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Study guide

Comprehensive Final

QuestionAnswer
When does the WV Board of examiners for RNs renew prescriptive authority for APNs or CNMs? Biennially, by June 30, odd number years
An APRN is writing a prescription for a brand drug and does not want the pharmacist to change the drug to a generic form. What is necessary to write on the script? Dispense as written
When considering an enteric coated tablet the APRN recognizes that: All of the above are correct, the release of the drug is delayed, the stomach acid is protected from the drug and the drug is protected from the stomach.
An NP is considering prescribing a generic version for a patient. The NP understands that generic drugs are a/an Therapeutic equivalent
The FDA now requires additional information on some drug labels related to genetic testing, such as Warfarin. The effects of genetic differences on a person's response to drugs is known as Pharmacogenomics (the study of the effects of genetic differences among people and the impact that these differences have on the uptake, effectiveness, toxicity, and metabolism.
55 yo pt. has HTN and mild osteoarthritis. You prescribe HCTZ, a diuretic, for HTN. She asks if she can take OTC Naproxen, and NSAID. You know that NSAIDS cause fluid retention which counteracts the action of the diuretic. The drug interaction is: Antagonistic- when the action of one drug counteracts the action of another, the drug/drug interaction is termed antagonistic.
Which DEA defined drug substance cannot be prescribed in the U.S. by anyone? Schedule 1
A 22 yo pregnant woman reports a hx of seizure disorder and says she recently ran out of her medication. She asks you to write her an Rx for Dilantin. You find that it is pregnancy Category D. Which of the following statements is true of this category? There is positive evidence of human fetal risk, but the benefits from use in pregnant women may be acceptable despite the risk.
You are treating a patient for asthma. The patient is responding well. After checking the labs you notice the levels of the drug are lower than the therapeutic level. You should: Continue the current dose
The APN knows that a drug that is an agonist: binds to the receptor site and activates it.
What type of drug interaction occurs when the combining effects of the two drugs together is greater than either drug by itself: additive
Which of the following characteristics is more predictive of addiction: deterioration in ability to function at work, in family, or socially
Therapeutic range (also called therapeutic index) is: the range of drug concentrations between minimum effective concentration and maximum tolerable concentration.
The metabolism and excretion of drugs and as they are removed from the body is referred to as: Drug elimination- the metabolism and excretion of drugs and as they are removed from the body is referred to as drug elimination.
The APN collaborative agreement with a physician should include: forward mutually agreed upon written guidelines for Rx authority, statement describing individual and shared responsibilites, periodic and joint eval of RX practice and periodic review updating guidelines to WV BON
Which line below uses techniques to prevent medication errors when writing an Rx: Hydrochlorothiazide 25mg PO daily for hypertension
A 62 yo pt. began taking a controlled release tablet. He noticed an intact tablet in his stool. He surmised that he wasn’t getting the medication in the tablet, so he decided to chew it from now on. As the NP you should advise the patient that: he should not chew the tablet because it could alter the proper absorption. His body had properly absorbed the active ingredients of drug and the tablets that he saw in his stool were “ghosts”
The PDR is: Helpful in prescribing since it contains the official labeling developed by the FDA and drug company
Half-life is the length of time it takes for 1/2 of a drug to be cleared from the circulation. It can be calculated for an individual if one obtains both peak & trough, but is only applicable to those drugs with 1st order kinetics. A major exception is: phenytoin
Pediatric dosing is usually based upon the weight of the child
In the state of WV, as long as you have prescriptive authority, is it legal to prescribe medications to yourself, neighbors or family members? yes, as long as it is a non-controlled substance, it is recorded, and it meets all of the prescribing rules.
The first stage of pharmacokinetics is absorption-drug absorption is the first stage becase t is where the drug enters the systemic circulation.
Distribution is the second stage: it is where the drug is distributed throughout the body.
Metabolism is the third stage: it is where the drug is changed to a different compound called a metabolite.
Elimination is the fourth stage: it is the final stage where it is excreted from the body.
Which of the following patients should you obtain drug levels for? a patient who was recently started on digoxin for heart failure
You would like to prescribe Amoxicillin for a 4 year old child who weights 35 pounds. The appropriate dose is 20-50 mg/kg/day in divided doses and the drug is supplied as 250mg/5ml solution. What is the appropriate dose? 1 teaspoonful TID- dose range 320-800 mg/day
Hydrocodone is a substrate of CYP 3A4. Grapefruit juice is an inhibitor of CYP 3A4. What is the expected outcome if a patient takes hydrocodone with grapefruit juice? Hydrocodone levels will likely become high
Which of the following stages in fetal development is considered the danger window concerning pharmacodynamics: embryonic- the danger window associated with pharmacodynamics in fetal development is the embryonic stage. The embryonic stage consists of week 3-9 and is considered the most dangerous due to the developing of the placenta and major organs.
If an NP delegates the task of phoning in a prescription to a nurse, and an error occurs, who retains the responsibility for the error? The NP
As the PCP, should prescriptions be used for off-label use: The APRN should consider prescribing the medication, with knowledge of similar cases of indication and use with validated research.
In WV, the physician who collaborates with a NP for prescriptive authority must periodically, evaluate the APNs prescribing practice
The process by which a drug gets from its site of administration to the site where it is measured (usually the circulation)is called: Absorption
Beta blockers and beta agonists both bind B2 receptors. When administered simultaneously, their interaction is: antagonistic- they work against each other
When dealing with the geriatric population, kinetics to include: all of the above: decreased GI acid production, decreased hepatic metabolism, and diminished renal function.
Pharmacokinetic parameters include which of the following: absorption, distribution, metabolism, excretion
The most common Cytochrome P450 enzyme that is responsible for metabolizing over 50% of all drugs is: CYP3A4
Which of the following holds the most power when regulating prescriptive practice Federal level
The effects of a drug on the body is termed Pharmacodynamics
A female patient presents to your office because she has just found out she is pregnant. Which medication would you discontinue immediately due to its teratogenic effects: Retinoids
The process of transforming drugs so that the body can eliminate them is called Metabolism
Type B adverse drug reactions include developing a rash from PCN (type B adverse drug reactions are allergic or indiosyncratic effects that are not dose dependent nor are they expected based on the pharmacological actions of the drug.)
When switching a place of employment, what should be done about your DEA number? notify the DEA ahead of time of the new ob, but keep the same DEA number.
The FDA states that one of their responsibilities is to evaluate new drugs for efficacy and safety in which way does the FDA carry out this task? The FDA reviews safety and efficacy research as provided by drug companies
PCN and sulfa drugs are associated with which type of allergic reaction? Type 3- immune complex hypersensitivity. IgG and IgM binds with the cells drug protein complexes, causing the release of complement and subsequent local vascular destruction.
Which is true regarding collaborative agreements in the state of WV Any changes in the agreement must be given in writing and ahead of time to the WV BON to approve before the APRN can prescribe under these changes.
Type A adverse drug reactions are: the result of an unwanted normal pharmacological action of a drug and are predictable.
Type B adverse drug reactions are: allergic or idiosyncratic effects that are not dose dependent or expected
Type C adverse drug reactions are: the cumulative effects of a drug seen with chronic use of meds and are dose related and time related.
Type D adverse drug reactions are: seen at the end of drug therapy with a physiological withdrawal seen after the medication is discontinued.
Non-controlled substances or antipsychotics can be prescribed for how long? no more than a 90 day supply and no more than 1 refill
Benzodiazepines can be prescribed for how long? 72 hour supply with one refill
How long can oral contraceptives be prescribed for by the APRN? one year duration
Phenothiazines can be prescribed for how long? 30 day supply with no reflls
When alcohol, drugs or cigarette smoke stimulate the synthesis of drug metabolizing enzymes, this is called? Enzyme induction
Under WV law, the APRN and collaborating physician must review their collaborative agreement: every 2 years
Probiotics are used to restore the normal gut flora that is distributed by all of the above....
A female patient comes into your clinic to start a smoking cessation program. She is taking a beta blocker for BP control. Upon beginning a smoking cessation program, what should you as a nurse practitioner be concerned about once she stops smoking? Nicotine causes increased metabolism of beta blockers and decreased blood levels. With cessation blood vessels of beta blocker may rise causing increased BP reduction
Nicotine takes how many seconds to reach the brain when inhaled 7 seconds
What is the half-life of nicotine around 2 hours
The five A's of smoking cessation -ask about smoking -advise quitting -assess current willingness to quit -assist in the quit attempt -arrange timely follow-up
More than 10 cigarettes/day start on: 21 mg patch
Less than 10 cigarettes/day start on: 14 mg patch
Do not use transdermal nicotine patch if: Severe uncontrolled eczema or psoriasis Recent MI (less than 2 weeks) Serious underlying arrhythmias
Length of treatment for the patch: 8-10 weeks
Dosing gum 25 or more cigs/day 4mg/ 1 every 1-2 hours X 6 weeks 1 every 2-4 hours X 3 weeks 1 every 4-8 hours X 3 weeks
Chew and park method is how to use gum, make sure: you rotate to different sites in the mouth.
Gum peeks in 15-20 minutes
Nicotine gum education Do not eat or drink 15 minutes prior to use
Cons of nicotine gum may cause nausea, hiccups, coughing, heartburn, headache and flatulence.
Length of treatment for gum up to 12 weeks
Bupropion SR 150mg dosing 7 day up titration prior to quitting days 1-3 150 mg tab each am days 4 to end 150 mg tab bid Dose should be 8 hours apart not dependent on number of cigs smoked may be combined with NRT
Bupropion precautions Immediate release form increased risk of seizures, do not use with seizure disorder, heavy drinking, eating disorder or MAOI, can increase suicidal thoughts in children and adolescents, can cause agitation
Bupropion side effects disturb sleep dry mouth
Bupropion length of treatment 7-12 weeks, may take up to 6 months of total therapy to prevent relapse
Chantix dosing 7 day up titration prior to quitting days 1-3 (0.5 mg per day) days 4-7 (0.5 mg bid) days 8 to end (1mg bid)
Chantix how to take take after eating with full glass of water
Precautions of Chantix Dosage adjustment with severe renal impairment Not recommended for combination therapy with NRT Can cause sleep disturbances and abnormal dreams Can cause nausea in up to 30% of patients
Chantix length of treatment 12 weeks If quit at 12 weeks may take for additional 12 weeks to prevent relapse
Which treatment option has best odds of abstinence in tobacco after 6 months Chantix
Smoking cessation increases the blood levels of antipsychotics: Haloperidol, chlorpromazine, fluphenazine, olanzapine, clozapine
Smoking cessation increases the blood level of antidepressants: Clomimpramine, desipramine, doxepin, imipramine, nortriptyline
Smoking cessation increases the blood levels of mood stabilizers carbamazepine
Smoking cessation increases the blood levels of anxiolytics desmethyldiazepam, oxazepam
Smoking cessation increases the blood levels in other medications: heparin, insulin, tacrine, acetaminophen, caffeine, warfarin
What is the average number of attempts to quit smoking before success 3 attempts- success is tobacco free for 12 months
Altered metabolism can be caused due to: sepsis, trauma, burns, cancer, AIDS, and critical illness
Macronutrients are: water, protein, dextrose, and fat
Micronutrients are: vitamins, trace elements, and electrolytes
When you increase the calorie/cc you increase: osmolality, which can increase GI distress
Examples of formulas for a patient with respiratory failure Pulmacare, Nutrivent, and Respalor
Examples of formulas for diabetics Glytrol and Glucerna (lower carbs, higher fat and more fiber to prevent gastroparesis)
Common use for parenteral nutrition pancreatitis, rest the gut and less aspiration risk.
Polymeric solutions resembles the food we eat (have intact proteins) most often prescribed May cause dehydration- need to supplement water
Polymeric examples Boost, Carnation Instant Breakfast, ensure, Isocal, Nutren, Osmolite, Jevity
Monomeric solutions more expensive more hypertonic (higher osmotic load) can cause diarrhea
Monomeric used for pancreatic insufficiency short bowel syndrome
Monomeric examples Subdue, Modulen, Peptamen, Reablin, Optimental, Alitraq
Modular solutions only deliver macronutrients and require a registered dietician to follow them.
Ways to decrease diarrhea and N/V with tube feeds slow rates and lower calorie content limit large bolus feedings intermittent or continuous feedings recommended
Lack of Iron can cause: weakness, fatigue, and decreased immunity
What can increase absorption of non-heme iron meat protein and vitamin C
What can decrease absorption of iron tannins (tea), calcium, soybean proteins, polyphenols and phytates found in legumes and whole grains
How long before iron levels will rise after treatment started 4-6 weeks, may not achieve normal la levels until 3 months
fat soluble vitamins A, D, E, K
Varicella and MMR given SQ, all others are given IM
T/F premature infants get same dosage as full term infants True
what is a vaccine a substance used to stimulate the production of antibodies and provide immunity against one or several diseases, prepared from the causative agent of a disease, its products, or a synthetic substitute, without inducing the disease
Attenuated means that the infective agent is modified live
Inactivated means killed or dead infective agent
Attenuated MMR, OPV, Varicella, Influenza (flu mist), rotavirus, shingles, BCG, yellow fever
Inactivated DTP, Hib, influenza (Fluzone), IPV, MCV4, HPV, Hep A
Conjugate vaccines preferable to polysaccharide vaccines b/c conjugate vaccines can induce immune memory that lasts more than 10 years, ensure booster effects either through exposure in community to the organism or by periodic reimmunization, many conjugate vaccines reduce nasopharygeal carriage
Herd immunity conferring protection not only to those vaccinated, but the population in general
Adding albumin to a vaccine stimulates production of antibodies
Thimerosal a preservative that may help prevent the vaccine from spoiling; it is 49.6% mercury by weight (a heavy metal)
Diptheria and Tetanus Give big D before age 7 and little d after age 7
True/False- Absorption differences is not expected as a racial difference in pharmacokinetics True
What is the average weekly weight loss with diet pills 2lbs/week
Non-pharmacological methods should be tried and continued for how many months before addition of pharmacological interventions 6 months
Is it safe for a breastfeeding mother to use warfarin? Yes- it is excreted through beast milk as an inactive medication and is safe to use with breastfeeding
Which vaccine is safe to give a 16 year old pregnant patient? DTap and influenza
Which supplement would you prescribe that is most like the food we eat Polymeric, less likely to cause diarrhea.
What is the most successful combination for smoking cessation Wellbutrin and nicotine replacement combined
Some effects of nicotine are its ability to produce dosage tolerance, produce relapse behavior, and produce withdrawal symptoms upon cessation. Which of the following is another effect of nicotine. Nicotine produces mood alterations, increases energy levels, and decreases appetite.
How long should it take to exhibit seroconversion with hepatitis B 6 months
If seroconversion is not occurring within 6 months, what should you do? Repeat 1-3 vaccines, if no seroconversion above 10 mIu/ml then it is unlikely they will develop antibodies.
What type of feeding would you prescribe for short bowel syndrome. monomeric solution- educate regarding risk of diarrhea
Recommended dosage for folic acid with childbearing women. 400 mcg/d
Dilantin can interfere with the absorption of which vitamin? Folic acid, which can lead to pernicious anemia
Can you continue to smoke while taking Chantix? Yes- you an smoke while taking Chantix and Wellbutrin
Dilatin side effects Its use necessitates good oral hygiene to prevent bleeding, tenderness, and gingival hyperplasia
True or False/ all classes of antidepressants are equally effective True, SSRI, SNRI, MAOI, and Tricyclics are all equally effective
To differentiate between a major depressive disorder and dysthymic disorder, the nurse should ask which question? How long have you been feeling this way?
Which of the following would indicate an opiate addiction? I accidentally overdosed on my pain med and need a new RX because that is the only thing that works.
First line treatment for early Parkinsons Sinemet
How does Sinemet work? Sinemet is levodopa/carbidopa, allowing buildup of dopamine in the brain and inhibiting the conersion of levodopa to dopamine.
Which anti-gout medication is classified as hepatoxic Colchicine and Allopurinol
What is the most common medical disorder causing depressive symptoms hypothyroidism
Which 2 beta blockers are approved for migraine prevention Timolol and Propanolol
Which herbal medication is contraindicated with SSRIs St. Johns Wart
Enterococcal infections very drug resistant and few drugs to treat
Moraxella Catarrhalis responsible for otitis media and upper respiratory infections
Gram positive Bacilli Listeria monocytogenes- responsible for meningitis, food borne illnesses and teratogenic in pregnancy.
Corynebacterium diptheria live on the skin and sometimes don't need to treat, can contaminate blood cultures
Gram negative bacilli deal with the most, longest list
Commonly in community and cause UTI proteus mirabilis, escheria coli, klebsiella pneumoniae
Haemophilus influenzae common in respiratory infections, resistant to becta lactamase
Pleomorphic may have awkward shapes and do not gram stain well
chlamydiae trachomatis STI- chlamydia
chlamydophila pneumoniae walking pneumonia
anaerobes often responsible for abscesses
What is MIC the MIC is read at the lest concentration of antibiotic which inhibited bacterial growth
Inherent resistance example gram negative wall is small, vancomycin can't be used due to structure
transformation obtain free DNA wih resistance gene
transduction resistance gene transferred by bacteriophage
conjugation plasmids (extrachromosal) and transposons (DNA segments) may be transferred from other bacteria.
ESBL Extended Spectrum Beta lactamase
Community acquired pneumonia may require combination therapy
Aminoglycosides Gentamicin, Tobramycin, Streptomycin, Amikacin, Kanamycin, Neomycin
Aminoglycosides used intravenously mostly for Tuberculosis or serious infections, Some like (amikacin, kanamycin, neomycin used to sterilize the gut for surgery)
Aminoglycosides used a lot for topical skin infections for the skin, eye and ear.
Aminoglycosides action inhibit protein synthesis
Aminoglycosides never used as monotherapy, why? Increased resistance
Aminoglycosides drug reaction nephrotoxicity, ototoxicity,neuro-muscular paralysis
Beta lactams Penicillins
Penicillin G routes PO, IV, IM
Penicillin V route PO (Pen VK oral best choice for strep throat)
PCN is drug of choice for spirochetes, what does sprirochetes cause Syphilis
Beta lactams are eliminated how renally eliminated and renally dosed.
Aminopenicillins Ampicillin (PO, IV), Amoxicillin (PO) Broader spectrum of activity They pick up gram negative agents where regular PCN does not
Aminopenicillins- cover which germs- work on typical gut flora Good for Strep, non-penicillinase staph, non-pcnase hemophilus influenzae, e. coli, proteus mirabilis, listeria monocytogenes
Amino-PCN drug reactions rash, allergic reactions, diarrhea, seizures (rare)
Ampicillin has enhanced activity for enterococcus and listeria
Antibiotics that focus on killing gram negative bacteria have a higher likelihood of causing c diff colitis
Most common pathogen for causing respiratory infections strep pneumo- PCN used to be drug of choice, now many are resistant or you have to increase dosage.
Antistaphylococcal PCN methacillin (IV) Nafcillin (IV) Oxacillin (PO, IV) CLoxacillin (PO) Dicloxacillin (PO)
Anti-staph PCN Spectrum Similar to Pen G but stable to pcnase staph strep No gram negative or enterococcal activity
Anti-staph drug reactions rash diarrhea interstitial nephritis (rare)
Anti-staph PCN drug of choice for staph infections skin infections bacteremia
Increased LFTs for: nafcillin or oxacillin
Beta lactam/ Beta lactamase inhibitor products Ampicillin/sulbactam (unasyn) Amoxicillin/clavulanic acid (augmentin) Ticarcillin/clavulanic acid (timentin) Piperacilli/tazobactam (zosyn)
Augmentin great for staph but not: MRSA
Good for anaerobes Usasyn Augmentin Timentin Zoyn
Accelerated reactions within PCN usually happen within the first hour and IgE mediated reactions. Don't rechallenge these patients with PCN.
1st Generation Cephalosporins cefazolin (Ancef, Kefzol) IV cephalexin (Keflex PO) (Cefadroxil Duricef PO)
1st gen. cephalosporins good gram positive activiy
No cephalosporin has activity against enterococci
Cefazolin often used preop to kill germs on the skin
2nd generation cephalosporins More gm negative activity than 1st generation. PO drugs: Ceftin Cefzil Ceclor
Mefoxin (Cefoxitin) and Cefotan (cefotetan) have this activity anaerobic activity
Ceftin, Cefzil and Ceclor will still work on beta lactam producing staph infections
3rd generation cephalosporins- less gram + activity Rocephin (ceftriaxone) Claforan (cefotaxime) Fortaz (ceftazidime) Cefobid (cefoperazone)
3rd generation action even more affective on gram negatives (enterobacter and providencia)
Ceftazidime (fortaz) used in community a lot because it is given as a once a day dose and can also be given IM
Cefazidime is most effective cephalosporin against: strep pyogenes, becomes important drug for URI and skin infections
Ceftriaxone no renal dosing necessary
Carbapenems (IV/IM) Imipenem/cilistatin (Primaxin) meroppenem (Merrem) doripenem (Doribax) ertapeem (Invanz) NO PSEUDOMONAS
Invanz similar to ceftriaxone except Invanz has anaerobe activity, ceftriaxone does not
Carbapenems are related to PCN and cephalosporins- watch for cross sensitivity
Glycopeptide Vancomycin
Vancomycin covers what gm positive only, very few anaerobes
Fluoroquinolones action inhibits DNA gyrase (topoisomerase II) inhibits topoisomerase IV
Fluoroquinolones spectrum (works well on) No Pneumococcal activity great gm negative pseudomonas (CIP) some gm positive mycobacteria atypical pathogens some anaerobes
Fluoroquinolones adverse effects tendon development in children tendon rupture in adults
fluoroquinolones drug interactions bind to Ca, Al, Mg, Zn, sucralfate, dairy products
fluoroquinolones P-450 interactions ciprofloxacin theophylline
fluoroquinolones examples Norfloxacin PO Ciprofloxacin PO, IV Pneumococcal Activity Levofloxacin (PO, IV) Moxifloxacin (PO, IV) Gemifloxacin (PO)
Fluoroquinolones ADRs GI (all oral quinolones) prolonged QT interval (Moxifloxacin) phototoxicity CYP drug interactions (theophylline, caffeine) Cipro specifically CNS/Neurotoxicity- cipro altered glucose homeostasis tendon rupture
Macrolides Erythromyin (PO/IV) Advanced generation Clarithromycin (Biaxin)PO Azithromycin (Zithromax) PO/IV
Macrolides spectrum Strep, some staph, atypical pathogens, h.influenzae (C, A), some mycobacteria (C, A)
Macrolide ADRs GI, ototoxicity, phlebitis, cholestatic hepatitis
Macrolide drug interactions Theophylline, cyclosporine, warfarin, carbamazipine, dig, phenytoin, rifabutin, ergotamine (interactions not generally seen with azithromycin)
Folate antagonists Sulfa drugs (PO) sulfamethoxazole sulfasoxazole sulfadiazine sulfadoxine Dapsone (PO) Trimethoprim (PO)
Folate antagonists action inhibit the exogenous production of folate in susceptible pathogens
Bactrim drug of choice in UTI Also works well on gm negatives Staph and some Strep Not enterococci and Not pseudomonas aeruginosa
Bactrim also DOC for weird bugs PCP pneumonia
Folate Antagonists- ADRs Hemolytic anemia in G6PD deficiency Rash (Steven Johnson) Photosensitivity GI Kernicterus (neonates) Hepatic or real failure Leukopenis and thrombocytopenia Aseptic meningitis
Folate Drug interactions Warfarin pheytoin oral hypoglycemics MTX cyclosporine
Anti-anaerobic agents Metronidazole (Flagyl PO/IV Clindamycin (Cleocin) PO/IV
Flagyl DOC in C diff Can have Disulfarim reaction when ingested with alcohol
Clindamycin- similar to macrolides (covers staph and strep) often used for CAMRSA Can be used oral and IV Most associated with C diff colitis
Tetracyclines Tetracycline PO Doxycycline (PO/IV) Minocycline (PO/IV)
Tetracyclines Spectrum some gm negatives and gm positives, atypicals, spirochetes
Tetracycline ADRs photosensitivity vestibular toxicity (minocycline) contraindicated in pregnancy and children bnds to Ca, Al Mg, Zn, sucralfate, dairy products
Fanconi's syndrome Syndrome (multi-organ failure) when taking outdated tetracycline
Tetracycline hepatoxicity
Oxazolidinone Class Lineolid (Zyvox)
Zyvox and Vancomycin act on Gram positive only
Zyvox works on MRSA and VRE
Zyvox used mainly for bad skin and soft tissue infection also MRSA pneumonia Very expensive
Zyvox drug reactions N/V/D thrombocytopenia neutropenia neurotoxicity lactic acidosis
Zyvox serious drug interactions Serotonin syndrome with (SSRI and meperidine) Sympathomimetic bronchodilators Vasopressors Cyclic and misc antidepressants Indirect-acting sympathomimetics (HTN crisis?) Amphetamines and related stimulants
Rifamycins Rifampin (PO/IV) Rifabutin (micobutin)PO
Rifamycins used for Mycobacteria- tuberculosis infections Also staph, H. Flu, N meningitidis, legionella Rapid development of resistance
Rifabutin blood dyscrasias
Rifamycins patient teaching discoloration of tears, sweat, contact lenses
Rifamycins drug interactions Cytochrome P-450 enzyme inducer no dosage adjustment in renal patients
Chloramphenicol major side effect idiosyncratic aplastic anemia an shut down bone marrow and can be irreversible
Pharyngitis is mostly caused by either Strep pyogenes (PCN) or a virus
PCN resistance in strep pneumo is not a beta lactamase phenomenon,it's an interaction in the binding protein. PCN can not penetrate or bind to bacteria
Hemophaelus influenza use 2nd or 3rd generation cephalosporins or quinolones Also cefuroxime or cefprozil
Strep pyogenese mostly viral by PenVK and Amoxicillin first line of choice 250-500 BID or TID X 10 days
Pathogens in otitis media Most to least common strep pneumoniae hempohilus influenzae moraxela catarrhalis
Amoxicillin resistant otitis media are common in day care and patients that have had antibiotics less than 3 months ago.
Moraxela catarrhalis produce beta lactamase which means Amoxicillin will never be effective for this organism
Antibiotic therapy for otitis media Amoxicillin 40-45mg/kg/day every 8 hours High dose Amoxicillin 80/90mg/kg/day q8hours High dose Augmentin 80-90mg/kg/day q12hours
For otitis media in children Cephalosporins taste REALLY BAD Azithromycin may have resistance Clindamycin not used a whole lot Bactrim rarely used and may have resistance
Sinusitis mostly caused by Strep pneumo and H. flu 9% caused by anaerobes
Antibiotcs commonly used for sinusitis Amoxicillin 500mg every 8 hours 10-14 days Augmentin 875mg every 12 hours 10-14 days Cefuroxime 250mg every 12 hours 10-14 days Azithromycin 500mg day 1, 250 days 2-5
Common causes of community acquired pneumonia Strep pneumo Mycoplasma pneumo H. flu Chlamydophila pneumo Legionella pneumo (serious and often hospitalized)
Prescribing regimen for pneumonia use Macrolides Fluroquinolones Doxycycline
Adult outpatient previously healthy treatment for pneumonia first line: Macrolide (erythromycin or clarithromycin) or an azalide (azithromycin or doxycycline
If patient fails or is allergic to first line pneumonia treatment use fluoroquinolones active against strep pneumo (Levofloxacin or moxifloxicin)
Adult outpatient with comorbidities of risk of resistant organisms with pneumonia if patient has not received abx within last 3 months- respiratory fluoroquinolone alone or combination of oral beta lactam (high dose amox. or amox/clav or 2nd 3rd generation cephalosporin plus macrolide or azalide
Adult inpatient with pneumonia do not give cipro as monotherapy because it does not cover strep pneumo well.
Cellulitis on the skin are most commonly gram + organisms Strep pyogenes Staph aureus
Skin infection following bites- first line therapy Amoxicillin/clavulanate
Bullous impetigo caused by staph aureus and erysipelas Oral penicillinase-resistant pcn, oxacillin and dicloxacillin
Impetigo caused by Group A strep Pen V and Pen G are used
Skin infections with PCN allergy erythromycin clindamycin doxicycline Bactrim Cephalosporin for strep
Most commonly used drug for MRSA skin and tissue infection is cephalexin, other first line drugs are: amoxicillin/cavulanate and azithromycin
Other drugs used for MRSA skin infections are TMP-SMZ, doxycycline or clindamycin
First generation cephalosporins should not be used for cat bites
Tuberculosis treatment results improvement should be noted within the first 3 months of therapy, if no improvement then either resistance or inaccurate diagnosis must be considered.
The CDC recommends that all patients with TB have testing for HIV infection at the time treatment is initiated
Treatment for TB has 2 phases: the first phase or initiation phase (bactericidal or intensive phase) lats for 2 months
The second phase is the continuation phase (sterilizing phase) lasts for 4 to 7 months
The 2 month regimin consists of four-drug therapy administered daily isoniazid (INH) rifampin (RIF) pyrazinamide (PZA) ethambutol (EMB)
Followed by 4 months of INH and RIF
for community acquired MRSA Clindamycin and Bactrim are drugs of choice
Impetigo Bactroban topical Strep pyogenes bacteria present
Diabetic wounds often staph and/or strep
Drug of choice for bites Augmentin For PCN allergy Doxicycline Clindamycin
Ecoli is most common organism in uncomplicated cystitis, other causes are S. saprophyticus, K pneumoniae, P. mirabilis, enterococcus spp
Drug of choice for UTI Bactrim
trimethoprim can be used alone for people with what allergy sulfa allergy, 3 day therapy for uncomplicated
Syphilis PCN drug of choice
When treating for chlamydia, also treat for gonorrhea Drug regimen azithromycin-single dose or doxycycline
treatment of gonorrhea ceftriaxone or cefixime plus azithromycin or doxycycline
Topical anti-infectives are more readily absorbed through denuded or burned areas
Mupirocin (Bactroban) should not be used on burns, especially extensive burns or wounds, or other damaged skin because the vehicle for the medication may be a problem if he patient has renal impairment.
Impetigo is usually caused by staph aureus or strep pyogenes. if impetigo is bullous is probably pure staph aureus
Treatment for impetigo if only 1 or 2 lesions use OTC ointment if up to 5 singular lesions use bactroban tid add oral antibiotics if more than 5 lesions (Keflex, augmentin, or dicloxacillin)
People predisposed of furuncle (boil or abscess) people with immunosuppression, malnutritio, blood dyscrasias, atopic dermatitis, DM, or renal dialysis
Furuncle usually caused by staph aureus
Furuncle treatment topical antibiotics are ineffective, must use systemic antibiotics: Augmentin 1st generation cephalosporin dicloxacillin
Violet cellulitis with bullae suggests Strep pneumoniae (pneumococcus)
Mild cellulitis treatment oral antibiotics such as Augmentin or a broad spectrum cephalosporin, re-evaluate in 24-48 hours.
Nasal MRSA treatment Mupirocin (bactroban) BID X 5 days
Topical antifungals are poorly absorbed from intact skin
systemic antifungals are primarily metabolized in the liver
Which topical antifungals are teratogenic- avoid during pregnancy and lactation ketoconazole (Nizoral) econazole (Spectazole)
which topical antifungals are safe in use for children nystatin, gentian violet, and miconazole
Do not use these antifungals in children under 2 Tolnaftate (Tinactin) Ketoconazole (Nizoral) Clotrimazole (Lotrimin)
Griseofulvin- antifungal may be hepatotoxic possible cross sensitivity to penicillin
Candidiasis often presents as erythematous confluent rash with red satellite lesions.
Always take Griseofulvin with a fatty meal for better absorption
Tinea capitis (ringwom of the scalp) Always treat with systemic antifungal antifungal of choice is griseofulin taken daily for 6-8 weeks.
Tinea corporis ringworm on the skin annular lesions diagnoses with KOH scrapings topical treatment
Tinea cruris jock itch treat with topical miconazole tolfanate clotrimazole (Nystatin is not effective)
Tinea Pedis Athletes foot treatment is topical and should continue for at least a month
Tinea unguium Nail fungus treatment involves months of systemic antifungal medications
Nail fungus drug of choice griseofulvin given for at least 4 months for fingernail and 6 months for toenail
Griseofulvin labs renal, liver function, cbc q 2 months
First line for moderate and severe acne Minocycline Doxycycline Tetracycline Limit erythromycin to those that cannot use tetracyclines (prenant, children under 8)
Systemic Retinoids- Isotrentinoin (Accutane) Limited to severe recalcitrant nodular acne
Topical corticosteroids contraindicated in primary bacterial infections, rosacea, or acne vulgaris
Use of high-potency or very-high potency topical steroids contraindicated on the face, groin or axilla
Ointments more potent and effective due to their occlusive nature generally preferable in dry brittle, fissured, scaly, or hyperkeratinized skin Should not be used in axilla, groin or intratriginous areas
Creams are cosmetically more acceptable
Gels non-greasy, non-occlusive, non-staining, and quick drying. Most useful in hairy or facial areas where residue is unacceptable.
Lotions least occlusive type of vehicle. Useful when large skin areas or skin flexures are affected.
hallmark sign of chronic bronchitis chronic cough
Recommended asthma assessment peak flow morning assessment
Short acting beta agonists albuterol (Ventolin, ProAir, Proventil) Levalbuterol (Xopenex) Pirbuterol (Maxair)
Long acting beta agonists Salmeterol- serevent Formoterol- foradil perforomist Arformoterol- Brovana Indacaterol- Arcapta
Beta agonists mechanism bind beta adrenergic receptors, stimulate adenylate cyclase, increase cAMP Effects- smooth muscle relaxation, bronchodilator
Short disctinctions (beta agonists) Levalbuterol has slightly longer duration than parent albuterol
Long distinctions (beta agonists) Salmeterol has long onset (about 30 min) Formoterol has short onset (rapid onset) Indacaterol has longest duration
long acting beta agonists not recommended for asthma therapy by itself, beta cells can down regulate and not be effective when needed
Anticholinergics Short acting Ipatropium (Atrovent) Long acting Tiotropium (Spiriva) Aclidinium (Tudorza)
Anticholinergics mechanism block acetylcholine receptors Effects Prevent bronchoconstriction reduce mucus formation
Ipatropium dosing (used in acute situation) Typically qid
Tiotropium -spiriva (usually first choice in COPD) Dry powder inhaler once q 24 hours
Aclidinium- Tudorza 1 inhalation q 12 hours
Anticholinergic side effects dry mouth nausea urinary retention, glaucoma (rare) arrhythmias
Anticholinergic drug interactions cholinesterase inhibitors (alzheimers medications) anticholinergics
Theophylline therapeutic Peak serum level 5-15 mcg/ml
Theophylline adverse effects N/V, tachycardia, tremor, nervousness, insomnia, seizures, death
Theophylline drug interactions Cimetidine, fluvoxamine Rifampin, barbiturates, phenytoin, carbamazepine, St. Johns Wort
Roflumilast only approved for COPD not asthma
Mast cell stabilizer Cromolyn 20 mg neb qid reduces release of histamine
Leukotriene antagonists effects inhibit bronchoconstriction anti-inflammatory
Leukotriene antagonists example Accolate Singular 10mg once/day Headache most common side effect
Singulair Asthma has clear data to support use, COPD offers some theoretical benefit, but little in prospective studies.
Inhaled corticosteroids ICS flunisolide (Acrospan) beclomethasone (QVAR) budesonide (Pulmicort) fluticasone (Flovent) Mometasone (Asmanex) ciclesonide (Alvesco)
Effects of ICS on COPD reduce hospitalizations improved pulmonary function reduced airway inflammation increased pneumonia
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