NURS 5334/ NURS5334 Test 1 – Advanced Pharmacology Review | UTA (Latest 2026/ 2027 Update) 500+ Verified Questions & Answers | Grade A

NURS 5334/ NURS5334 Test 1 – Advanced Pharmacology Review | UTA (Latest 2026/ 2027 Update) 500+ Verified Questions & Answers | Grade A 2026/2027 | GRADED A+ | 100% VERIFIED Question: Pregnancy: Changes in drug metabolism Answer -Hepatic metabolism and GFR increase during pregnancy, dosages of some drugs may need to be increased -For some drugs, hepatic metabolism increases during pregnancy-- some drugs may need to be increased -Tone and motility of the bowel decrease in pregnancy, causing intestinal transit time to increase --more time for drugs to be absorbed-- might need to reduce dosage -Prolongation of drug effects total 1-2 life increases Question: Fetal development in pregnancy (stages) Answer -preimplantation/presomite: conception-2 weeks: all or nothing -embryonic period: weeks 3-8: gross malformations -Fetal period: week 9- term: exposure disrupts function not gross anatomy Question: Pregnancy Labeling Answer -As of 2015, the Food and Drug Administration had a Pregnancy and Lactation Labeling Rule change. -No more lettering of the categories of drugs for pregnancy. According to the lettering system, drugs can be put into one of five risk categories: be A, B, C, D, and X. -By 2020, all prescriptions must remove lettering labels altogether. -The PLLR requires three sections for labeling: o (1) pregnancy, (2) lactation, and (3) females and males of reproductive potential. Question: How do you decrease risk in the infant during breastfeeding? Answer o Take the drugs immediately after breastfeeding o Avoid drugs that have long half-lives o Choose drugs that tend to be excluded from milk, and that are least likely to affect the infant o Avoid the drugs that are known to be hazardous o Use the lowest effective dosage for the shortest possible time o Abandon plans to breastfeed if a necessary drug is known to be harmful to the child. Question: How do pediatric patients differ in their response to medication? Absorption? Answer o Oral administration -Gastric emptying time is prolonged & irregular in early infancy · Adult function at 5-8 months · For drugs that are absorbed primarily from the stomach, delayed gastric emptying enhances absorption · For drugs that are absorbed primarily from the intestine, absorption is delayed · Because gastric emptying time is irregular, the precise effect on absorption is not predictable - Gastric Acidity · Very low 24 hours after birth · Does not reach adult values for 2 years · Low acidity absorption of acid-labile drugs is increased o Intramuscular -Slow, erratic in neonates - Delayed absorption as a result of low blood flow during the first few days of life - By early infancy, absorption of IM drugs is more rapid than in neonates and adults o Skin - More rapid and complete in infants than in older children and adults - The stratum corneum of the infant's skin is very thin, and blood flow to the skin is greater in infants than in older patients. Because of this enhanced absorption, infants are at increased risk for toxicity from topical drugs. Question: How do pediatric patients differ in their response to medication? Distribution r/t protein binding? Answer -Binding of drugs to albumin and other plasma proteins is limited in the infant - Amount of serum albumin is relatively low - Endogenous compounds (fatty acids, bilirubin) compete with drugs for available binding sites - Limited drug/protein binding in infants -- concentration of free levels of drugs that usually undergo extensive protein binding in adults is relatively high in the infant -- intensified effects - Reduced dosage needed - Adult protein binding capacity by 10-12 months of age Question: How do pediatric patients differ in their response to medication? Distribution r/t BBB? Answer - Not fully developed at birth - Drugs and other chemicals have relatively easy access to the CNS - Infants are especially sensitive to drugs that affect CNS function - all medicines employed for their CNS effects (e.g., morphine, phenobarbital) should be given in reduced dosage - Dosage should also be reduced for drugs used for actions outside the CNS if those drugs are capable of producing CNS toxicity as a side effect Question: How do pediatric patients differ in their response to medication? Metabolism r/t Hepatic function? Answer o The drug-metabolizing capacity of newborns is low o Neonates are especially sensitive to drugs that are eliminated primarily by hepatic metabolism o The liver's capacity to metabolize many drugs increased rapidly about 1 month after birth o The ability to metabolize drugs at the adult level is reached a few months later o Complete liver maturation occurs by 1 year of age o Dosages must be reduced Question: How do pediatric patients differ in their response to medication? Renal excretion? Answer o Significantly reduced at birth o Low renal blood flow, glomerular filtration, and active tubular secretion o Drugs eliminated primarily by renal excretion must be given in reduced dosage and/or longer dosing intervals o Adult levels of renal function achieved by 1 year Question: Definition of polypharmacy Answer Treatment with multiple drugs Question: Beers List Answer a list of drugs for which monitoring is especially important and possible inappropriate to administer in elderly patients -should avoid these drugs Question: Geriatric patient changes in absorption Answer o Altered GI absorption is not a major factor in drug sensitivity -Oral dose does not usually change with age o Rate of absorption may slow with age - D/t Delayed gastric emptying and reduced splanchnic blood flow also occur - Drug responses may be delayed o Gastric acidity is reduced -- may alter the absorption of certain drugs -some drug formulations require high acidity to dissolve, and hence their absorption may be reduced. Question: Geriatric patient changes in distribution Answer (1) increased percentage of body fat · Increased storage depot for lipid-soluble drugs (e.g., propranolol) · Results in decreased plasma level -- reduction in response (2) decreased percentage of lean body mass (3) decreased total body water · Because of the decline in lean body mass and total body water, water-soluble drugs (e.g., ethanol) become distributed in a smaller volume than in younger adults -- the concentration of these drugs is increased, causing effects to be more intense. (4) reduced concentration of serum albumin · Although albumin levels are only slightly reduced in healthy older adults, these levels can be significantly reduced in older adults who are malnourished -- reduced albumin levels -- sites for protein binding of drugs decrease-- levels of free drug rise Question: Geriatric changes in metabolism Answer o Hepatic metabolism declines with age o Reduced hepatic blood flow, reduced liver mass, and decreased activity of some hepatic enzymes occur o The half-lives of some drugs may increase, and responses are prolonged o Response to oral drugs (e.g., those that undergo extensive first-pass effect) may be enhanced because fewer drugs are inactivated before entering the systemic circulation. o Important to note: the degree of decline in drug metabolism varies greatly among individuals. As a result, we cannot predict whether drug responses will be significantly reduced in any particular patient. Question: Geriatric changes in renal excretion Answer o Renal function undergoes progressive decline beginning in early adulthood. - Reduction in renal blood flow, GFR, active tubular secretion, and # of nephrons o Drug accumulation secondary to reduced renal excretion is the most important cause of ADRs in older adults. o when patients are taking drugs that are eliminated primarily by the kidneys, renal function should be assessed. - In older adults, the proper index of renal function is creatinine clearance, not serum creatinine levels (because lean muscle mass which is the source of creatinine declines parallel to kidney function creatinine levels may be normal even though kidney function is greatly reduced) -Although most medication adjustments for renal problems use creatinine clearance, for a few medications the estimated glomerular filtration rate (eGFR) is used. Question: Gram positive bacteria Answer Staph, strep, enterococcus, some other atypicals (everything else is gram negative) Bacteriostatic (drugs that slow bacterial growth but do not cause cell death) Answer ECSTaTiC -Erythromycin -Clindamycin -Sulfamethoxazole -Trimethoprim -Tetracycline -Chloramphenicol Bactericidal (Drugs that are directly lethal to bacterial) Answer Very Finely Proficient At Cell Murder -Vancomycin -Fluoroquinolones -Penicillin -Aminoglycosides -Cephalosporins -Metronidazole What is empiric antibiotic use? Answer -Empiric-based on clinical presentation -Covering most likely organisms -Cultures should be obtained prior to initiation -Re-evaluated upon results Which antibiotics work by weakening the cell wall? Penicillin's, cephalosporins, carbapenems, vancomycin, telavancin, monobactam, Fosfomycin (monurol) Which PCNS are narrow spectrum with penicillinase resistance (antistaphylococcal penicillin's)? Nafcillin, oxacillin, and dicloxacillin (good for s. aureus and s. epidermidis) *drug of choice for staph infections *not affected by beta-lactamase bacteria Which PCN's are narrow spectrum and penicillinase sensitive? Which are good for strep and syphilis? Penicillin V (strep) & G (syphilis) There is a sensitive cleavage of and inactivation of the beta-lactam ring Penicillin V -similar to PCN G stable in stomach acid-- better for oral therapy than penicillin G -Take with meals Penicillin G (Benzylpenicillin) organism coverage -Bactericidal -Narrow-spectrum -Covers: gram-positive bacteria (except penicillinase-producing staph) -and some gram-negative (N. meningitidis and non-penicillinase-producing strains of N. gonorrhoeae) -anaerobic bacteria -spirochetes (t. pallidum) -gram-negative are mostly resistant -least toxic of all abx and very safe Penicillin G adverse effects -Pain at IM site -procaine in PCN G might cause bizarre behavioral effects -hyperkalemia when large iv doses of Potassium PCN G are given -electrolylte imbalance when giving sodium PCN G (dont give this when pt is on a Na restricted diet) Broad Spectrum PCNs (names and organism coverage) -ampicillin & amoxicillin -Same as PCN G + increased activity against some gram neg bacilli (H. influenzae, E. coli, salmonella, and shigella) -Inactivated by beta-lactamases (don't work on staph infection) Ampicillin organism coverage E. fecalis, P. mirabilis, e. coli, salmonella, shigella, and h. influenza Ampicillin side effects rash & diarrhea When oral therapy is indicated, should you prescribe amoxicillin or ampicillin? Why? Amoxicillin because it is more acid stable & causes milder diarrhea compared to ampicillin (blood levels of amoxicillin are greater compared to ampicillin when given in the same dose) Extended spectrum (antipseudmonitmonal) PCNs (name and organisms) Piperacillin -covers: organisms that are susceptible to aminopenicillins + p. aeruginosa, Enterobacter species, proteus species that are indole positive, b. fragilis, and many klebsiella species -susceptible to beta-lactamases (don't work on staph infections) Penicillin adverse effects bleeding s/d to platelet function disruption -dosage should be reduced in pts with renal impairment what are the beta lactamase inhibitors? do they cover MRSA? -Clavulanic acid, tazobactam, sulbactam -no active against mrsa -given with penicillins (ampicillin/sulbactam, amoxicillin-clavulanic acid, piperacillin/tazobactam- effective against pseudomonas) Cephalosporins -broad spectrum, widely used, have a beta-lactam ring like pcn -low toxicity -Most widely used antibiotics have a beta-lactam ring like PCN 1st, 2nd, 3rd, 4th, 5th generation cephalosporins MOA -Bind to penicillin-binding proteins -- disrupts cell wall synthesis and causes the cell to lyse -most effective against cells undergoing active growth and division -not all cephalosporins are equally susceptible to beta-lactamases First generation cephalosporins: names Destroyed by beta lactamases -cefadroxil, cefazolin, cephalexin First generation cephalosporins: therapeutic uses -Prophylaxis in surgical pts (gram pos) -rarely used for active infections -exception: used for sensitive staph and strep infections Second generation cephalosporins: names -Less sensitive to destruction by beta-lactamases -cefaclor, cefotetan, cefoxitin, cefprozil, cefuroxime, cefmetazole, cefonicid, cefotetan and loracarbef Second generation cephalosporins: therapeutic uses rarely used for active infections -cover h. influenzae, klebsiella, pneumococci, and staphylococci -used for otitis, sinusitis, and respiratory infections -cefuroxime: URI or pneumonia from h flu, pneumococci, and staph -gives some beta-lactamase coverage but doesn't cover Pseudomonas or meningitis 3rd generation most prescribed cefdinir, cefditoren, cefixime, cefotaxime, cefpodoxime, ceftazidime, ceftibuten, ceftriaxone, cefoperazone, and ceftizoxime 3rd, 4th, and 5th generation agents are more ---- than first and second generation cephalosporins to beta lactamase destruction resistant 3rd generation cephalosporins: therapeutic uses -cover p. aeruginosa, n. gonorrhoeae, klebsiella, strep pneumonia, beta-hemolytic strep, MSSA, h flu, meningitis, e coli, proteus, and Serratia -the preferred choice for meningitis (able to penetrate CSF) -preferred therapy for several infections -gram neg organisms 4th generation cephalosporins Cefepime & ceftozolane 4th generation cephalosporins: therapeutic uses -Treats hospital-associated pneumonia/pseudomonoas (including those caused by the resistant organism P. aeruginosa) -complicated intra-abdominal and UTIs 5th generation cephalosporins ceftaroline and ceftolozane 5th generations cephalosporins: therapeutic uses -Ceftaroline: Treats skin infections, MRSA/VRSA, and hospital-associated pneumonia -Ceftozolane: broad spectrum with gramp os and gram neg (pseudomonas and some Enterobacteriaceae species) Cefidorocol a new cephalosporin that does not fall into a generation similar to ceftazidime or cefepime w/ an extended side chain used for adults w/ complicated utis and pyelonephritis very expensive Carbapenems: Names & Other info -Imipenem, meropenem, ertapenem, doripenem -Beta-lactam antibiotics that are extremely broad spectrum w/ low toxicity -Weakens bacterial cell wall -- lysis and cell death -All given parenterally -Reserved for pt's who cant be treated with narrow-spectrum agents (cover almost everything) What organisms does Imipenem cover? -Most bacterial pathogens, including resistant organisms (extremely broad spectrum) -Treats mixed infections (with anaerobe, s, and gram neg involvement) -gram pos and gram neg -anaerobic bacteria -not MRSA -Resistant to almost all beta-lactamases -not given alone-broadest spectrum (usually given w/ vanc) What are the side effects of Imipenem? -GI (N/V/D): most common -Superinfections -Rare: Seizures (can reduce blood levels of valproate which controls seizures) -Hypersensitivity reactions What organism does Vancomycin treat? -MRSA & c. diff What are the therapeutic indications of vancomycin? -Severe infections when pts are allergic to penicillin When is oral vancomycin indicated? Initial occurrence of c. diff What are the side effects of vancomycin? -Major toxicity: Renal failure (draw trough levels to minimize risk, if Cr increases by %50 reduce dose, don't use with other nephrotoxic drugs) *trough: just before the 4th dose of a new regimen (prior to the 3rd dose for dosing intervals 24 hrs or changing renal function) *trough levels should be obtained within 30 mins before the next schedule dosed) -Ototoxicity -"red man" syndrome -thrombophlebitis (common) -thrombocytopenia (rare) -allergy What are tetracyclines? Tetracycline, demeclocycline, doxycycline, eravacycline, omadacycline, sarecycline, and minocycline How do tetracyclines work?s -Bacteriostatic -Suppress bacterial growth by inhibiting protein synthesis (inhibit bind of tRNA to mRNA-ribosome complex) --- prevents amino acid addition to the growing peptide chain What organisms are tetracyclines effective for? Rickettsia, spirochetes, brucella, chlamydia, mycoplasma, h. pylori, borrelia burgdorferi, bacillus anthracis, and vibrio cholerae What are the tetracycline therapeutic indicates? When are they the first line drug? Rickettsia disease, chlamydia trachomatis infections, brucellosis, cholera, pneumonia caused by mycoplasma pneumoniae, Lyme disease, anthrax, GI infections w/ h. pylori, topically/orally for severe acne vulgaris What are the adverse effects of tetracyclines? GI irritation, effects on bone and teeth- binds to calcium, staining teeth, superinfection, hepatotoxicity, renal toxicity, and photosensitivity (*wear sunscreen outside) What interferes with tetracycline absorption? -Chelating agents: calcium, iron, mag, aluminum, zinc, -seen in milk products, Ca supplements, Fe supplements, magnesium laxatives, and antacids -decreases absorption of medication -wait to take at least 1 hour before or 2 hours after ingestion chelating agents Why can tetracyclines not be given in children under 8? It will permanently stain their teeth What are the macrolides? erythromycin, clindamycin, azithromycin, clarithromycin *good for patients that are allergic to penicillin What are the therapeutic uses of erythromycin? Treatment of choice of Corynebacterium diphtheriae -whooping cough, acute diphtheria, eliminating diphtheria carrier state, chlamydia infection, m. pneumoniae, group strep pyogenes -used as an alternative to pen G w/ penicillin allergy What are the adverse effects of erythromycin? very safe, small risk for sudden cardiac death from QT prolongation, GI effects (epigastric pain, n/v/d are the most common-- take with meals) How do macrolides work? inhibit protein synthesis broad spectrum used if pt is allergic to penicillin What drug class does telithromycin belong? First member of the ketolide class of abx What organism does telithromycin belong? strep pneumonia What are the side effects of telithromycin? Can be severe severe liver injury, GI effects, visual disturbances, prolonged QT interval BB warning: worsened muscles weakness in patients w/ myasthenia gravis (some pts have died from resp failure) What organisms does linezolid cover? VRE, MRSA What are the side effects of linezolid? Generally well tolerated diarrhea, nausea, headache neuropathy and myelosuppression (weekly blood count) What organisms does tedizolid cover? MRSA infections of the skin and soft tissue caused by staph and strep species (s. pyogenes, s. agalactiae, streptococcus anginous, e. fecalis) What are the side effects of tedizolid? n/v/d, dizziness, and headache neuropathy and myelosuppression What is the BB warning for chloramphenicol? Reversible bone marrow depression & fatal aplastic anemia What instanced can chloramphenicol be used? Only used for life threatening infections in which safer drugs are ineffective or contraindicated What is dalfopristin/quinupristin? First member of the streptogramins (new class of antibiotics) -MOA: inhibits bacteria protein synthesis What bugs are susceptible to Dalfopristin/quinupristin? Vancomycin-resistant enterococcus What are the adverse effects and drug interactions of dalfopristin? -hepatotoxicity -interacts with drugs metabolized by the CYP3A4 system What are aminoglycosides? Gentamicin Tobramycin Amikacin What bacteria are susceptible to aminoglycosides? -p. aeruginosa and Enterobacteriaceae (e. coli, klebsiella and Serratia species, p. mirabilis) -serious infections with certain gram pos (enterococcus, some strep, and staph) What are the major side eprffects of aminoglycosides? Serious injury to inner ears and kidneys (don't gives with other ototoxic or renal toxic drugs like NSAIDs) BB warning: ototoxicity, nephrotoxicity, neuromuscular blockage (inhibits neuromuscular transmission-- flaccid paralysis and fatal resp depression) What instance can chloramphenicol be used? Only used for life threatening infections in which safer drugs are ineffective or contraindicated What are peak and trough levels of aminoglycosides? -the same aminoglycoside dose can produce very different plasma levels in different patients -Peak levels must be high enough to kill bacteria -Trough levels must be low enough to minimize toxicity -Monitoring depends on the dosing schedule employed (i.e., once-daily dosing or use of divided doses) · When once-daily dosing is employed o only trough levels need to be measured. o As a rule, there is no need to measure peak levels because, when the entire daily dose is given at once, high peak levels are guaranteed. · When divided doses are employed o need to measure both the peak and the trough. -Timing · When blood samples for aminoglycoside levels are being drawn, timing is important. · Samples for peak levels o Should be taken 30 minutes after giving an IM injection or after completing an IV infusion. · Sampling for trough levels depends on the dosing schedule. o For patients receiving divided doses, trough samples should be taken just before the next dose. o For patients receiving once-daily doses, a single sample can be drawn 1 hour before the next dose. The value should be very low, preferably close to zero. Name the first, second, third and fourth generation of fluroquinolones What are the therapeutic indications of metronidazole? obligate anaerobes -b. fragilis, c. diff, fusobacterium species, Gardnerella vaginalis, peptococcus species, and Peptostreptococcus species -used to treat c. diff -prophylaxis in surgeries where there is a high risk for infection (colorectal, abdominal, gynecologic surgery) What are the major side effects of metronidazole? disulfuram like reaction with alcohol -BB warning: increased carcinogenic risk in mic and rats How do sulfonamides work? inhibit folic acid synthesis-- inhibits tetrahydrofolic acid-- bacteria then can't synthesize DNA, RNA, and proteins What are the therapeutic indications of sulfonamides? primary use: UTIs What are the drug-drug interactions with sulfonamides? -They intensify the effects of warfarin, phenytoin, sulfonylurea-type oral hypoglycemics (glipizide, glyburide) by inhibiting hepatic metabolism of these drugs (will need to reduce dosage of these drugs to prevent toxicity) -cross-hypersensitivity with sulfasalazine what portion of sulfamethoxazole/trimethoprim is used to determine pediatric dosing? What are causative organism for UTIs? e. coli (most), klebsiella pneumoniae and Enterobacter, proteus, Providencia ,and pseudomonas species; staph saprophyticus, enterococci, Proteus mirabilis, Klebsiella, (gram +) What is the first line treatment for uncomplicated UTI? Trimethoprim/sulfamethoxazole, nitrofurantoin, fosfomycin What is the second line treatment in complicated utis and acute uncomplicated pyelonephritis? amoxicillin/clavulanate, cefadroxil, cefdinir, cefpodoxime What is the second line treatment for uncomplicated UTI? Fluoroquinolones (cipro) are good alternatives when drug resistance exceeds 20% in a certain community -levofloxacin -given 3-5 days• -If allergic to sulfa or nitrofurantoin may use amoxicillin clavulanate or cephalexin if allergic to beta lactams may use fluroquinolones (see algorithm in book) What is the first line treatment for uncomplicated pyelonephritis and complicated UITs trimethoprim/sulfamethoxazole, cipro, levofloxacin give 7-14 days What is the second line treatment in complicated utis and acute uncomplicated pyelonephritpis? • Amoxicillin/clavulanate • Cefadroxil • Cefdinir • Cefpodoxime gives 7-14 days What is considered complicated UTI? How is this treated? Associated with predisposing factors such as calculi, prostatic hypertrophy, indwelling catheter, or an impediment to the flow of urine (physical obstruction) -the identity and drug sensitivity of the causative organism must be determined. - urine for microbiologic testing should be obtained before giving any antibiotics. - mild sx: treatment should wait until test results are available. -severe sx: immediate treatment with a broad-spectrum antibiotic can be instituted. · After test results are known, a drug specific to the pathogen can be substituted. -Duration of treatment ranges from · 7 days (for cystitis) to · 14 days (for pyelonephritis or when there is systemic involvement) How is recurrent UTI treated? -If reinfections are infrequent (only one or two a year): each episode should be treated as a separate infection (Single dose or short-course therapy can be used) -When reinfections are frequent (three or more a year): long-term prophylaxis may be indicated - Prophylaxis can be treated with low daily doses of several agents, including · trimethoprim (100 mg) for 6 mo · nitrofurantoin (50 or 100 mg) for 6 mo · trimethoprim/sulfamethoxazole (40 mg/200 mg) 3 times weekly for 6 months o Prophylaxis should continue for at least 6 months. o If reinfection is associated with sexual intercourse the risk can be decreased by voiding after intercourse and by single-dose prophylaxis (e.g., trimethoprim/sulfamethoxazole [80 mg/400 mg] taken after intercourse). Why is nitrofurantoin ineffective in treating pyelonephritis? The drug metabolize quickly and concentrates in the bladder What are medications used for UTI in pregnancy? Cephalexin, nitrofurantoin, amoxicillin/clavulanate What are the first line treatments for complicated UTIs? • Trimethoprim/sulfamethoxazole • Ciprofloxacin • Levofloxacin • Amoxicillin/clavulanate • Cephalexin • 7-14 days What are the 3 topical antibiotics used to treat impetigo? Mupirocin, retapamulin, and ozenoxacin (this is a new fluoroquinolone for impetigo, expensive, can be given 2 months and older) What are 2 species of tuberculosis? Mycobacterium tuberculosis & mycobacteria bovis (?) When is TB treatment considered effective? -2 consecutive monthly sputum tests are negative (a chest xray is done in pt's whos pretreatment sputum tests were negative) -symptoms (fever, malaise, anorexia, cough) are markedly decreased within 2 weeks How are drugs chosen for TB treatment? -Based on drug sensitivity tests (sputum sample cultures 6-16 wks.) -Initial drug selection is empiric (based on patterns of drug resistance in the community & if the pt. is immunocompetent or not such as HIV pt's) -Adjust regimen based on test results -Drug selection is based on if the organism is multi-drug resistant TB (MDR-TB), extensively drug resistant TB (XDR TB) or non resistant TB What are the first line drugs for TB? Isoniazid Rifampin Pyrazinamide Ethambutol Rifapentine Rifabutin What are the second line drugs for TB? Cycloserine Ethionamide Capreomycin Para-aminosalicylic acid (PAS) Aminoglycosides: streptomycin & amikacin Quinolones: Levofloxacin & moxifloxacin What is the induction (initial/intensive) phase of TB treatment? -Eliminates actively dividing extracellular tubercle bacilli and thereby renders the sputum noninfectious -Lasts 8 weeks -Drugs: isoniazid, rifampin, pyrazinamide, and ethambutol What is the second (continuation) phase of TB treatmetn? -Elimination of persistent intracellular organisms -Lasts 18 weeks -2 drugs: isoniazid and rifampin Define multidrug-resistant TB Isolate of M. tuberculosis that's resistant to both isoniazid and rifampicin (the two most effective TB drugs) Define extensively resistant TB Resistant not only to isoniazid & rifampin but also all the fluroquinolones (levofloxacin & moxifloxacin) and at least one of the injectable second line anti-tb drugs (amikacin, capreomycin and streptomycin) What are the adverse reactions and drug interactions for Isoniazid? AR: peripheral neuropathies (can be reverse with pyridoxine) hepatotoxic possibharmle anemia crosses BBB-- optic neuritis, seizures, dizziness, ataxia and psychological disturbances Drug Interactions: Strong inhibitor of CYP2C9, CYP2C19, and CYP2E1 Can raise levels of phenytoin, carbamazepine, diazepam and triazolam What are the adverse reactions and drug interactions for rifampin? AR: hepatotoxicity discoloration of body fluids (harmless) GI disturbances Drug interactions: -Induces the Py450 systems -- increasing metabolism of certain drugs (decreases effect of oral contraceptives-- women should used another of method of BC) -warfarin -any drugs that are also hepatotoxic should not be given w/ rifampin-- HIV drugs) What are the adverse reactions of pyrazinamide? Most hepatotoxic of all first line drugs nongouty polyarthralgia's hyperuricemia GI disturbances photo sensitivity What are the adverse reactions of ethambutol? optic neuritis Hyperuricemia Dermatitis GI upset Peripheral neuropathy Renal damage Thrombocytopenia. *decreased vision What are the adverse reactions of capreomycin (injectable)? Renal toxicity (should not be used in pt.'s with renal disease) -May also cause damage to the 8th cranial nerve, resulting in hearing loss, tinnitus and disturbed balance What are the adverse reactions of amikacin (injectable)? -BB warning: nephrotoxic and may also damage the eighth cranial nerve. . -These drugs are not absorbed from the GI tract; hence administration is parenteral What is the treatment for drug sensitive TB? 2 phases: 1) Initial phase: 8 weeks 4 drugs: isoniazid, rifampin, pyrazinamide, and ethambutol 2) continuous phase: 18 weeks 2 drugs: isoniazid and rifampin *regimens always contain 2+ drugs What is the treatment for multi drug resistant TB (MDR-TB and XDR-TB)? -at least 24 months -Must use 2nd and 3rd line drugs, less effective than the first-line drugs generally more toxic -Initial therapy 5-7 drugs -- might include (1) isoniazid; (2) rifampin; (3) pyrazinamide; (4) ethambutol; (5) amikacin or capreomycin; (6) levofloxacin; and (7) Cycloserine, ethionamide, or PAS. -As a last resort, infected tissue may be removed by surgery -Prognosis is often poor -XDR-TB- 40% -60% die. -Factors that determine outcome include the extent of drug resistance infection severity immunocompetence of the host. What are the considerations for treatment in pts with TB and HIV? -Need more aggressive therapy -Last several months longer (6 months+) -Interactions between HIV and TB drugs especially rifampin- accelerate the metabolism of most protease inhibitors and most nonnucleoside reverse transcriptase inhibitors (NNRTIs) prescribed to treat HIV, and this can decrease the effects of the latter. -Best to avoid combining rifampin with these agents. -But that 30means denied optimal treatment for one of their infections. -Have to stop taking either rifampin for TB or NNRTIs for their HIV. -rifabutin can also accelerate the metabolism of antiretroviral drugs. However, much less. -Many antiretrovirals still be used in patients taking rifabutin. -Directly observed therapy (DOT) is now considered the standard of care for TB. -Usually observed by representative of the health department -DOT & intermittent dosing (2 to 3 times a week), helps ensure adherence. -Also facilitates the ongoing evaluation of the clinical response and adverse drug effects What is the treatment for latent TB? -Must rule out active infection prior to treatment -treated with 1-2 drugs -Will cause resistance if on that regimen but has active infection Four treatments are recommended based on patient status: -Isoniazid alone daily or twice weekly for 9 months. -Isoniazid daily or twice weekly for 6 months. -Rifampin alone daily for 4 months -Isoniazid plus rifapentines taken weekly for 3 months. How do you promote treatment adherence? Directly observed therapy & intermittent dosing (2-3 times a week) How do you evaluate TB treatment? -evaluation of sputum Evaluated monthly until 2 consecutive tests are negative -Chest radiographs Done in patients with negative pretreatment sputum tests Repeated every 2 months after initiating treatment -Clinical evaluation Fever, malaise, anorexia, cough must be evaluated at every clinic visit Should be markedly decreases within 2 weeks. What are therapeutic uses, side effects, and drug/drug reactions of caspofungin? Uses: Iv therapy invasive aspergillosis in pt.'s unresponsive to traditional agents & systemic candida infections -it is a narrow spectrum echinocandin that cant be dose orally SE: ? D/D reactions: ? What drugs treat tinea pedis (feet)? Terbinafine, butenafine, undecylenic acid, ciclopirox, azoles (itraconazole), tolnaftate The most common fungal infection -Generally responds well to topical therapy. -Patients should be advised to wear absorbent cotton socks, change their shoes often, and dry their feet after bathing. What drugs treat tinea corporis (body)? -usually responds to a topical azole or allylamine (terbinafine, butenafine). -Treatment should continue for at least 1 week after symptoms have cleared. -Severe infection may require a systemic antifungal agent (e.g., griseofulvin). What drugs treat tinea cruris (groin)? Responds well to topical therapy. -Treatment should continue for at least 1 week after symptoms have cleared. -If the infection is severely inflamed, a systemic antifungal drug (e.g., clotrimazole) may be needed; -topical or systemic glucocorticoids may be needed as well -terbinafine, butenafine What drugs treat tinea capitis (scalp)? -difficult to treat. -Topical drugs are not likely to work. -Oral griseofulvin, taken for 6 to 8 weeks, is considered standard therapy. -However, oral terbinafine, taken for only 2 to 4 weeks, may be more effective What drugs treat vulvovaginal candidiasis? -Topical antifungals or 1 dose of fluconazole 150 mg. -Recurrent: weekly fluconazole. What drugs treat onychomycosis (fungal infection of the nails)? Oral: terbinafine & itraconazole Topical: ciclopirox, tavaborole, efinaconazole What is the treatment of chlamydia? o Uncomplicated infections in adults and adolescents -Doxycycline 100 mg PO twice daily for 7 days -or Azithromycin 1 gm orally once -or Levofloxacin 500 mg by mouth daily for 7 days. o During pregnancy -azithromycin -or amoxicillin 500 mg orally 3 times daily for 7 days is an alternative regimen. -If the patient cannot take this amoxicillin may be given. o In infants -erythromycin is preferred for pneumoniae and conjunctivitis -azithromycin can be a substitute o In pre-adolescent children (sexual abuse is likely the cause) -Erythromycin is preferred for children less than 45 kg. · Dosage is 50 mg/kg body weigh/day orally divided into 4 doses daily for 14 days. -Azithromycin is an alternative regimen at 20 mg/kg body weight/day orally, 1 dose daily for 3 days. o Children older than eight can have -azithromycin or doxycycline What is the treatment for gonorrhea? -ALL cases of gonorrhea should be treated with two antimicrobials with different mechanisms of action (d/t high rate of resistance) For uncomplicated cervix, urethra, rectum infection: · single 500 mg IM dose of ceftriaxone (persons weighing ≥150 kg, single 1g IM dose) · If chlamydial infection has not been excluded o doxycycline 100 mg orally twice a day for 7 days o When ceftriaxone is not available - Single dose Gentamicin 240mg IM plus a single 2g PO dose of azithromycin - or single dose of PO Cefixime 800 mg - For uncomplicated gonococcal infection of the throat: · ceftriaxone 500 mg IM in a single dose for persons weighing less than 150 kg, for those over 150 kg 1 g IM should be given. - For uncomplicated conjunctival infection in adults and adolescence: · Ceftriaxone 1 g IM in a single dose plus azithromycin 1 g orally. · Cephalosporin allergies: consult infectious disease specialist. o Use of third generation cephalosporins is recommended in patients who report "reactions" to penicillin. - Exception: patients who report IgE-mediated reactions (anaphylaxis, Stevens Johnson syndrome or toxic epidermal necrolysis) or history of cephalosporin allergies. - PTF or antibiotic-resistant N. gonorrhea: · consult infectious disease specialist. · ALL suspected cases of PTF or antibiotic-resistant N. gonorrhea must be retested prior to and after retreatment using NAAT, culture and AST testing. - Child w/ gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, proctitis: · Weight ≤45 kg: ceftriaxone 25-50 mg/kg IV or IM, not to exceed 125 mg · Weight 45 kg: ceftriaxone 250 mg IM PLUS azithromycin 1 g PO. - Newborn/neonate with known infection and prophylactically (should include a consultation with infectious disease specialist). Gonococcal conjunctivitis: · ceftriaxone 25-50 mg/kg IV or IM, not to exceed 125 What is the treatment for syphillis? -For primary and secondary syphilis: Benzathine penicillin G 2.4 million units IM in a single dose is given. o Early latent syphilis: Benzathine penicillin G 2.4 million units IM in a single dose. o Late latent & Tertiary: Benzathine penicillin g 2.4 million units IM each at 1 week intervals for 3 weeks for a total of 7.2 million units What is the treatment for genital herpes? Genital herpes can be treated with three drugs: acyclovir, famciclovir, and valacyclovir. o These agents cannot eliminate the virus, but they can reduce symptoms and shorten the duration of pain and viral shedding. -Patients with recurrent infections may take these drugs every day (suppressive therapy) or just when symptoms appear (episodic therapy). · Continuous daily administration reduces the frequency and intensity of episodes, whereas, treatment reduces symptom intensity after an episode has begun. o For Infants who acquire the infection -Acyclovir o To decrease transmission -Valacyclovir (500 mg once daily) · can decrease transmission of genital herpes by almost 50%. · No other drug has been shown to reduce transmission of this STD. o For first clinical episode -Acyclovir 400 mg orally 3 times daily for 7-10 days -or famciclovir 250 mg orally 3 times daily for 7-10 days -or valacyclovir 1 g orally 2 times daily for 7-10 days. o Suppressive therapy -acyclovir 400 mg orally twice daily -or valacyclovir either 500 mg or 1 gm orally once daily -or famciclovir 250 mg orally twice daily. What is the treatment for bacterial vaginosis? Recommended: metronidazole ge. 0.75% one full applicator intravaginally once daily for 5 days o Pregnant women: -Only oral clindamycin and metronidazole What is the treatment of trichimoniasis? -Metronidazole 500 mg twice daily for 7 days for women -Metronidazole 2 g orally in a single dose for men. o Alternative regimen for women and men -tinidazole 2 g orally in a single dose. what tests are definitive for diagnosis of tb? sputum culture, ppd What do you tell the patient taking metronidazole about drinking alcohol? It can cause a disulfiram-like reaction if taken with alcohol What lab test would you want to order prior to starting an antiviral? Bun/cr What med is used for herpes labialis? Penciclovir What meds can be given if started within 48 hours of onset of flu symptoms oseltamivir, zanamivir What of the following antivirals does the CBC no longer recommend for flu due to resistance? amantadine What is the first drug givne for HIV prophylaxis? sustiva All antiviral drugs used to treat hiv Are inducers or inhibitors of one or more CYP450 isoenzymes what is the most common cause of resistance in hiv treatment? nonadherence to prescribed regimen What are the anthelmintic drugs? Mebendazole, albendazole, pyrantel pamoate, praziquantel, diethylcarbamazine, ivermectin Important to know with anthelminthic drugs anthelmintic drugs are generally devoid of serious adverse effects Its important to match drug with infesting worm Many worms are both asymptomatic and self limited-- drug therapy is therefore optional What is acyclovir used to treat? What are the side effects? Agent of choice for herpes simplex virus or varicella-zoster virus Se: Oral: n/v/d, headache, vertigo; topical causes burning/stinging; IV can cause renal failure, neurotoxicity, phlebitis What is valacyclovir used for? What are the side effects? (it is a prodrug form of acyclovir and is more bioavailable than acyclovir) -treats: herpes zoster (shingles), herpes simplex genitalis (genital herpes), herpes labialis (cold sores), and varicella (chickenpox) side effect: Can cause thrombotic thrombocytopenic purpura/hemolytic uremic syndrome in immunocompromised patients What is famciclovir used to treat? what are the side effects? Prodrug of penciclovir used to treat acute herpes zoster or genital herpes infections Side effects: low doses: minimal effects; small chance of headache and nausea High doses: acute renal failure What are neuraminidase inhibitors used for? What are they? influenza oseltamivir (Tamiflu) zanamivir peramivir baloxavir marboxil How soon of onset of symptoms do flu drugs need to be given to be effective? 48 hours *some sources recommend not using at all because benefits are minimal and drugs are expensive Oseltamvir (Tamiflu) Can be given in children 2 weeks+ pill & suspension form given 2 times daily for 5 days side effects: n/v Zanamivir Can be given in children 7 years+ Should not be given to pts w/ asthma or COP side effects: bronchospasm Peramivir Can be given in children 2 yrs+ IV only side effects: diarrhea Baloxavir marboxil: Can be given in children 12 yrs + Given once po Not recommended to pregnant or lactating women What are the hepatitis c drugs? Simeprevir, daclatasvir, sofosbuvir, interferon alpha and ribavirin What are the side effects of Simeprevir? hepatic injury, photosensitivity, and severe rashes most common ae: headache, nausea, and fatigue What are the side effects of daclatasvir? headache & fatigue (when combined with sofosbuvir) nausea and anemia (when combined with ribavirin) What are the side effects of sofosbuvir? fatigue, headache when combined with ribavirin nausea, anemia and insomnia when combined with interferon alfa symptomatic bradycardia when taken with amiodarone What are the side effects of interferon alpha & ribavirin? hemolytic anemia birth defects: don't given in pregnancy flu-like symptoms severe depression What are the hepatitis B drugs? interferon alfa-2b, peginterferon alfa 2a, lamivudine, adefovir, entecavir, telbivudine, tenofovir What are the side effects for the interferon alfa hep b drugs? neuropsych effects (depression) autoimmune disorders infectious & ischemic conditions What are the side effects of lamivudine? usually minimal rare complications: lactic acidosis, pancreatitis, and severe hepatomegaly What are the side effects of adefovir? nephrotoxicity What are the side effects of entecavir? very well tolerated se: dizziness, headache, fatigue, nausea (possibility of lactic acidosis and hepatomegaly) What are the side effects of tenofovir? weakness, headache, lactic acidosis with hepatomegaly, and Gi reactions (v/d and flatulence) What are the 5 classes of antivirals used in treatment of HIV? Inhibitor enzymes required for HIV: reverse transcriptase inhibitors, integrase strand transfer inhibitors, protease inhibitors Block viral entry into cells: fusion inhibitors and CCR5 antagonists *All of these drugs are either inducers or inhibitors of one or more CYP450 iso enzymes-- so lots of adverse drug reactions What is the MOA and side effects of Zidovudine? MOA: It is a nucleoside reverse transcriptase inhibitors (NRTI) Inhibitors HIV replications by suppressing synthesis of viral DNA AE: hematologic toxicity, lactic acidosis w/ hepatomegaly, myopathy, GI effects, CNS reactions Drug interactions: fewer drug interactions than most antivirals What are the NNRTI drugs? What are the side effects? efavirenz, nevirapine, delavirdine, etravirine, rilpivirine side effects: transient adverse CNS effects in 50% of patients, rash, teratogenicity What are the adverse effects of protease inhibitors for HIV? (lopinavir, ritonavir, indinavir, saquinavir, nelfinavir, fosamprenavir, atazanavir, tipranavir) hyperglycemia/diabetes fat redistribution hyperlipidemia increased bleeding in people w/ hemophilia reduced bone mineral density elevation of serum transaminase What are the side effects of the integrase strand transfer inhibitors? (raltegravir, dolutegravir, bictegravir, elvitegravir) insomnia, headache, and rare hypersensitivity reactions FDA pregnancy risk few adverse effects What are the adverse effects of fusion inhibitors (enfuvirtide)? injection site reactions, pneukmona, and hypersensitivity reactions What are the adverse side effects of CCR5 antagonsits? (maraviroc) cough, dizziness, pyrexia, rash, abd pain, MSK symptoms, and URIs What are the lab tests used to guide treatment of HIV? CD4 t-cell count (indicator of how much immunocompetence remains) plasma HIV RNA (viral load) What causes resistance to treatment of HIV? Because of base pare errors that occur when the virus rapidly mutates What HIV meds can be used in pregnancy? When is tenofovir/emtricibine indicated? The CDC recommends preexposure prophylaxis with these meds for people who are at high risk for HIV acquisition (high risk people: (1) have sexual partners with known HIV-1 infection or are sexually active with people who belong to social networks with high HIV-1 prevalence and (2) have one or more of the following risk factors: do not regularly use condoms; have sexually transmitted infections; engage in sex for money, drugs, or other supplies; use recreational drugs or are dependent on alcohol; and are imprisoned What are the broad spectrum pnc's that are good for strep and acute otitis media? ampicillin, amoxicillin *macrolides are the drug of choice for patients with allergies Can you give cephalosporins if the patient has an allergy to penicillin? Yes unless their allergy to penicillin was anaphylaxis Cephalosporin side effects Hardly any Alcohol reactions: cephazolin, cefmetazole, cefoperazone and cefotetan Bleeding: cefotetan and ceftriaxone, cefmetazole, cefoperazone decrease PT through inference with vit k What does meropenem treat? meningitis What does Ertapenem not cover? pseudomonas used for: acute pelvic infections, complicated gi/gu/soft tissue infection; cap What is doripenem used to treat? complicated intraabdomina infections or complicated utis What is avibactam used to treat? used in combination with ceftazidime for intraabdominal and UITs Telavancin lipoglycoprotein skin infections and hospital acquired pneumonia prolong QT Dalbavancin and oritavancin: glycopeptide antibiotics both used for skin and soft tissue infections alternative for vanc for staph and MRSA, strep infections, and enterococcus faecalis daptomycin binds to cell membrane and depolarizes it inhibits DNA, rna, and protein synthesis used for skin (MRSA) and soft tissue infections and enterococcus faecalis (gram pos only) IV only Teicoplanin narrow spectrum gram po only MRSA Aztreonam a monobactam gram neg bacteria only: h flu, pseudomonas, Enterobacteriaceae, e coli, klebsiella, proteus, salmonella, shigella Only ___ can be used for c diff oral vancomycin what causes most skin infections? staph and strep (gram pos organism) Fosfomycin First line for UTIs can be given in pregnancy 1 time dose (good for compliance issues) e. coli or e. faecalis UTIs