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Sepsis
UMSOPPY3 Sepsis Case
122
Pharmacology
Graduate
04/07/2011

Additional Pharmacology Flashcards

 


 

Cards

Term
4 main criteria for SIRS:
Definition

1. Fever (>38C/100.4F) or Hypothermia (<36C/96.8F)

2. Tachypnea (RR>20-24 breaths/min)

3. Tachycardia (HR>90bpm)

4. Leukocytosis (>12-14cells/mm3 or microL), Leukopenia (<4000), or >10% immature bands

Term
Sepsis Triad
Definition

1. Systemic Inflammation

2. Procoagulant State

3. Reduced Fibrinolysis

Term
Top 3 locations where sepsis originates in the body?
Definition

1. Pulmonary

2. Intraabdominal

3. Urinary Tract

Term
Breakdown (approx %) of causes of sepsis.
Definition
Gram + (40%)> Gram - (38%)> Fungal (17%)
Term
6 risk factors:
Definition

1. Age: infants, >65

2. Weak immune system

3. Hospitalized

4. Urinary cath, artificial joints, breathing tubes, surgical incisions, wounds, burns

5. Long term AB use

Term
5 Hypotensive molecules:
Definition

1. Nitric Oxide

2. B-endorphin

3. Bradykinin

4. PAF

5. Prostacyclin

Term
What types of bacteria have lipopolysaccharide (LPS) moieties?
Definition
Gram NEGATIVE
Term
When CD4 T-cells are stimulated they secrete type 1 and type 2 helper T-cells. Which type is pro-inflammatory and which type is anti-inflammatory?
Definition

Type 1: Pro-inflammatory

Type 2: Anti-inflammatory

Term
What are the two mechanisms of refracotry hypotension?
Definition

1. Progressive high-output cardiac failure - cannot sustain high CO 

2. Circulatory failure - severe vasodilation and hypotension refractory to resuscitation 

Term
What is a primary component in the development of multiple-organ failure?
Definition
microvascular collapse - from injury, inflammation, + obstruction (aggregation of neutrophils)
Term
How does mortality relate to # failed organs?
Definition

2 organs ~50%

3 organs ~ 70%

5 organs ~100%

 

Term
3 most frequent organs dysfunctions
Definition

1. Respiratory (~18% of pt)

2. Circulatory

3. Renal (~15%)

Term
What are the characteristics of acute respiratory distress syndrome (ARDS)?
Definition

1. refractory hypoxia

2. decreased lung compliance

3. noncardiogenic pulmonary edema

4. pulmonary hypertension

Term
What does DIC stand for?
Definition
Disseminated Intravascular Coagulation
Term
Basically the pathophysiology of ARDS can be broken down into 2 dysfunctional componenets. 
Definition
Fibrin deposition in injured lung + abnormalities of coagulation and fibrinolysis = ARDS
Term
What is the hallmark hemodynamic effect?
Definition

hyperdynamic state

- high cardiac output

- abnormally low systemic vascular resistance

Term
If a pt has MODS and is oliguric or anuric, what should be initiated promptly?
Definition

1. adequate renal perfusion

2. trial of loop diuretics

Term
What are some nonspecific lab abnormalities that you could see with sepsis?
Definition

1. respiratory alkalosis

2. leukocytosis

3. mild liver function abnormalities

Term
What are the early signs and symptoms of sepsis?
Definition
temp changes, tachycardia, tachypnea, n/v, hyperglycemia, myalgias, lethargy, malaise, proteinuria, hypoxia, leukocytosis, hyperbilirubinemia
Term
What lab tests should be done?
Definition
hemoglobin, WBCwDiff, platelet count, chemistries, coag parameters, serum lactate, arterial blood gases
Term
How does sepsis affect Vd? Why is this important?
Definition

leaky capilaries and altered protein binding = increased Vd

drugs (esp. AB) will have lower serum concentrations

Term
Which AB class should be used for non-neutropenic UTI?
Definition
fluoroquinolones 
Term
Which are the "respiratory" fluoroquinolones?
Definition

Levofloxacin (Levaquin)

Moxifloxacin (Avelox)

Gemifloxacin (Factive)

Term
What drug is preferred over vancomycin in MRSA?
Definition
linezolid, bc vanc has poor penetration into lungs and there is a global emergence of glycopeptide resistant S. aureus
Term
Of the two carbapenems, which is thought to have better activity against G(+) and which for G(-)?
Definition

Imipenem - G(+)

Meropenem - G(-)

 

Seizures rates are probably similar.

Term
What is the DOC for anaerobes like Bacteroides, Prevotella, and Porphyromonas?
Definition
Metronidazole
Term
What are the 4 antifungal treatment options?
Definition

1. amphotericin B based preparations

2. azole antifungals

3. echinocandin antifungals

4. combo of fluconazole with amphotericin B

Term

Of the amphotericin-B products available, what is the brand name for:

1. Convential amphotericin B (C-AMB)

2. Colloidal dispersion (ABCD)

3. Liposomal (L-AMB)

4. Lipid Complex (ABLC)

 

Definition

1. Fungizone 

2. Amphotec, Amphocil 

3. Ambisome 

4. Abelcet

Term

What happens when CAMB is given with the addition of electrolytes?

 

Definition
aggregation of colloid
Term
amphotericin B + cholesteryl sulfate =
Definition
ABCD - colloidal dispersion - Amphotec, Amphocil
Term
Which formulation of amphotericin acheives higher blood levels CAMB or ABCD?
Definition

CAMB - Fungizone

ABCD also has more chills and hypoxia than CAMB and premedication can be used to reduce febrile reactions

Term
Amphotericin B accumulation in the liver and spleen is higher with CAMB or LAMB?
Definition
LAMB - Ambisome
Term

What are the ADE related to LAMB?

 

How should Ambisome be administered?

Definition

Nephrotoxicity, hypokalemia, infusion-related reactions

 

In D5W with initial doses infused over 2 hours (doses up to 10mg/kg)

Term

Amphotericin B + dimyristoylphosphatidylcholine + dimyristoylphosphatidylglycerol = ?

 

Which is more nephrotoxic, LAMB or ABLC?

 

 

Definition

ABLC - Abelcet

 

ABLC

Term
MOA of amphotericin B
Definition

binds to sterol moiety (primarily ergosterol) in membranes -->

polyenes appear and form pores/channels -->

increased membrane permeability -->

leakage of small molecules

 

Term

Which amphotericin-B formulation acheives the highest blood levels?

 

Which formulation has the worst infusion-related reactions?

 

What is used for pretreatment?

 

Rankings for nephrotoxicity?

Definition

LAMB - Ambisome

 

ABCD (Abelect) > CAMB (Fungizone) >

ABLC (Amphotec, Amphocil) >LAMB (Ambisome)

 

APAP (po) or IV hydrocortisone hemisuccinate (0.7mg/kg)

 

ABLC<LAMB<ABCD (lipid formulations are less nephrotoxic)

Term
What is the cumulative dose for CAMB that correlates with permanent functional impairment due to histological changes in the renal tubules?
Definition
>3-4g
Term
What are 2 treatments for renal tubular acidosis and renal wasting of potassium and magnesium?
Definition

1. Supplemental K -1/3 of pts on prolonged therapy should get it

2. Saline loading - administer 1 L of IV NS on the day CAMB is given

Term
What is a reversible ADE associated with CAMB treatment usually seen after at least 2 weeks of therapy?
Definition
hypochromic, normocytic anemia
Term

What are the 2 broad classes of azole antifungals? Which agents are in each class? Differences between the two classes?

 

What is their shared MOA?

 

 

Definition

1. Imidazoles - 

(clotrimazole, miconazole, ketoconazole, econazole, butoconazole, oxiconazole, sertaconazole, sulconazole)

2. Triazoles -

(terconazole, itraconazole, fluconazole, voriconazole, posaconazole, isavuconazole) - systemic drugs, metabolized more slowly and less effects on sterol synthesis.

 

MOA: inhibition of 14-alpha-sterol demethylase (microsomal CYP)

- impairs the biosynthesis of ergosterol (for cytoplasmic membrane)

- results in accumulation of 14-alpha-methylsterols (causes disruption of packing of acyl chains of phospholipids = impaired function of membrane enzymes and inhibited growth)

 

Term

Fluconazole:

1. Class

2. CYP inhibitor

3. Route of Elimination

4. T½

5. CSF availability?

6. PPB?

7. ADE?

8. Pregnancy category? Breast milk?

9. Formulations

 

Definition

Diflucan(R):

1. Triazole

2. CYP3A4, 2C9

3. >90% renal excretion (adjust interval based on creatinine clearance)

4. 25-30h

5. yes, 50-90% of plasma levels

6. ~10%

7. reversible alopecia may occur, rare hepatic failure or SJS

8. Preg C, + breast milk

9. T(50,100,150,200), Susp(10,40mg/mL), IVwNaClorDextrose(200mg/100mL;400mg/200mL), 

Term

Voriconazole:

1. Class

2. Metabolism/Inhibition

3. T½

4. IV formulation component that is excreted entirely by the kidneys and accumulates if CrCl<50mL/min

5. Preg Class?

6. ADEs

7. Formulations

Definition

B: Vfend

1. Triazole "conazole"

2. CYP2C19 (Asians=poor 2C19), 2C9, 3A4

3. 6h

4. SBECD - sulfobutyl ether B-cyclodextrin

5. Preg Class D

6. hepatotox, QTc prolongation, visual, anaphylactoid, rash

7. T(50,200mg), Susp(40mg/mL), IV(200mg)

Term

Echinocandins:

1.  MOA

2. Susceptible fungi

3. Resistant mutation

Definition

1. inhibit glucan synthesis complex in plasma membrane that catalyzes the sythesis of glucan = reduced integrity of cell wall = osmotic instability and death

2. Candida and Aspergillus

3. Fks1p, a subunit of glucan synthase

 

 

Term
Which 3 drugs are echinocandins?
Definition

1. Caspofungin (Cancidas) 70mg

2. Micafungin (Mycamine) 75mg

3. Anidulafungin (Eraxis) 200mg

Term

Which echinocandin:

1. has the shortest t½ and smallest Vd?

2. is water insoluble and diluted in ethanol for IV infusion?

3. is a mild CYP3A4 inhibitor?

4. has the longest t½ and largest Vd?

 

 

Definition

1. Cancidas (Caspofungin)

2. Anidulafungin (Eraxis)

3. Micafungin (Mycamine)

4. Anidulafungin (Eraxis)

Term
What are the 3 primary reasons fluid therapy is used for volume expansion?
Definition

1. increases intravascular volume

2. enhances cardiac output 

3. delays development of refractory hypoxia

Term

What is mean arterial pressure (MAP)?

 

Equation?

Definition

average arterial pressure during a single cardiac cycle

 

MAP = (CO*systemic vascular resistance)+ central venous pressure

Term

Where do crystalloids increase volume?

 

Which fluids are crystalloids?

 

 

 

 

Definition

Extracellularly: 25% intravascular and 75% extravascular

 

NS (0.9% sodium chloride/154mEq/L-NaCl), lactated ringer solution (130mEq/L of Na), & hypertonic saline(513mEq/L-NaCl)

Term

Which are colloids?

What are some advantages of colloids over crystalloids?

How do colloids distribute in the body?

Definition

1. 5% albumin, 6% hetastarch (synthetic)

2. more rapid restoration of intravascular volume (> expansion per quantity infused), preferred when serum albumin <2.0g/dL

3. intravascularly, albumin can shift fluids from intracellular and interstitial spaces

Term

What are 2 inotropic agents used to improve CO?

 

When do you use vasopressors?

 

What are some complications of inotropes and vasopressors?

Definition

Dopamine + Dobutamine

 

SBP<90mmHg or MAP <60-65mmHg after adequate LV preload and inotropic therapy

 

tachycardia, myocardial ischemia, myocardial infarction

Term

1. Which cardiovascular agent used in septic shock has dopaminergic activity?

2. Which agent has no activity at B2 receptors?

3. Which agent has the most activity at both alpha and beta receptors?

4. Which agent has the least activity at the alpha receptors?

Definition

1. Dopamine

2. Phenylephrine

3. Epinephrine

4. Dobutamine

Term

Which receptors does epinephrine affect at low doses? high doses?

 

What are the benefits of epinephrine?

 

ADE?

 

Administration/Formulation?

Definition

1. Low doses - B2 stimulation (skeletal muscle dilation)

2. High doses - Alpha stimulation (constriction of blood vessels in kidney, skin, mucosa)

 

↑ contractility (inotropic) + ↑ HR (chronotropic)= ↑ CO (also ↑ SV and LV work/beat)

 

increased lactate level, impaired bloodflow to splanchnic system

 

IV infusion, SQ, IM inj, nebulized, inhaled

Term

1. What are the brand names for injectable epinephrine devices?

 

2. Injectable solution? Nasal solution?

 

3. What is the name of the OTC aerosol solution?

Definition

1. Adrenaclick & Twinject (0.15mg/0.15mL, 0.3/0.3)

EpiPen (0.3/0.3) and EpiPenJR (0.15/0.3)

 

2. Adrenalin 1mg/mL and 0.1%

 

3. Primatene Mist (0.22mg/act)

Term
How do sympathetic stimulants increase flow to coronary vessels?
Definition

1. increased relative duration of diastole at higher HR

2. Increased strenght of contraction and myocardial oxygen consumption from direct effects of epi on cardiac myocytes → metabolic dialator effect

Term

How does epinephrine affect the tone of the stomach?

 

What are the metabolic effects of epinephrine?

 

Definition

If tone is relaxed it causes contraction.

If tone is high it causes relaxation.

 

1. Elevated glucose and lactate concentration in blood.

-Insulin secretion is inh by an int with a2 and enhanced by act of B2

-Glucagon secretion is enhanced by action at B receptors on pancreatic alpha-cells 

-Epi stimulates glycogenolysis (through B receptors)

2. Elevated FFA concentration

- stimulation of B receptors in adipocytes activates TG lipase and increases metabolism

 

Term
What are some misc effects of epinephrine?
Definition

1. increases Hct and plasma protein conc. by reducing circulating plasma volume (loss of protein-free fluid to extracellular space)

2. increases circulating PMN leukocytes

3. Accelerates blood coagulation and promotes fibrinolysis

4. decreased glandular secretions

5. mydriasis

6. stimulates K uptake into cells (decreased renal K excretion)

Term

Which epinephrine dosage is used as/for:

1. SQ, IM, or IV

2. hypersensitivity reactions to drugs/allergens

3. IV inj for acute hypersensitivity uncontrolled by other formulations

4. respiratory distress from bronchospasm

5. Stokes-Adams syndrome

Definition

1. 1mg/mL (1:1,000)

2. 1mg/mL (1:1,000)

3. 0.1mg/mL (1:10,000)

4. 1mg/mL (1:1,000)

5. 0.1mg/mL (1:10,000)

Term

When comparing NE, Epi, and Isoproterenol, which agent:

1. Reduces pulse rate?

2. Increases blood pressure?

3. Increases peripheral resistance?

4. Has the most moderate effects on pulse rate, BP, peripheral resist?

 

Definition

1. NE

2. NE

3. NE

4. Epinephrine

 

Term

Norepinephrine has more or less B-adrenergic activity than epinephrine?

 

What "tropic" effect(s) are seen with NE?

 

ADE?

Definition

LESS

 

Positive inotropic

Positive chronotropic effects are overcome by baroreflex compensation

 

Like epinephrine, extravasation can occur - use long plastic cannula

Term
What are the treatment options for extravasation from epinephrine or norepinephrine? 
Definition

Warmth

NTG application

Phentolamine (a-receptor antagonist)

 

Term

What is the brand name for NE?

What is NE's BBW?

What is a sign of NE overdose?

Dilution?

Definition

Levophed (1mg/mL)

 

Antidote for extravasation ischemia - phentolamine ASAP

 

HA

 

In D5W or NaCl with D5W (not just saline because oxidation=loss of potency)

 

Term
MOA of phenylephrine?
Definition

pure a-adrenergic agonist

vasoconstriction → increased SBP, DBP, and MAP

no B-effects so reflex bradycardia

 afterload + myocardial O2 consumption → ↑ coronary blood flow

Term

Which stimulating agent is the least likely to produce tachycardia?

 

Which agent has a BBW instructing physicians to become familiar with the complete monograph before prescribing it as an IV, IM, or SQ injection?

Definition

Phenylephrine

 

Phenylephrine(Neo-Synephrine)-1%;10mg/mL;1+5mL vials, 1mL amp

 

Term

How does dopamine affect

1. MAP?

2. CO?

3. SV?

4. HR?

5. CI?

 

Definition
All are increased
Term

What is the MOA of dopamine?

 

Which component of BP does dopamine affect primarily?

 

Drug interactions?

Definition

stimulates D1 receptors → activation of adenylyl cyclase→ raises intracellular cAMP→vasodilation (increases GFR, renal blood flow, and Na excretion)

 

SBP, may have no effect on DBP or slight increase

 

MAOIs, TCAs

Term

What is dopamine's BBW for?

 

Onset of action? Half-life? Duration?

 

Metabolism?

 

Elimination?

Definition

Antidote for peripheral ischemia - extravasation; use phentolamine (0.1-0.2mg/kg up to 10mg per dose)

 

5min, 2min, 10min

 

MAO and COMT; ~25% hydroxylated to NE in specialized neurosecretory vesicles (adrenergic nerve terminals)

 

80% excreted in urine within 24h

Term
Whic drug is preferred for improvement in CO and oxygen delivery, particularly in early sepsis before peripheral vasodilation?
Definition
Dobutamine
Term

Which isomer of dobutamine is:

1.a1 agonist?

2. a1 antagonist?

3. a more potent B-ag by about 10x?

 

Definition

1. negative(-): pressor responses

2. positive(+): can block the effects of the negative isomer

3. positive(+): both are full beta agonists

Term

Relative to dopamine, dobutamine has increased OR decreased: 

1. CO

2. myocardial oxygen demand

3. pulmonary shunting

Definition

1. increased

2. decreased 

3. decreased

Term

What are the major metabolites of dobutamine?

 

What is the t½?

Definition

conjugates of dobutamine and 3-O-methyldobutamine

 

2min

Term

What are the initial resuscitation goals:

1. CVP

2. MAP

3. UO

4. CV or mixed venous O2-sat

Definition

1. 8-12mmHg

2. > 65mmHg

3. > 0.5mL/kg/h

4. > 70%

Term

What are the goals for adjunctive therapy with:

1. Oxygen

2. Insulin (if hyperglycemia requires)

 

Definition

1. >90% O2 sat

2. glucose <150mg/dL 

Term

Is it appropriate to have adjunctive therapy with:

1. corticosteroids? (hydrocortisone, fludrocortisone)

2. DVT prophylaxis (UFH, LMWH)

3. Stress ulcer prophylaxis (PPI, H2RA)

Definition

1. controversial - maybe IV hydrocortisone 200-300mg/day for 7 days in 3-4 divided doses for pt with septic shock

 

2. yes

 

3. yes

Term

What are the brand names for the following sedatives that can be used in pt with sepsis in the ICU?

1. Propofol

2. Midazolam

3. Lorazepam

4. Dexmedetonidine

Definition

1. Diprivan

2. Versed

3. Ativan

4. Precedex

Term

Which goes with which?!

(propofol, midazolam, lorazepam, dexmedetonidine):

1. Maximum dose of 20mg

2. Risk of propylene glycol toxicity

3. Maximum dose of 0.7mcg/kg/hr

4. An onset of 1-2 mins + duration <20 min

5. Monitor for TG

6. Approval for use <24h

7. Not good for renal dysfunction

8. Not for IV push bolus

9. Increased delerium

10. No respiratory depression

11. Onset in 5-10min with duration of 1½-2h

12. Infusion syndrome

Definition

1. Propofol (Diprivan)

2. Lorazepam (Ativan)

3. Dexmedetonidine (Precedex)

4. Propofol

5. Propofol

6. Dexmedetonidine

7. Midazolam (Versed)

8. Propofol, Dexmedetonidine

9. Midazolam, Lorazepam

10. Dexmedetonidine

11. Midazolam 

12. Propofol

Term

What is the MOA of Drotrecogin Alpha?

 

Brand name?

 

Dosage formulations?

 

Infusion duration?

 

Administration information?

Definition

Activated protein C; inhibits coagulation by proteolytic inactivation of factors Va (5a) and VIIIa (8a)

 

Xigris - indicated for sepsis

 

5 & 20mg IV solution

 

96h

 

administer via IV infusion pump or syringe pump, use a dedicated IV line or lumen of a multilumen CVC, can only be admin through same line as NS, RL, dextrose, and NaCl inj

Term
What are the CI for Xigris?
Definition

1. HSR to drotrecogin alfa or any component

2. active internal bleeding

3. hemorrhagic stroke within 3 mo

4. intracranial or intraspinal surgery or severe head trauma within 2 mo

5. trauma with increased bleeding risk

6. epidural catheter

7. intracranial neoplasm or mass lesion or evidence of cerebral herniation

Term
Warnings/Precautions of Xigris (Drotrecogin alfa):
Definition

 

  1. concurrent heparin use
  2. plt <30,000*10^6/L
  3. INR >3
  4. GI bleed within 6 weeks
  5. thrombolytic therapy within 3 days
  6. oral anticoags or GP2b/3a inh within 7 days
  7. ASA >650mg/day or other platelet inh within 7 days
  8. ischemic stroke within 3 mo
  9. intracranial arteriovenous malformation or aneurysm
  10. known bleeding diathesis
  11. chronic severe hepatic disease
  12. any other conditions where bleeding would be hazardous or particularly difficult to manage

 

Term

Which antibiotic drug class inhibits protein synthesis by binding to 50S ribosomal subunit to block aminoacyl translocation reaction and formation of an initiation complex?

 

Static or Cidal?

 

Spectrum?

 

Preg Class?

 

Misc:

Definition

Macrolides (Erythromycin, Azithromycin, Clarithromycin, Dirithromycin)

 

Static

 

G+/- cocci, G+ bacilli

staph/strep/mycobacterium, good atypical, no g(-)bacilli

 

B (Clarith = C)

 

QT prolongation; renal dosing for clarithromycin

Term

 

Which antibiotic drug class inhibits acetylation of transpeptidases in bacterial cell walls by binding to PBPs?

 

Static or Cidal?

 

 

 

 

Definition

Penicillins 

natural: Pen G Na, PenVK, Pen G Benz, Pen G Pro

amino: amoxicillin, ampicillin

penicillinase-resistant: methicillin, nafcillin, oxacillin, cloxacillin, dicloxacillin

extended spectrum: piperacillin, ticarcillin

 

Cidal

Term

What is the spectrum of PCNs?

 

Preg Cat?

 

MISC:

Definition

G(+), little G(-)

not good for staph, blactam-G+, Staph only

extended spectrum for pseudomonal activity, some anaerobes

 

B

 

time-dependent, extended-spectrum after pH function

Term

Which antibiotics inhibit peptidoglycan synthesis by binding to PBPs?

 

Static/Cidal?

 

Spectrum?

 

Pregnancy Cat?

 

Renal Dosing?

 

Misc:

Definition

Penems:

Primaxin (imipenem/cilastatin)

Invanz (ertapenem)

Merrem (meropenem)

Doribax (doripenem)

 

Static/Cidal

 

broad spec G(+/-), not for MRSA or enterococcus, no pseudomonas with ertapenem, good anaerobes

 

B (C for Primaxin)

 

Yes

 

concentration independent, high risk of seizures

Term

Which antibiotics bind to the 30S and 50S ribosomal subunits to interfere with protein cell wall synthesis?

 

Static/Cidal?

 

Spectrum?

 

PregCat?

 

Renal dosing?

 

MISC:

Definition

Aminoglycosides

(gentamicin, tobramycin, amikacin, streptomycin, netilmicin)

 

Cidal

 

some G+, some staph, good G-, good pseudomonas

 

D

 

Yes

 

Concentration-dependent nephrotox and ototox, post antibiotic effect 

Term

Which antibiotics inhibit DNA gyrase and Top IV relaxing supercoiled DNA and promoting strand breakage?

 

Static/Cidal?

 

Spectrum?

 

PregCat?

 

Renal Dosing?

 

Misc:

Definition

Fluoroquinolones(ciprofloxacin, levofloxacin, moxifloxacin, ofloxacin, norloxacin, gemifloxacin)

 

Cidal

 

BS, pseudomonas, some atypical, Moxi covers anaerobes, not for MRSA, g+ coverage improves with newer agents

 

C

 

Yes

 

QT prolongation, tendonopathy

Term

Which antibiotics inhibit mucopeptide cell wall synthesis?

 

Static/Cidal?

 

 

Definition

CEPHS - CIDAL

1st generation:

Keflex (cephalexin) - PO

Duricef (cefadroxil) - PO

Ancef (cefazolin) - IV

 

2nd generation:

Ceclor (cefaclor) - PO

Cefzil (cefprozil) - PO

Lorabid (loracarbef) -PO

Ceftin/Kefurox (cefuroxime) - PO/IV/IM

Mefoxin (cefoxitin) - IV

 

3rd generation:

Suprax (cefixime) - PO

Omnicef (cefdinir) - PO

Vantin (cefpodoxime) -PO

Spectracef (cefditoren) -PO

Fortax (ceftazodime) -IV/IM

Cefobid (cefoperazone) - IV/IM

Claforan (cefotaxime) - IV/IM

Cefizox (ceftizoxime) - IM/IV

Rocephin (ceftriazone) - IV/IM

 

4th generation:

Maxipime (cefepime) - IV/IM

 

5th generation:

Teflaro (ceftaroline) - IV

Term
Activity of each ceph generation:
Definition

 

  1. mod broad (~amox/amp); best G+ act, stable to B-lactamases and penicillinases but not to cephalosporinases
  2. broader G- with less G+; stable to BLase, PCNases, and some CEPHases
  3. broad G- with less G+; some pseudomonas, stable to BLases, PCNases, many CEPHases
  4. broad G- with significant G+, very active against pseudomonas and enterobacteriaceae, not for anaerobes, stable to BLases, PCNases, and almost all CEPHases
  5. selective G-/+; MRSA, S pyogenes, S agalactiae, E coli, K pneumonia, K oxytoca

 

Term

More on Cephs:

1. pregnancy category

2. renal dosing

3. misc

Definition

1. B

2. Yes, except Rocephin (ceftriaxone)

3. concentration independent

Term

Which antibiotics bind to 30S ribosomal subunit to inhibit protein synthesis?

 

Static/Cidal?

 

Spectrum?

 

PregCat?

 

Renal Dosing?

 

Misc:

Definition

Tetracyclines [Tetracycline, Doxycycline, Minocycline, Demeclocycline, Tygacil (tigecycline)]

 

Static

 

BS, good anaerobes, good atypical, good against Rickettsia and Chlamydia, Tige good for MRSA

 

PregD

 

NO

 

works on actively dividing only; avoid dairy/antacids

Term

Which antibiotics bind to D-ala-D-ala precursor in bacterial peptidoglycan and prevent cell wall formation as well as some protein synthesis?

 

Static/Cidal

 

Spectrum

 

PregCat

 

Renal dosing

 

misc:

Definition

Vancomycin

 

Cidal

 

G+, MRSA, C.difficile

 

Preg: PO-B; IV-C

 

yes

 

concentration-independent; trough >10best at 15-20

Term
Which AB only work on actively dividing cells?
Definition
PCNs & Tetracyclines
Term
Which AB can cause QT prolongation?
Definition
Fluoroquinolones & Macrolides
Term

Which AB have high risk of seizures?

 

Which should you not take with daily/antacids?

 

tendonopathy?

Definition

1. penems

2. tetra

3. fluoroquinolones

Term
Which AB are concentration independent?
Definition

penems

cephs

vanc

Term

Which FQ works on anaerobes?

 

Which tetracycline has MRSA activity?

 

Which CEPHs can be give IM?

 

Which 2nd generation Ceph has anaerobic coverage?

Definition

Moxi

 

Tigecycline

 

cefuroxime, ceftazodime, cefoperazone, cefotaxime, ceftizoxime, rocephin, cefepime 

 

cefoxitin (Mefoxin)

 

 

Term
Which PCNs have pseudomonal activity?
Definition

Piperacillin

Ticarcillin

Term
Which AB have antipseudomonal activity?
Definition

Ticarcillin/Tazobactam (Zosyn)

Ampicillin/Sulbactam(Unasyn)

Meropenem (Merrem)

Gentamicin (Garamycin, Septopal, Cidomycin)

Tobramycin (Tobi, Tobradex)

Levofloxacin (Levaquin)

Ciprofloxacin (Cipro)

Cefepime (Maxipime)

Term
Which antibiotics are used to treat pulmonary infections?
Definition
ticaracillin/tazobactam (Zosyn), ampicillin/sulbactam (Unasyn), cefazolin (ancef), ceftriaxone (Rocephin), cefoxitin (), cefepime (Maxapime), meropenem (Merrem), gentamicin, tobramycin, azithromycin, doxycycline (Doryx), clindamycin, levofloxacin, ciprofloxacin, trimethoprim/sulfamethoxazole (bactrim)
Term

Which drug class inhibits synthesis of beta (1-3)-glucan resulting in disruption of the cell wall synthesis = cell death?

 

static/cidal?

 

spectrum?

 

Renal dosing?

 

PregCat?

Definition

echinocandin antifungals 

Cancidas (caspofungin), Mycamine (micafungin), Eraxis (anidulafungin)

 

Cidal

 

Candida, Aspergillus, no C neoformans, zygomycosis or mucomycosis

 

No

 

Preg C

Term

Common causes of sepsis (pathogen classification)?

 

Risk factors for septic shock?

 

What non-specific blood levels are elevated in severe sepsis?

Definition

Gram-negative bacilli OR Gram-positive cocci

 

DM, cirrhosis, leukopenia (esp associated with cancer or cytotoxic drugs), invasive devices (trach tubes, caths, drainage tubes), prior tx with AB or corticosteroids

 

Procalcitonin and C-reactive protein

Term
During sepsis what is going on in terms of alkalosis/acidosis?
Definition

Lactic acidemia (metabolic acidosis) may cause compensatory hyperventilation (respiratory alkalosis)

 

 

Term

What are some signifiant drug-drug interactions with aminoglycoside ABs?

 

DDI with Ampicillin?

Definition

increased nephrotoxicity (w/ enflurane, cisplatin, possibly vanc)

increased ototoxicity (w/ loop diuretics)

increased paralysis (w/ NM blocking agents)

 

Increased frequency of rash with allopurinol

Term
When should you consider using drotrecogin alfa?
Definition
severe sepsis with APACHE score >24, no increased risk of bleeding, no TCP w platelets <30,000, no sepsis-induced organ dysfunction for >24h, no hypercoaguability, no chronic renal or hepatic failure, not for children, not during pregnancy, and it's very, very $$$$$
Term
What are the causes of rapidly progressing cases of sepsis?
Definition

Meningococcemia

P. aeruginosa

Aeromonas

Term
What are the 3 most common g+ pathogens?
Definition

Staphylococcus aureus

Streptococcus pneumoniae

Coag-negative staphylococci

Term

All of the following are proinflammatory except:

A. TNF-a

B. IL-6

C. IL-8

D. Activated protein C

Definition
D. Activated protein C
Term

What is the preferred treatment option for a 56-year-old male with community-acquired pneumonia who was recently prescribed azithromycin for sinusitis:

A. ertapenem

B. moxifloxacin

C. amoxicillin

D. doxycycline

E. clarithromycin

Definition
B. moxifloxacin
Term

Complication(s) associated with sesis:

A. persistent hypotension

B. disseminated intravascular coagulation

C. ARDS

D. acute renal failure

E. all of the above

Definition
E. all of the above
Term

Which of the following agents used against MRSA is incorrectly matched with its clinically significant adverse reaction?

A. Vancomycin - nephrotoxicity

B. Linezolid - neutropenia

C. Quinupristin/dalfopristin-myalgia

D. Daptomycin-hyperbilirubinemia

Definition
D. Daptomycin-hyperbilirubinemia
Term

Polymicrobial infections such as secondary peritonitis can be treated with the following agents except:

A. ceftazidime and gentamicin

B. piperacillin/tazobactam

C. ampicillin plus gentamicin plus metronidazole

D. meropenem

E. ciprofloxacin plus metronidazole

Definition
A. ceftazidime and gentamicin should not be used for polymicrobial infections like secondary peritonitis
Term

The preferred agent for a 37 yo male with advanced AIDS and candidemia is:

A. fluconazole

B. amphotericin B deoxycholate

C. itraconazole

D. amphotericin B lipid complex

E. ketoconazole

Definition
B. Amphotericin B deoxycholate
Term

Dopamine affects the following receptors except:

A. a1

B. a2

C. b1

D. b2

Definition
B. A2; dopamine does NOT affect a2
Term

The following treatment regimen is preferred in case of nosocomial pneumonia with a suspicion of PA?

A. levofloxacin

B. ceftazidime + azithromycin

C. piperacillin + gentamicin

D. ceftriaxone + levofloxacin

E. vancomycin + ertapenem

Definition
C. Piperacillin + Gentamicin
Term

Regarding hemodynamic support, which of the following agents is the best initial therapeutic intervention?

A. 5% albumin

B. LR

C. NS

D. NE

E. DA

Definition
C. NS
Term

Invasive candidiasis can be treated with all of the following EXCEPT:

A. fluconazole

B. voriconazole

C. caspofungin

D. amphotericin B deoxycholate

E. itraconazole

Definition
E. itraconazole (sporanox)
Term

Which of the following agents is effective against Candida glabrata?

A. fluconazole

B. voriconazole

C. itraconazole

D. ketoconazole

Definition
B. voriconazole is effective against C. glabrata
Term

Of the cephalosporins

1. which agents cover anaerobes?

2. which agents cover Pseudomonas aeruginosa?

Definition

1. Cefoxitin (Mefoxin)

 

2. Ceftazidime (Fortaz)

     Cefepime (Maxipime)

Term
What is the MOA of daptomycin (cubicin)?
Definition
binds to components of the bacterial cell wall causing rapid depolarization and cessation of DNA, RNA, and protein synthesis
Term

What are the cell membrane agents?

 

MOA?

Definition

Polymixin (Poly-Rx)

Colistin (Coly-Mycin M)

 

damages the cell membrane and permits leakage of intracellular constituents

Term
What are the 3 classes of DNA synthesis inhibitors and their MOAs?
Definition

1. Quinolones - inh DNA gyrase (topoisomerase 2) relax supercoiled DNA and break

2. Nitroimidazoles - disrupts the helical DNA structure and damages the strands resulting in inh of protein synth

3. Rifamycins - bind to the beta subunit of DNA-dependent-RNA-polymerase to block RNA transcription

Term
How do the folic acid inhibitors work?
Definition

SMZ inh dihydrofolic acid formation from PABA

TMP inh dihydrofolic acid reduction to THF

 

static + static = cidal

Term
Which drugs target the 30s ribosomes?
Definition

Tetracyclines

Glycylcyclines (Tigecycline)

Aminoglycosides

 

Term
Which drugs target 50s ribosomal units?
Definition

Macrolide

Lincosamide

Chloramphenicol

Streptogrammin (Synercid)

Oxazolidinone (Linezolid)

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