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ID1 C/P
Infectious Diseases I - Clinical pearl
| Question | Answer |
|---|---|
| Q1. Anti-staphylococcal penicillins (ASPs) | • IV Nafcillin, Oxacillin, Cloxacillin • PO Dicloxacillin |
| Q2. Natural penicillins | • IV penicillin G (aqueous): Pfizepen • IM penicillin G Benzathine: Bacillin L-A • Bacillin C-R: above + pen G procain • PO Penicillin V (Pen-Vee K, Veetids): 250-500 mg PO QID EMPTY stomach |
| Q3. Additional coverage for Aminopenicillin + beta-lactamase inhibitor vs Aminopenicillin | • Anaerobes, MSSA |
| Q4. Which penicilline cover MSSA | • Anti-staphylococcal penicillins • Aminopenicillin + beta-lactamase inhibitor • Extended spectrum penicillins |
| Q5. What penicillines cover Atypicals | • NON of them |
| Q6. What penicillines cover Anaerobes | • Aminopenicillin + beta-lactamase inhibitor • Extended spectrum penicillins |
| Q7. Amoxicillin: common indications and doses | • Acute otitis media: 80-90 mg/kg/day (pick 90 for calculation) • Infective endocarditis prophylaxis: 2 grams PO x1 • H. pylori regimens |
| Q8. Amoxicillin/Clavulanate (Augmentin): common indications and doses | • Acute otitis media: 90 mg/kg/day • Use lowest dose of clavulanate possible |
| Q9. Penicillines Class effects | • Beta-lactam allergy, risk of seizures (with accumulation) • Renal dose adj --> oki for seizures |
| Q10. Penicillin G Benzathine (Bicillin L-A): common indications and doses | • Syphilis: 2.4 million units IM x 1 |
| Q11. Pennicilline w/o renal dose adjustments | • Nafcillin and Oxacillin (inj) • Dicloxacillin (PO) |
| Q12. What cephalosporines cover Atypicals | • NON of them |
| Q13. What cephalosporins cover MRSA | • 5th generation (ceftaroline) |
| Q14. What cephalosporins cover Anaerobes | • Cefoxitin / cefotetan |
| Q15. Cepha vs peni coverage | • Most of peni + Enterococcus (not VRE) |
| Q16. 1st Generation PO: Cephalexin - common indications and doses | • Strep throat, MSSA skin infections |
| Q17. 2nd Generation PO: Cefuroxime - common indications and doses | • Acute otitis media, CAP |
| Q18. 3rd Generation PO: Cefdinir - common indications and doses | • Acute otitis media |
| Q19. 1st Generation (Parenteral): Cefazolin - common indications and doses | • Surgical prophylaxis |
| Q20. 2nd Generation: Cefotetan, Cefoxitin - common indications and doses | • Surgical prophylaxis (GI procedures) • Cefotetan: disulfiram-like reaction |
| Q21. 3rd Generation: Ceftriaxone and Cefotaxime - common indications and doses | • CAP, meningitis, SBP, pyelonephritis • Ceftriaxone: no renal dose adjustment, do not use in neonates |
| Q22. Cepha Pseudomonas coverage | • 3rd Generation (Ceftazidime) • 4th Generation (Cefepime) |
| Q23. • Meropenem/vaborbactam • Imipenem/cilastatin/relebactam | Additional activity against some carbapenemase-producing gram-negatives |
| Q24. Ertapenem vs other Carbapenems | Lack of PAE: • Pseudomonas • Acinobacter • Enterococcus (not VRE) |
| Q25. Aztreonam vs Carbapenems | Lack of: • Gram positive (Enterococcus - not VRE, MSSA, Streptococcus) • Anaerobes |
| Q26. Ertapenem must be diluted in NORMAL SALINE. | YES |
| Q27. Penicillin allergy | Do not use carbapenem, instead use Aztreonam |
| Q28. Seizure risk | Carbapenem • Risk increase w higher doses, failure to dose adj in renal dysfunction, or use of imipenem/cilastatin Penicillines Risk w accumulation w/o renal dose adj --> If adjust renal dose: oki for seizures |
| Q29. Aminoglycosides spectrum | • Gram-negative bacteria (including Pseudomonas) • Synergy for gram-positive infections • Toxicities: Nephrotoxicity (watch for additive effects), Ototoxicity |
| Q30. Aminoglycosides dose | • Traditional: 1.5-2.5 mg/kg Q8H. Monitor: Peaks/troughs • Extended Interval: 4-7 mg/kg Q24H. Monitoring: Mid-interval (10-14H post dose) • Use adjusted body weight if obese |
| Q31. Respiratory Quinolones | • Levofloxacin • Moxifloxacin w reliable S. pneumoniae activity (in pneumonia) |
| Q32. Antipseudomonal Quinolones | • Ciprofloxacin, levofloxacin • Used for Pseudomonas infections (including pneumonia) |
| Q32. Quinolones - Common Uses | • Can vary by agent: pneumonias, UTIs, IAIs, travelers' diarrhea |
| Q33. Atypical pathogen activity | • Quinolones • Macrolides • Tetracyclline |
| Q34. Quinolone - not use for UTIs | • Moxifloxacin • Only quinolone that is not renally adjusted |
| Quinolone - IV to PO Ratio 1:1 | Levofloxacin and moxifloxacin |
| Quinolone - Counseling | • Avoid sun exposure, separate from polyvalent cations, monitor blood glucose (in diabetes) • Watch for tendon rupture, neuropathy, CNS or psychiatric side effects |
| Quinolone - Profile Review Tips | • Caution with CVD, reduce K/Mg and with other QT-prolonging drugs (e.g., azole antifungals, antipsychotics, methadone, macrolides) • Avoid in patients with a seizure history or if using seizure drugs • Avoid in children |
| Macrolides coverage | • Atypicals, Bordetella pertussis |
| clarithromycin & erythromycin contraindicated with | lovastatin and simvastatin |
| Macrolides Drug interactions (clarithromycin & erythromycin) | CYP INHIBITORS |
| Tetracyclines | • Atypicals, gram-positives (MRSA), some gram-negatives, unique pathogens • Does not prolong QT • Avoid in pregnancy and children < 8 years of age • Photosensitivity, chelation |
| Sulfamethoxazole/trimethoprim | • MRSA, PEK, opportunistic pathogens (Stenotrophomonas, Pneumocystis, Toxoplasma) • SMX:TMP 5:1, dose TMP • SEs (photosensitivity, hemolytic anemia: + Coombs test) • Warfarin interaction • Hyperkalemia: particularly with IV therapy and/or high doses |
| Vancomycin Dosing for MRSA | • IV, weight-based (renal adjustments) • Cause infusion reaction (it is infused too quickly) |
| Vancomycin Dosing for C. difficile | PO, fixed dose |
| Monitoring | • Serious MRSA infections: AUC/MIC ratio 400-600 or goal trough 15-20 mcg/mL • Other infections: goal trough 10-15 mcg/mL |
| Daptomycin | • CPK elevations/muscle-related ADRs • Inactivated by pulmonary surfactant (will not treat pneumonia) •Compatibility with NS |
| Linezolid (Zyvox) | • IV:PO ratio is 1:1 • "Serotonergic" / drug interactions • Thrombocytopenia |
| Clindamycin (Cleocin) | • Anaerobic and gram-positive activity • D-test: Positive result indicates inducible clindamycin resistance • High risk of C. diff |
| Metronidazole (Flagyl) | • Anaerobic activity only • Patient counseling: Disulfiram reaction, Metallic taste, Drug interactions (warfarin) |
| Nitrofurantoin (Macrodantin, Macrobid) | • Cystitis only • CrCl < 60 ml/min: not recommended • Gl upset (take with food) • Urine discoloration (brown) |
| Methicillin-susceptible Staphylococcus aureus (MSSA) | • Dicloxacillin, nafcillin, oxacillin • Cefazolin, cephalexin (and other 1st and 2nd generation cephalosporins) • Amoxicillin/clavulanate, ampicillin/sulbactam |
| Methicillin-resistant Staphylococcus aureus (MRSA) | • Vancomycin (consider using alternative if MIC ≥ 2) • Linezolid • Daptomycin (not in pneumonia) • Ceftaroline • SMX/TMP (CA-MRSA SSTIs) • Doxycycline, minocycline (CA-MRSA SSTIs) • Clindamycin* (CA-MRSA SSTIs) |
| Vancomycin-resistant Enterococcus (VRE) | • Pen G or ampicillin (E. faecalis only) • Linezolid • Daptomycin |
| HNPEK | • Beta-lactam/beta-lactamase inhibitor • Cephalosporins (except 1" generation) • Carbapenems • Aminoglycosides • Quinolones • SMX/TMP |
| ESBL producing gram-negative rods (E. coli, K. pneumoniae, P. mirabilis) | • Carbapenems • Ceftazidime/avibactam • Ceftolozane/tazobactam |
| Carbapenem-resistant gram-negative rods (CRE) | • Ceftazidime/avibactam • Colistimethate, polymyxin B • Meropenem/vaborbactam • Imipenem/cilastatin/relebactam |
| Gram-negative anaerobes (Bacteroides fragilis) | • Metronidazole • Beta-lactam/beta-lactamase inhibitor • Cefotetan, cefoxitin • Carbapenems • Moxifloxacin (reduced activity) |
| Pseudomonas aeruginosa | • Piperacillin/tazobactam • Cefepime • Ceftazidime • Ceftazidime/avibactam • Ceftolozane/tazobactam • Carbapenems (except ertapenem) • Ciprofloxacin, levofloxacin • Aztreonam • Tobramycin • Colistimethate, polymyxin B |
| Abx work on Cell wall synthesis - Plasma membrane integrity | • Daptomycin • Polymyxins |
| Abx work on Cell wall synthesis - Peptidoglycan synthesis | Vancomycin |
| Abx work on Cell wall synthesis - Peptidoglycan cross-linking | • Penicillins • Cephalosporins • Monobactam • Carbapenems |
| Abx work on Ribosome/protein synthesis - 30S subunit (A T) | • Aminoglycosides • Tetracyclines |
| Abx work on Ribosome/protein synthesis - 50S subunit (M C L) | • Macrolides • Clindamycin • Linezolid |
| Abx work on RNA synthesis | • Rifampin |
| Abx work on DNA synthesis (F Me) | • Fluoroquinolones • Metronidazole |
| What Abx should be avoided due to musculoskeletal toxicity during pregnancy, when breastfeeding & in children | Fluoroquinolones (eg, levofloxacin) should be avoided during pregnancy due to the risk of musculoskeletal toxicity in the developing fetus. |
| Enterobacter cloacae | Gram egative, more drug-resistant (AmpC beta-lactamase) (1st, 2nd, 3rd cepha: avoid). Pip/tazo, cefepime (4th), and carbapenems have activity against E. cloacae. |
| What Abx has the highest risk for seizure? | Imipenem (a carbapenem) carries the highest risk of seizures among all beta-lactam antibiotics. |
| What Abx cause Hemolytic anemia (identified with a positive Coombs test)? | • Cephalosporins • Penicillins • Bactrim (G6PD deficiency) |
| Macrolides coverage | • Atypicals (Legionella spp., Mycoplasma pneumoniae, Chlamydophila pneumoniae) • MAC • Bordetella pertussis, Haemophilus spp., Moraxella catarrhalis • Streptococcus pneumoniae • Chlamydia trachomatis |
| Minocycline SEs | Drug-induced lupus erythematosus (minocycline only, not other tetracycline) |
| Factors should be considered when recommending an empiric antibiotic regimen | • Drugs (route, spectrum, PK/PD, SEs) • Pt (Age, weight, allergy, renal / liver function, resistant risk, pregnancy, immune status) • Diseases (Site of infection, severity) |
| Prior initiate Nitrofurantoin, what lab to be assessed | • Nitrofurantoin: reduced efficacy and increased risk of AEs (pulmonary toxicity, hepatotoxicity, peripheral neuropathy) in renal impairment. • Contraindicated with a CrCI ≤ 60 mL/min. |
| Bactrim coverage | • (+): Streptococcus spp., MSSA, MRSA • (-): Proteus spp., Escherichia coli, Klebsiella spp. • Opportunistic pathogens (eg, Pneumocystis jirovecii, Stenotrophomonas maltophilia, Toxoplasma gondii) |
| Daptomycin monitoring | • SCr (for renal dose adjustments) • CPK at baseline and weekly • Signs/symptoms of myopathy (muscle pain or weakness) |
| Gentamicin or tobramycin traditional dose: goal of peak / trough | For 4th dose: • Peak (goal 5-10 mcg/mL): 30 min after the end of infusion • Trough (goal < 2 mcg/mL): before infusion (< 30 min) |
| Abx cover Atypical bacteria • Legionella spp. • Mycoplasma pneumoniae • Chlamydophila pneumoniae | • Fluoroquinolones (eg, levofloxacin, ciprofloxacin) • Macrolides (eg, azithromycin, clarithromycin) • Tetracyclines (eg, doxycycline, minocycline) |
| Select type of body weight for gentamicin & tobramycin dosing | • TBW if TBW < IBW • IBW • Adj BW if TBW > 120% IBW |
| 1st cephalosporin | • PO: cephalexin & cefadroxil • IV: cefazolin |
| 2nd cephalosporin | • PO: cefaclor & cefprozil • IV/PO: cefuroxime • IV: cefotetan & cefoxitin |
| 3rd cephalosporin | • PO: cefdinir, cefpodoxime & cefixime • IV: ceftazidime • IV/IM: ceftriaxone |
| 4th cephalosporin | • IV: cefepime |
| 5th cephalosporin | • IV: ceftaroline fosamil (Teflaro) & ceftobiprole |
| Cephalosporin/beta-lactamase inhibitor combination | • IV: ceftolozane/tazobactam (Zerbaxa) • IV ceftazidime/avibactam (Avycaz) |
| Counsel Fluoroquinolones | • Pain or tenderness at the back of your ankle: contact MD • Monitor your BG more frequently while taking this medication. • Protect your skin from sunlight • Psychiatric effects (eg, agitation, delirium) • Musculoskeletal toxic • (QT prolongation) |
| Aminoglycosides toxicities | • Nephrotoxicity • Ototoxicity. Regular monitoring creatinine, urine output and auditory function (ie, audiometric testing) are essential to minimize risks. |
| VCM infusion rate | • Not to exceed 1 gram/hr (INCREASE risk of infusion reaction if infused more quickly) |
| What effect does clavulanate have on amoxicillin in amoxicillin/clavulanate | • Expands spectrum of activity • Inhibits degradation |
| Lipoglycopeptides | • Telavancin (Vibativ) • Oritavancin (Orbactiv, Kimyrsa) • Dalbavancin (Dalvance) (Vancomycin - glycopeptides) |
| Cyclic lipopeptide | • Daptomycine |
| Liquid oral antibiotics - Refrigerate | • Peni V • Augmentin (optional for Amox) • All Cepha, except Cefdinir • Fidaxomicin • Vancomycin |
| Which antibiotic requires a D-test to verify that its reported susceptibility is reliable prior to use? | • Clindamycin D-testing is used to detect inducible resistance in clindamycin-susceptible Staphylococcus aureus isolates. A positive test indicates that resistance to clindamycin can develop during treatment and that clindamycin should be avoided. |
| Glycylcycline | Tigecycline |
| Lincosamide | Clindamycin |
| Oxazolidinone | Linezolid |
| Dificid (fidaxomicin) | • Target C. difficile. • Large, complex structure and poor water solubility limit systemic absorption, achieve high concentrations in the colon where C. difficile resides. • Minimizing systemic adverse effects. |
| Zyvox (linezolid) DDI | Concurrent use of linezolid (a monoamine oxidase inhibitor) with other serotonergic medications (eg, St.John's wort, tramadol) increases the risk of serotonin syndrome. |
| Storage, handling of select IV antimicrobials | • NOT refrigerate: Acyclovir, Metronidazole, Moxifloxacin, Bactrim • Protect from light: Doxycycline, Micafungin, Pentamidine |
| Compatibility of select IV antimicrobials | • Dextrose: Amphotericin B, Pentamidine, Bactrim • Saline: Ampicillin, Unasyn, Ertapenem • Saline or lactated Ringer: Caspofungin, Daptomycin |
| Zyvox (linezolid) safety issues | • Myelosuppression (thrombocytopenia, anemia, leukopenia): increase risk when used > 14 days • Neuropathy (optic, peripheral): increase risk when used > 28 days • Hypoglycemia |
| Anaerobes | - Gram positive: Peptostreptococcus, Actinomyces spp., Clostridium spp. - Negative: Bacteroides fragilis, Prevotella spp. |
| C. diff | Gram positive Anaerobes |
| Atypicals (L - C - M) | - Legionella spp. - Chlamydia spp. - Mycoplasma pneumoniae, Mycobacterium tuberculosis |
| Listeria is an Atypical bug | - FALSE - Listeria monocytogenes is gram POSITIVE rod - Common in Meningitis in neonants, > 50 yrs, immunocompromised - Ampicillin - Ampicillin + gentamicin |
| Collateral damage | - C. diff infection: all Abx, BW for clindamycin - Healthy GI flora is killed by Abx - Overgrowth of resistant pathogens - Diarrhea, abdominal cramping, colitis - Can be fatal |
| ABx cover community MRSA | - Doxycilline - Common choice for skin infections, acne |
| Minocycline: DILE | TRUE |
| ABx w Red man syndrome with rapid infusion | - Vancomycin, NOT true allergy, infusion reaction - SHOULD NOT exceed 1g/1h |
| LIPOGLYCOPEPTIDES | - Skin infection - Telavancin (+ HAP/VAP) - oritavancin, dalbavancin: single dose regimens - red man syndrome |
| ABx are NOT allowed to use in G6PD deficiency 2/2 hemolytic anemia "Don't Need Pretty Pills, Sulfa" | D = Dapsone N = Nitrofurantoin P = Primaquine P = Probenecid S = Sulfamethoxazole Then remember: • Chloroquine (antimalarial cousin) |
| ABx are NOT allowed to use if Comb test positive "PCR-Q RINS" | P = Penicillins C = Cephalosporins R = Rifampin Q = Quinine R = (repeat Rifampin) I = Isoniazid N = Nitrofurantoin S = Sulfamethoxazole And remember: • Clavulanate/tazobactam can also be implicated |
| ABx cause Drug-induced lupus erythematosus (DILE): "butterfly" rash, achy joints, lab tests (RF+, T ANA, ESR, CRP) "MIT" | M = Minocycline I = Isoniazid T - Terbinafine Other: Hydrazaline, methydopa, Procainamide |
| Light protection during administration | Doxycycline Micafungin Pentamidine |
| Compatible with dextrose only | - Dalbavancin, oritavancin - Pentamidine - Quinupristin/Dalfopristin (Synercid) - Bactrim - Amphotericin B (conventional, Abelcet, Ambisome) |
| Compatible with saline only | - Ampicillin - Ampicillin/ Sulbactam - Ertapenem |
| Compatible with saline and LR | Daptomycin |
| Gram (+) cocci clusters | Staphylococcus spp. (incl MRSA, MSSA)| |
| Gram (+) diplococci | Strep, pneumonice |
| Other Gram (+) cocci Pairs & chains | - Streptococcus spp. (including Strep. pyogenes) - Enterococcus spp. (including VRE) |
| Gram (-) cocci | Neisseria spp. |
| Gram (-) rods Colonize gut "enteric" "PEK SEC" | - Proteus mirabilis - Escherichia coli - Klebsiella spp. - Serratia spp. - Enterobacter cloacae - Citrobacter spp. |
| Gram (-) rods Do not colonize gut | - Pseudomonas aeruginosa - Haemophilus influenzae - Providencia spp. |
| Gram (-) Coccobacilli A B M | - Acinetobacter baumannii - Bordetella pertussis - Moraxella catarrhalis |
| Gram (-) rods Curved or spiral shaped | - H. pylori, Campylobacter spp., Treponema spp. - Borrelia spp., Leptospira spp. |
| Clostridium spp. | C. perfringens (Gas gangrene) C. difficile (Pseudomembranous colitis) C. tetani (Tetanus) C. botulinum (Botulism) |
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