin V Potassium

B. Penicillin G benzathine

C. Penicillin G Aqueous

B. Penicillin G benzathine

Match with Formulations (1 each)

A. Penicillin V Potassium

B. Penicillin G benzathine

C. Penicillin G Aqueous

A. Penicillin V Potassium --> PO

B. Penicillin G benzathine --> IV

C. Penicillin G Aqueous --> IM

Augmentin renal adjustment cutoff

CrCl <30 do not use augmentin ER or 875 mg

what ABX class can cause seizures with accumulation if not renally adjusted?

BETA LACTAMS (Imipenem with the highest risk)

- So all penicillins, cephalosporins, and carbapenems

Pediatric dose for acute otitis media (know per video)

90 mg/kg/day

First gen cephalosporins drugs (2) + bugs

• Cephalexin PO

• Cefazolin IV

• Strep, staph, PEK (proteus, E coli, kleb)

Second gen cephalosporins drugs (5) + bugs

• Cefuroxime PO/IV/IM

• Cefotetan IV/IM

• Cefoxitin IV/IM

• staph, strep, HNPEK (haemophilus, neisseria, proteus, e coli, kleb)

Third gen cephalosporins drugs (3) + bugs

• Cefdinir PO & Ceftriaxone IV/IM --> strep, MSSA, gram + anaerobes, resistant HNPEK

• Ceftazidime IV/IM --> lacks gram + but covers pseudomonas

Fourth gen cephalosporins drugs (1) + bugs

• Cefepime IV/IM

• Broad gram - activity with gram +'s

Fifth gen cephalosporins drugs (1) + bugs

• Ceftaroline (teflaro): IV

• Broad gram +/-, MRSA

Ceftriaxone Contraindication (2)

• Hyperbilirubinemic neonates can cause biliary sludging, kernicertus

• Concurrent use with calcium IV products in neonates

What cephalosporin can cause a disulfiram like reaction with alcohol ingestion? (1)

Cefotetan

What cephalosporin has no renal adjustments? (1)

Ceftriaxone

What cephalosporin is avaliable in a chewable tablet? (1)

cefixime

T/F: If a patient with a PCN allergy on the exam, NEVER choose a cephalosporin

True - just dont even though we might in real life

What cephalosporins can be used in pseudomonas? (2)

• Cefepime

• Cefazidime

Cephalosporin DDI with PO agents

HRA & PPI; seperate by 2 hours

What carbapenem is NOT active against ESBL organisms?

Ertapenem

Carbapenem & VPA DDI

• Carbapenems can decrease VPA concentrations which can increase risk of seizures

Aztreonam coverage

• Gram - (PSA)

• has NO gram + or anaerobic activity

T/F: Aztreonam can be usd in penicillin allergies

TRUE

Aminoglycosides MOA

Bind to 30S ribosome to interfere with bacterial protein synthesis

Aminoglycoside drugs (3) + coverage **

• Gentamicin IV/IM/topical/opthalmic

• Tobramycin IV/IM/opthalmic/inhaled

• Amikacin IV/IM

• GRAM - (PSA)

• Synergistic for G+ organisms when combined with a beta-lactam or vancomycin

Aminoglycosides BW (4)

• Nephrotox

• Ototox

• Neuromusclar blockage

• Fetal harm

Aminoglycoside dosing ***

• Underweight use TBW

• Obese use AdjBW

• Traditional: 1-2.5 mg/kg/dose

- Draw trough or peak

• Extended: 4-7 mg/kg/dose

- Draw random & plot on nomogram

• CrCl ≥60: q8hr

what does post ABX effect mean with aminoglycoside?

killing continues after serum level drops below MIC

FQ MOA

Inhibit bacterial DNA topoisomerase IV and DNA gyprase (topo II) preventing supercoiling

FQ BW (3)

• Tendon rupture

• Peripheral neuropathy

• CNS effects (seizures)

FQ coverage

Broad spectrum against gram +, gram -, and atypicals.

Ciprofloxacin is contraindicated with concurrent administration of _______.

tizanidine

Cipro is a CYP1A2 inhibitor and can increase levels of tizanidine

What FQ has highest risk of QT prolongation?

Moxi>levo>cipro

FQ Adverse Effects (7)

• QT prolong

• Hypogly/Hypergly

• Psychiatric disturbances

• Photosensitivity

• Hepatotoxicity

• Crystalluria (stay hydrated)

• Aortic anuerysm/dissection

T/F: fluoroquinoles can be used in pregnancy

FALSE - do not use

Can ciprofloxacin oral suspension be put done an NG/feeding tube?

NO - the oil based suspension adheres to the tubing

What FQ should not be used for UTI because it does not concentrate in the urine?

Moxifloxacin

FQ DDI (5)

• Antacids/cations

• Phos binders (lanthanum, sevelamer)

• Warfarin

• QTc prolongers

• Cipro (CYP1A2 inhibitor): tizanidine, theophylline, caffeine

Macrolides MOA

Bind 50S ribosomal subunit to inhibit protein synthesis

Macrolide drugs (3) + coverage

• Azithromycin, Clarithromycin, Erythromycin

• Atypicals

Which macrolide has most risk of QTc?

Erythro>azithro>clarithro

Macrolide main adverse effects

GI upset

What macrolide should be cautioned with CAD?

Clarithromycin

Macrolide DDI & PK

• Azithromycin is a minor CYP3A4 substrate and has fewer DDI

• Erythro & Clarithro are MAJOR CYP3A4 inhibitors and have DDI with simvastatin, lovastatin

Tetracycline MOA

Reversibly binds 30S ribosomal subunit to inhibit protein synthesis

Tetracycline drugs (2) + coverage

• Doxycycline

• Minocycline

• Gram +, gram - (including respiratory flora), atypicals

Tetracycline warning to know!

• Dont use in <8yo, pregnancy, breastfeeding due to bone suppression and teeth discoloration

What antibiotic can cause drug induced lupus erythematosus?

Minocycline

Why should you sit upright for 30 mins after taking doxycyline?

To avoid esophageal irritation

Tetracycline DDI (1)

• Antacids/cations/dairy

Bactrim MOA

Folic acid pathway inhibition

Bactrim coverage

• Broad MRSA

• Does not cover PSA, enterococci, atypicals, or anaerobes

When dosing bactrim you dose off which component? ***

TMP

All products are formulated with SMX:TMP ratio of 5:1

Bactrim adverse effects (7)

• SJS/TEN/TTP

• Hemolytic anemia (+ Coombs; G6PD)

• Hypoglycemia

• Thrombocytopenia

• Hyperkalemia

• Crystalluria (drink water)

• Photosensitivity

Bactrim DDI (1)

WARFARIN due to bactrim being a CYP2C9 inhibitor

With vanco infusion reactions do not infuse faster than ___ gram per hour

1

Vancomycin MOA

Inhibit bacterial cell wall by binding the D-alanyl-D-alanine cell wall precursor

Which 2 "vancins" are a single dose?

Orita and Dalba

Telavancin BW (3)

• Fetal risk: must have negative pregnancy test before starting

• Nephrotox

• Increased mortality when used in pts with pre-existing CrCl ≤50

Oritavancin DDI ** (1)

• UFH - do not use IV UFH for 120 hrs (5 days) after due to false aPTT elevations

Daptomycin coverage

• Gram + (MRSA, VRE) with NO gram - coverage

Daptomycin adverse effects (3)

• Myopathy/rhabo (CPK, monitor weekly)

• False elevations in INR/PT

• Peripheral neuropathy

Linezolid MOA

binds 50S subunit

Linezolid adverse effects (4)

• Myelosuppression (dec plts) - need CBC weekly

• Optic neuropathy

• Serotonin syndrome

• Hypoglycemia

Linezolid DDI (1)

Do not use within or within 2 weeks of MAO-I

T/F: You can shake a linezolid suspension

FALSE - do not shake

Tigecycline BW (1)

Increased risk of death

Tigecycline has no activity against the "3 P's"

Pseudomonas, Proteus, Providencia

T/F: Do not use tigecycline for bloodstream infections

True - it doe not achieve adequate concentrations in the blood since it is lipophilic

What color should the tigecycline soltion be?

Yellow-orange

When are polymyxins used?

MDR gram negative pathogens in combo with other ABX

Polymyxins BW (3)

• Dose-dependent nephrotoxicity

• Neurotoxicity

• Only give to hospitalized patients

What medication is know to cause gray baby syndrome?

Chloramphenicol

Clindamycin MOA

Binds 50S inhibiting protein synthesis

Clindamycin coverage

• Gram + (CA-MRSA, anerobes)

• Has minimal gram -

Clindamycin BW (1)

C diff

Can flagyl be taken during pregnancy?

Not during the first trimester

Flagyl DDI (2)

• Alcohol (during or within 3 days of stopping)

• Warfarin (inc INR)

Lefamulin warning (1)

QT prolongation

Nitrofurantoin do not use in (2) *

• CrCl <60

• G6PD deficiency

Nitrofurantoin adverse effects (2)

• GI upset (take with food)

• Brown urine discoloration

ESBL DOC (2)

• Carabepenems

• Cefazidime/avibactam

VRE DOC (2)

• Daptomycin

• Linezolid

What ABX work on folic acid synthesis?

Bactrim

What ABX work on 50S subunit (3 mneumonic)?

• Macrolides

• Linezolid

• Clinda

FIFTY MEN LOVE CLINDA

What ABX work on 30S subunit? (2 mneumonic)

• Aminoglycosides

• Tetracyclines

TAT (thirty)

What drugs cause photosensitvity? (3)

• Fluoroquinolones

• Doxycycline

• Bactrim

What drug can cause a metallic taste?

Flagyl