Advanced pharmacology Exam 1

Oxalodinones: Linezolid

*not commonly used Pharmacodynamics:Inhibitors of bacterial ribosomal protein synthesis Most effective against aerobic gram-positive bacteria Resistance emerging Pharmacokinetics:Well-absorbed orally Does not use CYP 450 enzymes ADRs: Diarrhea, headache, nausea Myelosuppression has been reported, resolves with discontinuation of drug.

asthma facts

1 in 12 adults and 1 in 11 children. missed school and work days.. Asthma is a serious health and economic concern in the United States. It's expensive! Asthma costs the United States $56 billion each year and the average yearly cost of care for a child with asthma was $1,039 in 2009. 9 people die from it/day

COPD significance and RFs

3rd leading COD in U.S. People aged 65-74 years and ≥ 75 years. American Indian/Alaska Natives and multiracial non-Hispanics. Women. Individuals who were unemployed, retired, or unable to work. Individuals with less than a high school education. Individuals who were divorced, widowed, or separated. Current or former smokers. People with a history of asthma.

psoriasis disease process

A COMMON CHRONIC AUTOIMMUNE DISEASE OF THE SKIN RESULTUING IN A "WAXING AND WANING" PATTERN OF INFLAMATION... MOST COMMONLY PRESENTS WITH RAISED PLAQUES (REDDISH) COVERED WITH SILVERY-WHITE SCALING (COMMON ON ELBOWS/KNEES/SCALP)

Topical corticosteroids are used as a common treatment for eczema, mild psoriasis, and contact dermatitis. In The Prescribers Letter, find the Comparison of Topical Corticosteroids chart and identify cases that you might prescribe a medium or high potency topical corticosteroid. What important education should you include for the patient?

A medium or high potency topical corticosteroid . Patients should be educated that treatment with very-high potency topical corticosteroids should not exceed 2 weeks and total dosage should not exceed 50g/wk and high potency for up to 3 weeks. Moderate to high potency topical corticosteroids may be used for crusting and thickened conditions resistant to classic treatment (such as severe thick scaly psoriasis, or severe eczema) since psoriasis lesions are generally "steroid resistant". Higher potency doses are also used for areas such as palms and soles since these areas of the body have thick skin and require higher potencies to penetrate the condition. Additionally, as an alternative to lower potency twice daily dosing for a condition, another dosing schedule that may achieve therapeutic response with fewer side effects is short-term/intermittent therapy which uses high-potency agents for a short period of 3-4 consecutive days a week or once a week.

eczema

A term referring to a broad range of conditions resulting in dermatitis May be considered a form of "chronic dermatitis" Treatment: Topical steroids Analgesics

antivirals for influenza: ADRs, clinical use & dosing

ADRs Zanamivir: bronchitis and shortness of breath Clinical use and dosing: Oseltamivir, zanamivir are approved for the prophylaxis and treatment of influenza type A and B. Peramivir is approved for acute influenza in those 18 years and older. CDC updates prescribing recommendations annually.

Antivirals: ADRs & Drug interactions

ADRs: Acyclovir/valacyclovir: few ADRs when given orally Valacyclovir may cause thrombocytopenia purpura, hemolytic uremic syndrome in immunocompromised patients. Famciclovir: headache Ganciclovir: granulocytopenia, anemia and thrombocytopenia; may be carcinogenic Drug interactions:Few

antimycobacterials: ADRS for INH, rifampin, pyrazinamide, ethambutol, streptomycin and capreomycin, rifabutin. Drug interaction

ADRs: INH: peripheral neuropathy INH, rifampin, and pyrazinamide: hepatotoxicity Ethambutol: optic neuritis Streptomycin and capreomycin: ototoxic Rifabutin: neutropenia and thrombocytopenia Drug interactions: Many drug interactions Rifampin is an inducer of CYP 450 enzyme

Metronidazole and Nitazoxanide: ADRs, clinical use and dosing & rational drug selection

ADRs: Mitronidazole: anorexia, nausea, abdominal pain, dizziness, headache, metallic taste Clinical use and dosing: Metronidazole and tinidazole are used against the protozoal infections T. vaginalis, G. lamblia, and E. histolytica Metronidazole is used for anaerobic bacterial infections, bacterial vaginosis, and is one of the drugs in H. pylori treatment Rational drug selection: Metronidazole is on $4 retail lists Avoid metronidazole in first trimester of pregnancy

initiation of ART meds: who should it be initiated in?

ART should be initiated in patients with AIDS-defining illness or CD4 count less than 350 cells/mm3 HIV-associated nephropathy Co-infection with hepatitis B infection Pregnant women Patients with CD4 counts between 350 and 500 cells/mm3 Potential benefits of early intervention must be weighed against the risks of early therapy

TB goals of treatment

Accurate diagnosis Screening via purified protein derivative (PPD) or QuantiFERON-TB serum test Chest x-ray if PPD or QuantiFERON-TB positive Uninterupted completion of the recommended therapy Effective treatment to treat patient and prevent transmission

goals of HIV treatment

Achieve maximal suppression of plasma viral load for as long as possible Delay the development of medication resistance Preserve CD4 T-cell numbers Confer substantial clinical benefits, leading to reduction in morbidity and mortality

Blepharitis: what is it? causes? types? treatment

Acute or chronic inflammation of the eyelash follicles and meibomian glands of the eyelids Dandruff-like scales form on the eyelashes. It is a common and caused by either bacteria or a skin condition, such as dandruff of the scalp or acne rosacea. It affects people of all ages. Blepharitis is not contagious and generally does not cause any damage to eyesight. Blepharitis is classified into two types: Anterior blepharitis occurs at the outside front edge of the eyelid where the eyelashes attach. Posterior blepharitis affects the inner edge of the eyelid that touches the eyeball. Treatment Scrubbing the eyelashes with gentle, no-tears shampoo Applying erythromycin ophthalmic ointment

AOM pain management

Adequate pain relief Acetaminophen: 15 mg/kg/dose Ibuprofen: 5 to 10 mg/kg/dose Topical analgesic Drops: combination of anti-pyrine, benzocaine and glycerin TM must be intact. Auralgan has been taken off the market in the past, but a pharmacist told me recently that it is still available, but difficult to obtain.

HIV patient monitoring

Adherence to medications and medical visits Affective mental health problems Alterations in metabolism of lipids and glucose Cardiovascular risk Hepatitis B and C co-infection High-risk behaviors Immunization status Renal and hepatic function Sexually transmitted infections Somatic signs and symptoms Tobacco, alcohol, and substance use

opthalmic anti-infective patient education

Administration: Instruct on preventing contamination Instruct on how to instill drops or ointment Adverse Drug Reactions: Few and transient Lifestyle management : Excellent hand-washing No sharing of towels Throw away eye makeup Clear purulent discharge with wet cotton ball or washcloth

smoking cessation combination therapy

Agency for Health Care Policy and Research Smoking Cessation: Clinical Practice Guidelines Level A evidence for Long-term (more than 14 weeks) nicotine patch + other nicotine replacement therapy (gum and spray) Nicotine patch + nicotine inhaler Nicotine patch + bupropion sustained-release

exercise induced bronchospasm(EIB)

Albuterol: 2 puffs 15 minutes before exercise Salmeterol: 2 puffs 30 to 60 minutes before exercise Do not use if already on daily dose of salmeterol. Leukotriene modifiers taken daily may decrease EIB symptoms in 50% of patients, but patient will still need to use albuterol before exercise. ALL patients with any form of asthma should always have a SABA on hand.

contact dermatitis: types & common agents

Allergic or irritant Common agents causing contact dermatitis: Soaps/detergents Solvents Cosmetics Plants Metals Latex and rubber Local anesthetics

Additional commonly used ocular agents

Aminoglycosides invade the pathogen, but they are primarily narrow-spectrum antibiotics, very effective against gram-negative organisms, with good activity against Pseudomonas. However, there is emerging resistance. Fluoroquinolones are currently the most popular broad-spectrum antibiotics for treatment and prophylaxis of eye infections because of their safety, excellent penetration into the aqueous and vitreous, long duration of tear concentration and broad spectrum of antimicrobial activity including gram-positive, gram-negative, and intracellular organisms. Vancomycin and tetracylcines can be used but are not common in the primary care setting.

Antibiotic Choices for Acute Bacterial Sinusitis

Amoxicillin first line in Children Dose at 80 to 90 mg/kg/day in high-risk children; 45 mg/kg/day in low-risk children Augmentin 875/125 is the first line antibiotic in adults and in areas with developing resistance, higher dosing appropriate For penicillin-allergic patients Children: cefdinir, cefuroxime, or cefpodoxime Adults: doxycycline, azithromycin, sulfa drugs or respiratory fluoroquinolone (levofloxacin) if nothing else is an option

AOM tx for penicillin allergic

Cefdinir: 14 mg/kg per day in 1 or 2 doses Cefpodoxime: 10 mg/kg per day, once daily Cefuroxime: 30 mg/kg per day in two divided doses Ceftriaxone: 50 mg intramuscular (IM) 1 day or for 3 days

Conjunctivitis-otitis syndrome: organism, treatment

Children younger than age 6 H. influenzae is the causative organism in the majority (73%) of patients with conjunctivitis-otitis syndrome. Treatment: high-dose amoxicillin

Antivirals: Nucleoside Analogues: pharmacodynamics

Antiviral drugs must either block entry into the cells or be active inside host cells to be effective Acyclovir: active against herpes simplex viruses 1 and 2 (HSV-1 and HSV-2); varicella-zoster virus (VZV); Epstein-Barr virus (EBV), cytomegalovirus (CMV), and herpes virus 6 Valacyclovir is converted to acyclovir after oral administration and is active against the same viruses Famciclovir: active against HSV-1 and HSV-2, VZV, EBV, and hepatitis B virus Ganciclovir is active against CMV

sinusitis

Bacteria isolated in 70% of patients with sinusitis. Estimates of inappropriate prescriptions for antibiotics in one-third to two-thirds of sinusitis diagnoses. Strict criteria: persistent, not improving for at least 10 days Common pathogens: S. pneumoniae: 30% H. flu: 20% Moraxella catarrhalis: 20% Rarely, Staphylococcus

bacterial conjunctivitis: organism by age. treatment

Bacterial conjunctivitis Children 3 months through 8 years are most likely to have staphylococcal, streptococcal or Haemophilus conjunctivitis. Staphylococcus aureus and Pseudomonas aeruginosa are the most common pathogens in the elderly. Treatment: ophthalmic antibiotics Dacryostenosis: erythromycin ointment

pneumonia antibiotic choices for kids under5yo

Bacterial pneumonia (S. pneumoniae) Amoxicillin: 80 to 90 mg/kg/day Ceftriaxone: 50 mg/kg/day until able to take oral antibiotics Penicillin allergy: clindamycin or a macrolide Infant with suspected chlamydial pneumonia Azithromycin 20 mg/kg/day for 3 days OR erythromycin (EryPed) 50 mg/kg for 14 days

e-cigarettes

Battery-operated devices Inhaled nicotine Some use to help with nicotine withdrawal when attempting to stop smoking. Studies need to be done on safety due to potential toxic inhalants, therefore recommending use is premature.

what is asthma?

Chronic inflammatory disorder of the airways Recurrent episodes of wheezing, breathlessness, and chest tightness Airflow obstruction is reversible. National Asthma Education and Prevention Program Expert Panel 3 Guidelines (2007) are used for management of all types of asthma. 4 types are: Mild intermittent,Mild persistent, Moderate persistent,Severe persistent Adult and children definitions differ slightly. Important to know staging of asthma and how its controlled. People will see decrease in peak flow 2-4 days ahead of time prior to symptoms; warning that something is going to happen and can do something about it. Problem is its hard to get people to do daily peak flows

AOM goals of treatment

Clear infection from the middle ear fluid, thereby reducing pain and risk for complications Since treatment is empiric, a change of antibiotic may be necessary to clear infection.

mild acne treatment

Benzoyl peroxide (OTC), topical retinoid, or a topical antibiotic may be used to treat mild acne.

benzoyl peroxide

Benzoyl peroxide can be received over-the-counter or as a prescription. Benzoyl peroxide has both comedolytic and antibacterial effects against p.acnes. It also has a drying effect which removes excess sebum. Benzoyl peroxide can cause mild irritation to the skin, burning, blistering, crusting, itching, severe redness, swelling, pain or a mild rash. It is generally safe for use in pregnancy, It comes in a liquid wash, bar, mask, lotion, cream and gel formularies. Patients should be instructed to wash their face once or twice daily with the liquid washs and bars, and pat (don't rub) their face to dry. The other forms should be applied once daily after cleansing the skin and can be gradually increased to 2-3 times daily as needed. Benzoyl peroxide is in the over-the-counter forms Dryox, Fostex, Neutrogena AcneMask, and Clearasil or in the prescriptions Benzac, Desquam-X and Desquam-E.

HPV vaccine: forms of it, c/I, ADRs, how is it dosed? who gets it?

Bivalent HPV (Cervarix) vaccine for females (types 16, 18) 9-valent HPV (Gardisil9) vaccine for females, males (types 6, 11, 16, 18, 31, 33, 45, 52, 58) -these are tested for on pap smear Contraindications: allergic reaction ADRs: syncope, injection site pain, and redness Dosing: three doses at 0, 2, and 6 months Gardasil: females and males age 9 to 26 years- only 2 doses now, 3rd is not more effectie Cervarix: females age 10 to 25 years Both are started at the 11 to 12 year visit, if parents are willing to entertain the notion that their child might soon be sexually active!

What organism is being treated in Lyme disease?

Briefly explain the process in which the bacteria is transmitted to the human, and then describe your rationale for your decisions above. The disease being treated is Borrelia burgdorferi which is carried by black-legged ticks (Ixodes scapularis or pacifica). Ticks prefer warm, moist areas of the body and bites are therefore more common in the summertime. Once the tick gets on your body, they can migrate and when they're in a desirable spot, they bite into the skin and begin sucking in blood and remain attached to your body as they bite you. As they take in more blood, they grow and can stay on your body for up to 10 days before falling off.

beta2 agonists clinical use

Bronchodilators are used primarily in the treatment of bronchospasm associated with asthma, bronchitis (acute or chronic), and chronic obstructive pulmonary disease (COPD). Albuterol metered dose inhaler (MDI) dose is 2 puffs every 4 to 6 hours. Metered dose inhaler- More than every 20 minutes of albuterol is not going to help d/t absorption, mucus also inhibits absorption. Via nebulizer dose is 2.5 mg/dose Dose may be repeated twice after 5 to 10 minutes. May combine with ipratropium Levalbuterol via nebulizer every 6 to 8 hours Salmeterol DISKUS: 1 puff twice a day Do not use alone for persistent asthma, combine with an inhaled corticosteroid.

anti-depressants

Bupropion (Zyban) Unknown action in smoking cessation Start 1 to 2 weeks before quit date. Dose: 150 mg daily for 3 days Then increase to 150 mg twice daily Quit day Cold turkey OK to use nicotine replacement product Continue therapy for 7 to 12 weeks, may need longer.

Inhaled Anticholinergics:Clinical Use and Dosing

COPD Ipratropium: 2 puffs (36 µg) 4 times/day (maximum 12 puffs per day) Ipratropium: 1 unit dose via nebulizer 3 to 4 times/day, may be mixed with albuterol Ipratropium-albuterol combination (Combivent): 2 puffs 4 times/day Tiotropium (Spiriva): 2 puffs of a single capsule once/day Aclidinium bromide (Tudorza Pressair): 1 puff twice/day Asthma Ipratropium for asthma maintenance is 2 to 3 puffs 4 times/day for adults. Children under age 12 years: 1 or 2 puffs every 6 hours Ipratropium-albuterol combination (Combivent) is a second-line quick relief medication in the treatment of asthma. Tiotropium and aclidinium are not indicated for the treatment of asthma.

otis antiinfective-clincal use and dosing

Clinical use and dosing Acute otitis externa (a.k.a. swimmer's ear) Topical treatment with combination drop preparation(abx and steroid) Usual dose is 4 drops in the affected ear and treatment should continue for 7 to 10 days A topical acid or alcohol solution (Domeboro otic, Burow's otic, VoSol) can be instilled into the ear four times a day if the TM is intact Chronic otitis externa Can be inflammatory or infectious Mineral oil daily Steroid cream. cipro and cortisporhin is c/I if TM perforated

clindamycin: clinical use & dosing, Rational drug selection

Clinical use and dosing First-line therapy for MRSA in some areas Infections in PCN-allergic patients Drug-resistant Streptococcus Pneumoniae infections Dental infections Rational drug selection Considered second-line therapy, narrow spectrum of aerobic activity First-line therapy in special populations (pregnancy and children)

ophthalmic vasoconstrictors: clinical use and dosing, patient education

Clinical use and dosing Used for temporary relief of eye redness due to irritation or allergic conjunctivitis Tetrahydrozoline, oxymetazoline, naphazoline and phenylephrine Adult dose is 1 or 2 drops instilled in the eyes four times/day. Use in children is not recommended Patient education Avoid prolonged or excessive use, due to the potential for "rebound" redness and irritation once the drops are discontinued.

fluoroquinolone: clinical use&dosing & monitoring

Clinical use and dosing: Complicated UTI, pyelonephritis infections, chronic bacterial prostatitis Pneumonia/chronic bronchitis exacerbation PCN-resistant S. pneumoniae, skin infections, bone/joint infections, complicated intraabdominal, infectious diarrhea Monitoring: watch for prolonged use, ECG with at-risk patients before prescribing moxifloxacin, alcohol use, monitor for tendonitis/rupture

tetracyclines: clinical use & dosing, rational drug selection, patient education

Clinical use and dosing: Doxycycline is considered first-line therapy for C. trachomatis and Ureaplasma urealyticum Tetracycline and minocycline are used to treat P. acnes Some H. pylori regimens include tetracycline Rational drug selection:Doxycycline and minocycline can be taken with food Patient education Administration, ADRs, avoid pregnancy, avoid sun exposure with doxy

Macrolides, Azalides, Ketolides: clinical use & dosing, rational drug selection

Clinical use and dosing: Drug of choice for community-acquired pneumonia (mycoplasma)-zpac Chlamydia Pertussis H. Pylori infections (clarithromycin) Chronic bronchitis Rational drug selection: Often as alternatives for PCN allergies Increasing resistance Not appropriate for treating AOM or sinusitis

cerumenolytics

Carbamide peroxide (Debrox, Dent's Ear Wax, Murine Ear Wax Removal) softens and emulsifies the wax. Instill 1 to 5 drops (depending on the size of the ear canal) twice daily for up to 4 days. Once the cerumen is softened, the ear canal can be irrigated with warm water or saline. Advise patients to avoid using a Q-tip for deeper penetration into the ear. They should be used only in the outer portion of the ear.

beta2 agonists caution and c/i

Cardiac arrhythmias Diabetics: potential drug-induced hyperglycemia Long-acting beta agonists Black Box warning: The risks of salmeterol (Serevent) and formoterol (Foradil) outweighed the benefits and should not be used alone in asthma for all ages. Warning is b/c its not a rescue med and can increase change of death if someone trys it during an acute attack Two-fold increase in catastrophic events (asthma-related intubations and death) Terbutaline pregnancy category B (others category C) Children Albuterol safe for all age children Salmeterol should not be used in children less than age 4 years and never alone.

antimycobacterials: clinical use&dosing, rational drug selection, monitoring and patient education

Clinical use and dosing: Follow Centers for Disease Control (CDC) guidelines Active TB requires four-drug therapy Preventive therapy with INH Rational drug selection: Follow CDC guidelines Monitoring: Directly observed therapy Patient education: Importance of taking medication daily Reporting of ADRs

antivirals: clinical use &dosing, rational drug selection

Clinical use and dosing: Herpes simplex virus: genital herpes, both initial outbreak and suppression therapy Herpes zoster (shingles): Start therapy within 3 days of outbreak. Varicella (chickenpox): Start within 24 hours of outbreak Gingivostomatitis in children Bell's palsy Rational drug selection: Choice based on cost and convenience

acute otitis media: cause, usual pathogen, diagnosis

Caused by Eustachian tube dysfunction Negative pressure causes reflux of bacteria into middle ear Usual pathogens: S. pneumoniae Non-typeable H. influenzae M. catarrhalis Microbiology is changing due to pneumococcal conjugate vaccine. H. flu increasing, S. pneumoniae decreasing Respiratory viruses account for 40% to 75% of acute otitis media (AOM) cases in children. Diagnosis of AOM requires: Moderate to severe bulging of tympanic membrane (TM) or new onset of otorrhea Mild bulging of TM and less than 48 hours of ear pain or intense erythema of TM Bullous myringitis Thin-walled bulla

Sulfonamides, Trimethoprim, Nitrofurantoin: clinical use and dosing, monitoring

Clinical use and dosing: Most commonly used with UTI infections MRSA is susceptible in some areas Rational drug selection: Low-cost alternative in children less than 2mo and PCN allergies Monitoring: Control and status if treating UTI Long-term use check CBC Chest x-ray for patients that develop a cough when on nitrofurantoin

Anthelminthics: clinical use &dosing, rational drug selection

Clinical use and dosing: Pinworms: single dose of mebendazole, pyrantel pamoate,or albendazole Whipworms: pyrantel pamoate, albendazole, mebendazole Roundworms: mebendazole Hookworms: pyrantel pamoate, albendazole, mebendazole Threadworm: ivermectin or thiabendazole Scabies: off-label ivermectin in immunocompromised patients Rational drug selection Use CDC recommendations.

Oxalodinones: Linezolid: clinical use & dosing, rational drug selection

Clinical use and dosing: Pneumonia Complicated skin infections Use less expensive drugs first Rational drug selection:Expensive ($1,152 for 20)

Systemic Azoles and Other Antifungals: clinical use&dosing, rational drug selection

Clinical use and dosing:Oral antifungals used to treat superficial infections by yeasts (Candida, pityriasis versicolor) and dermatophytes (tinea infections) and invasive systemic mycoses Fluconazole requires loading dose Rational drug selection:Fluconazole has the fewest drug interactions

cocoon immunity

Cocoon Immunity is the idea of vaccination of the people in the vicinity of a high risk individual who is unable to be vaccinated. And what would be an example of cocoon immunity? New babies coming home, everyone around them should be vaccinated for flu since baby cant vaccine until 6months old. Not fully protected until they get 2 one half doses.MMR and rotavirus are live vaccines so don't give to immunocompromised

penicillins: clinical use & dosing

Commonly prescribed for infections seen in primary care Amoxicillin is first-line therapy for acute otitis media (AOM) and sinusitis Penicillin (PCN) is used for streptococcal pharyngitis Amoxicillin/clavulanate is first-line therapy for infection following bites, including human

what determines ART regimen?

Comorbid conditions Convenience Gender and pretreatment CD4 T-cell count (nevirapine) Genotypic drug resistance testing HLA B*5701 testing if considering abacavir Patient adherence potential Potential adverse drug effects Potential drug interactions with other medications Pregnancy potential

goals of smoking cessation treatment

Complete and permanent cessation of tobacco use Nicotine replacement therapy provides: Gradual, controlled reduction of nicotine to avoid withdrawal symptoms Bupropion (Zyban/Wellbutrin) Tobacco free by 7 to 12 weeks of therapy Varenicline (Chantix) Tobacco free by 12 weeks

severe psoriasis treatment

(may include arthritis) Do Systemic treatment Retinoids Mabs (monoclonal antibody drugs) methotrexate Humira TNF inhibitors

conjunctivitis symptoms

Conjunctivitis Symptoms can include: Pink or red color in the white of the eye(s) Swelling of the conjunctiva (the thin layer that lines the white part of the eye and the inside of the eyelid) and/or eyelids Increased tear production Feeling like a foreign body is in the eye(s) or an urge to rub the eye(s) Itching, irritation, and/or burning Discharge (clear, mucus and purulent) Crusting of eyelids or lashes, especially in the morning Contact lenses that do not stay in place on the eye and/or feel uncomfortable (wearing contacts may change treatment decisions)

Sinusitis: Worsening After 72 Hours

Consider bacterial resistance. Stay up to date on local resistance patterns and information. Switch to Augmentin if amoxicillin was first choice If started on Augmentin Adults: Consider azithromycin or respiratory fluoroquinolone (levofloxacin) Children: Consider cefdinir, cefuroxime, cefpodoxime

inhaled anticholinergics: cost& patient education

Cost Combined albuterol-ipratropium products are cheaper than the two individual drugs. Generic ipratropium/albuterol nebulizer solution is $13.97 for a month's supply. Tiotropium (Spiriva) costs ~$223 per month. Aclidinium bromide (Tudorza Pressair) costs $234 per month. Patient education Use as prescribed. Educate on use of inhaler or Handihaler. Rinse mouth after inhaling medication.

inhaled anticholinergics ADRs

Cough is most common Dry mouth Mild anticholinergic effects in a few patients Constipation Urinary retention (less than 2%) Rare allergic reaction Allergy to soybeans, legumes, or soy lecithin appears to be correlated with hypersensitivity to ipratropium bromide.

Immunomodulators

Cyclosporine (Sandimmune) and Azathioprine (Imuran) prescribed to organ transplant patients and severe rheumatoid arthritis Drug interactions: many due to liver metabolism, live virus vaccines Dosing: specialty drug

ART failure

Defined as the failure to achieve or maintain suppression of viral replication to less than 50 copies/mL May be either failure or virological rebound Causes Suboptimal adherence Toxicity

pediatric asthma challenges

Delivering medication to children: Use Aerochamber with mask for infants and young children. Use spacer for all children. Home nebulizer is an option. School-age and adolescent children need to use inhalers at school: Need education and observation of self-administration. Will need note for school to use medication at school. Provide asthma action plan for school nurse.

beta agonists MDI use: patient education

Demonstrate and have patient do return demonstration. Check correct inhaler use if patient says the inhaler isn't working. Use a spacer with all patients.

asthma in older adults

Determine if symptoms are reversible (asthma) or not (possibly COPD) Medications Increased risk for ADRs Increased interactions with medications taken for chronic medical conditions (e.g. beta blockers-can make a med like albuterol less effective) Anyone who smoke > ½ pack a day for over 5 years is going to have some level of COPD (emphysema)- chronic lung damage. You can send people for an initial pulmonary consult if having difficulty managing symptoms

cough suppressants

Dextromethorphan (DM) Codeine (or any narcotic for that matter, but codeine is more often prescribed) Action: centrally acting cough suppressant Evidence says: Codeine is no more effective than DM or placebo. However, patients are convinced that it is infinitely more effective...could it be just the sedating effect that allows them to sleep??? Little efficacy in cough due to URI Approximately 5% to 10% of Caucasians are poor DM metabolizers. DM + antidepressants may induce serotonergic syndrome Potential for abuse and recent research advises that codeine NEVER be given to children

beta2 agonists drug interactions

Digitalis glycosides: increased risk of dysrhythmia Beta adrenergic blocking agents: direct competition for beta sites resulting in mutual inhibition of therapeutic effects Including beta blocker eye drops Tricyclic antidepressants and monoamine oxidase inhibitors potentiate effects of beta agonist on vascular system.

Diphtheria, Tetanus, and Acellular Pertussis Vaccine: C/I, ADRs, who gets it Tdap vs Dtap? how often do adults get it?

Diphtheria, tetanus, and acellular pertussis vaccine (DTaP or Tdap or Td) Contraindications: anaphylactic reaction, progressive neurological disease, high temperature or seizure after previous DTaP dose (not Tdap) Use diphtheria vaccine before age 7 years and Tdap after ADRs: pain at injection site, low grade fever, aches, headache Give antipyretics to children with history of febrile seizures. Dosing DTaP: 2 months, 4 months, 6 months, 15 to 18 months and 4 to 6 years Tdap: 11 to 12 years Adults should receive Tdap or Td every 10 years

inactivated vaccines: types

Diphtheria, tetanus, and pertussis vaccine Haemophilus B conjugate vaccine Inactivated poliovirus vaccine Hepatitis B virus vaccine Hepatitis A virus vaccine Human papillomavirus vaccine Influenza vaccine Pneumococcal vaccine Meningococcal polysaccharide vaccine Typhoid vaccine Cholera vaccine Japanese encephalitis virus vaccine Plague vaccine Rabies vaccine

Discontinuation or interruption of ART

Discontinuation or interruption of ART is associated with HIV viral rebound, immune decompensation, and clinical progression. Interruption of ART may become necessary. Concurrent illness Severe drug toxicity Surgery that precludes oral therapy Antiretroviral medication nonavailability

HIV medication resistance

Due to: Poor patient adherence to the ART regimen Drug-drug or drug-food interactions Abnormal absorption, distribution, metabolism, or excretion of the medicine First sign of HIV resistance is detectable plasma viral RNA levels Phenotype assays are used to measure sensitivity to various antiretroviral agents

yellow fever vaccine: for which countries? who gets vaccinated? who caution in?

Endemic in Sub-Saharan Africa and tropical South America Certification required to enter some countries Vaccinate all persons over 9 months of age traveling to endemic areas Use cautiously in patients over age 60 years.

URI patient education

Explanation of what a viral URI is and the typical pattern of "catching a cold" until resolution URIs typically resolve in 7 to 10 days, with a cough lingering after No antibiotics necessary and will not help while the cause is viral Proper dosing of decongestants Avoid use of decongestants in Children under 4 years of age Elderly or patients with cardiovascular disease

TB patient education

Extensive and ongoing education is critical to treatment success. All medication must be taken as scheduled. Repeat education at each monthly visit. Educate in patient's primary language. Peer health counselors may be helpful.

Common Pediatric Skin Conditions (Infectious): viral

Fifth Disease (Parvo-virus) Warts (HPV) Chicken Pox (Varicella) Hand, Foot & Mouth Disease (Coxsackie)

fluoroquinolone: patient education

Food delays absorption Many drug interactions Take with full glass of water May cause dizziness If tendon tenderness occurs, stop medication and notify provider

Macrolides, Azalides, Ketolides: monitoring

For altered response to concurrent medications metabolized by CYP 450 3A4 or 2C9 Hepatic/renal impairment Hearing loss

cephalosporins monitoring

For diarrhea (C. difficile) Renal function, if prolonged therapy

Isotretinoin (Accutane)

For severe cases refractory to other treatments -cystic acne Skin photosensitivity May result in alterations in liver enzymes and blood triglycerides/cholesterol May cause psychological issues (depression)

common fungal infections of skin

Fungi love to grow in warm, moist environments! Candidiasis ("yeast infection") Tinea Pedis ("athlete's foot") Cruris ("jock itch") Capatis Corporis ("Ringworm")

anti-glaucoma agents

Glaucoma is diagnosed and treated by an ophthalmologist (we sometimes refill medications for patients who are stable and may see the ophthalmologist annually) Common anti-glaucoma agents Beta blockers(c/I hypotension, cardiac), adrenergic agonists (caution cardiac, renal, liver dz, MAOI, children & lactating. take contact out and wait 15mins before back in) Miotics(caution active inflammation and secondary glaucoma, pregnancy, lactating and children) Carbonic anhydrase inhibitors(c/I lactating. hyponatrenia, hypokalemia, renal and liver, adrenal dz, children.) Sympathomimetics (c/I clonidine hypersensitivity, narrow angle glaucoma,aphakic lactating and children) Prostaglandin agonist latanoprost (xalatan) (c/I inflammation aphakic. take contact out) Ophthalmic anti-glaucoma agents are absorbed and systemic levels reached in great enough amounts to cause complications of chronic conditions and drug interactions in some patients

mycobacteria

Grow slowly and are relatively resistant to drugs that are largely dependent on how rapidly cells are dividing Have a lipid-rich cell wall relatively impermeable to many drugs Are usually intracellular and inaccessible to drugs that do not have good intracellular penetration Have the ability to go into a dormant state Easily develop resistance to any single drug PPD test tells us if pt has had exposure to TB. Can be latent

expectorants

Guaifenesin (Robitussin) Action: stimulates respiratory tract secretions, decreases viscosity of respiratory secretion Evidence No evidence for efficacy in chronic cough or cough due to URI Some evidence advises that honey (especially locally produced honey) is every bit as effective as any OTC product

HIV med cost consideration

HIV medications are expensive Medication costs vary widely Patients may be eligible for state AIDS Drug Assistance Programs (ADAPs) Congress mandates funds be used for ADAPs Pharmaceutical companies have co-pays to provide financial assistance

Your patient was prescribed Humira for plaque psoriasis by a dermatologist. Briefly describe this drug and what you need to be aware of while caring for this patient.

HUMIRA is a TNF blocker medicine used to treat moderate to severe chronic plaque psoriasis. HUMIRA acts by binding to TNF-alpha which reduces inflammation that can cause plaque psoriasis skin symptoms. However, by suppressing the immune system, it reduces the body's ability to fight infection. The common side effects to watch for include "injection site reactions (pain, redness, rash, swelling, itching, or bruising), upper respiratory infections (sinus infections), headaches, rash, and nausea." While caring for this patient it is important to monitor for signs and symptoms of infection and be aware that these patients are at risk of serious infections including tuberculosis (TB) and various cancers.

adult community acquired pneumonia treatment

Healthy adults, no risk factors: Macrolide (level I evidence) (azithromycin or clarithromycin, erythromycin) Doxycycline if allergic to macrolide Treat for a minimum of 5 days. Adults with comorbidities or risk of drug-resistant streptococcus pneumonia: Respiratory fluoroquinolone (moxifloxacin, gemifloxacin or levofloxacin) Beta lactam plus a macrolide (amoxicillin, amoxicillin/clavulanate, or cefpodoxime, cefuroxime, or parenteral ceftriaxone followed by oral cefpodoxime Doxycycline may be used as an alternative to the macrolide. Adults more than age 60 years with comorbidities: Outpatient treatment option Ceftriaxone (Rocephin) 1 gm daily via IV or intramuscular or levofloxacin 500 mg IV daily Switch to oral therapy once patient can tolerate oral medications.

Hep A virus vaccine: how effective? forms of it, C/I, ADRS, who gets it?

Hepatitis A virus (HAV) vaccine provides 100% protection with two doses. HAVrix (0.5 mL for children/adolescents; 1.0 mL for adults) VAQTA (0.5 mL for children/adolescents; 1.0 mL for adults) Twinrix (HAV & HBV) adults only Contraindications: severe reaction to HAV, moderate illness, younger than 12 months ADRs: soreness at injection site Dosing: two doses 6 months apart All children at 12 months, dose 2 at 18 to 24 months Travelers to countries with high hepatitis A rates High-risk adults

Hep B Virus vaccine: what does it do? forms of it, C/I, ADRS, who gets it?

Hepatitis B virus (HBV) vaccine stimulates antihepatitis B surface antigen antibodies Alone or in combination (Pediarix, Twinrix, Combax) Contraindications: yeast allergy, moderate or severe illness, immunosuppression (give larger doses) ADRs: local reaction, 15% experience systemic complaints of fever, malaise Dosing: all ages, often administered at birth, three doses over 6 months 4 weeks between dose 1 and 2, 2 months between dose 2 and 3, and 4 months between dose 1 and 3

herd immunity

Herd Immunity is the concept of immunizing the majority of people in a population, resulting in the protection of the unvaccinated portion of the group.

MRSA Cellulitis

I & d w/ culture? Hospital acquired vancomycin Community acquired Clindamycin 300-450mg 3x/day Trimeth-sulfa ds 2x day Doxycycline 100mg 2x/day

HIV: when identified? how prevalent?where? transmission, types

Identified in 1981 25 million deaths worldwide 33 million people living with HIV 90% in Sub-Saharan Africa HIV induces defects in host cell-mediated and humoral responses The person becomes susceptible to opportunistic infections and certain neoplasms AIDS is characterized by progressive immune suppression leading to opportunistic diseases HIV-1 is responsible for human HIV infections Rapid dissemination into lymph system and organs after initial infection Host immune response limits viral replication initially Progression to AIDS in average 10 years if not treated HIV-2 is a zoonosis Lower transmission rate Less pathogenic Transmission: blood, sexual contact, and mother-to-child (vertical) transmission

If a patient presents with Poison Ivy, there are two different treatment options: topical and systemic. Please describe how you would decide to treat systemically, what medication you might prescribe, how long the patient should take it for, and what patient education you will share with the patient about the medication.

If a patient presents with Poison Ivy the systemic treatment may involve antihistamines, steroids and antibiotics. Steroids are given to reduce the symptoms, severity and duration of a poison ivy, oak, or sumac rash (allergic contact dermatitis) . Steroids are usually used only for more severe cases when poison ivy covers about 10% of the body's skin or when the face, hands, and genitals are affected. Oral corticosteroids are usually given for 14 to 21 days, with the dosage slowly decreased over time so patients should be educated how and when to taper the dosage. Additionally patients should be warned to NOT abruptly stop taking the steroids, and to take it for the full prescribed time to prevent rebound effects. Antihistamines (such as over-the-counter Diphenhydramine aka Benadryl or prescription Vistaril (hydroxyzine)) "do not help relieve the itching caused by poison ivy...they can help you ignore the itch while sleeping." Patients should be warned that with Benadryl marked drowsiness may occur, avoid alcoholic drinks since alcohol, sedatives, and tranquilizers may increase drowsiness, use caution when driving a motor vehicle or operating machinery, and excitability may occur, especially in children. Antibiotics would only be used if a skin infection develops because of itching related to poison ivy dermatitis.

AOM: Treatment Failure at 48 to 72 Hours

If initially treated with amoxicillin or other first-line therapy Augmentin Ceftriaxone IM/IV for 3 days Penicillin allergic: Clindamycin plus third-generation cephalosporin As you see, zithromax isn't really considered that good of coverage if you have already treated with amoxicillin. We continue to see tympanocentesis as an option. I don't know about you, but I am not interested in poking kids' tympanic membranes. But I do think we probably need to rethink using more clindamycin. If only it tasted better.

penicillins patient education

If not feeling better or getting worse after 48-72hr come back to office...it may be the wrong antibiotic for that bacteria resistance, ADRs, completing course, take a probiotic and/or eat a lot of yogurt

Bacillus Calmette-Guérin Vaccine: who is it most effective in?ADRs, PPD indications?

Immune stimulant Most effective in children ADRs: disseminated disease in positive tuberculosis patients Skin lesion at injection site is considered a normal reaction May cause false positive purified protein derivative (PPD) skin test, but having had the BCG vaccination does not mean that the positive PPD is disregarded

Common Pediatric Skin Conditions (Infectious): bacterial

Impetigo Acne Erysipelas Staph Scalded Skin Syndrome

sinusitis goals of treatment

Improve drainage of mucus and reduce swelling in the sinuses, thereby relieving pressure and pain. Resolution of infection without unwanted side effects and complications. Patient education about when antibiotics are warranted and useful. Resolution of all symptoms

nicotine gum

Improves cessation success Buccal absorption Patient needs to follow directions or nicotine will release too quickly, increasing adverse drug reactions (ADRs). More than 25 cigarettes per day: Start at 4 mg every hour. Less than 25 cigarettes per day: Use 2 mg every hour. Patient weans dose after 2 to 3 months of abstinence or when feeling ready.

Japanese Encephalitis Virus Vaccine (Travel)

Inactivated Vero cell culture-derived vaccine Contraindications: pregnancy, children, thimerosol allergy ADRs: local and systemic reactions, urticaria and angioedema of the face, lips, and oropharynx can occur Drug interactions: none Dosing: persons in endemic or epidemic areas, travelers spending more than 1 month in rural endemic areas

inactivated polio virus vaccine: forms of it, C/I, drug interaction, who gets it?

Inactivated poliovirus vaccine (IPV), IPV/DTaP (Pediarix), DTaP/HIB/IPV (Pentacel) Contraindications: allergy to neomycin, streptomycin, or polymyxin B Drug interaction: immunosuppressants Dosing: 2 months, 4 months, 6 to 18 months, 4 to 6 years

inactivated vaccines:general principles

Inactivated vaccines: contain "killed" inactivated virus May be co-administered with other vaccines No need to restart series if patient gets off schedule (use catch-up schedule)

home management of asthma exacerbation

Increase inhaled beta-agonist (2 to 6 puffs every 20 minutes) Oral corticosteroids Good response: stepped up therapy for several days

Non-pharmacological Treatment for Smoking Cessation Efforts

Individual or group counseling Support via telephone hot line or Internet support group Interventions should include problem solving, skills training, relapse prevention, and stress management. Education about what tobacco use does to a body and how to "beat it".

significance of infection

Infections are common chief complaints in primary care Inappropriate prescribing is common Antibiotics are given to more than 50% of hospitalized patients and nosocomial infections are often resistant to one or more antibiotics Resistant organisms used to be found primarily in hospitalized patients and now are common in community acquired infections - e.g. C.difficile and MRSA Why? Population is aging with faltering immune function and people return to their community sooner and sicker Antibiotic resistance varies across different areas of the country. Ex bactrim is resistant in Northeast Antibiotics are overprescribed VERY few upper respiratory infections need an antibiotic, more often than not it's a sinusitis Less than 2% of sinusitis are bacterial ,almost ALWAYS viral

TB pathophysiology

Infectious disease caused by M. tuberculosis Inhaled into the alveolus and spreads from lungs. M. tuberculosis grows slowly. Infection is spread almost exclusively by aerosolization of contaminated lung secretions. Only pulmonary and upper respiratory tree TB is contagious.

nicotine inhaler

Inhaled drug Patient puffs on inhaler for 20 minutes. Dose is weaned down gradually over 12 weeks. ADRs:Cough Mouth irritation Dyspepsia

beta lactams: penicillins (oldest class): pharmacodynamics

Inhibit the biosynthesis of peptidoglycan bacterial cell wall Sensitivity- Natural penicillins: Streptococcus, some Enterococcus strains, some non-penicillinase-producing Staphlococcus Aminopenicillins greater activity against gram-negative bacteria due to enhanced ability to penetrate the outer membrane organisms Used for gram-negative urinary and gastrointestinal (GI) pathogens E. coli, Proteus mirabilis, Salmonella, some Shigella species, and Enterococcus faecalis; active against the common gram-negative respiratory pathogens Moraxella catarrhalis (and Haemophilus influenzae type B) Combination with beta-lactamase inhibitors to broaden their spectrum: e.g. clavulanate (Augmentin) Less than 50% of penicillin allergies are TRUE allergies. If have penicillin allergy, azithyromycin is second choice for strep Stomach upset is a side effect of erythromycin not an allergy Gram neg-endotoxin. Found in urinary, GI Gram pos-exotoxin. Skin, respiratory

guidelines for AOM in children

Initial observation without antibiotics for 48 to 72 hours in children more than 2 years of age with non-severe illness. Estimates vary, but up to 80% of Oms in children will resolve without antibiotics. If treating AOM with antibiotics, amoxicillin dosed at 80 to 90 mg/kg/day is first choice. Amoxicillin/clavulanate 90 mg/kg/day as the next choice

prevention of otitis externa

Instill isopropyl ear drops (Swim-Ear, EarSol) or 1 or 2 drops of rubbing alcohol into the ear canal to dry the ear after soon after swimming A combination of 1:1 isopropyl alcohol and white vinegar may also be used Advise patients against vigorous use of Q-tips that can disrupt the delicate skin in the ear canal

nicotine nasal spray

Intranasal administration Rapid onset and peak Patient education Proper administration ADRs Abuse potential

inhaled anticholinergics

Ipratropium bromide (Atrovent) Blocks the muscarinic cholinergic receptors-to decrease secretions in the lungs, healthier, more receptive to other meds Tiotropium bromide (Spiriva)- once a day dosing is nice Inhibits the muscarinic M3 receptors in the lungs Both cause bronchial smooth muscle relaxation.

environmental allergies and the eyes

It is common for people who suffer from seasonal or animal allergies to have ocular symptoms. As with any allergy, avoidance is advised, but not always possible. And the same types of agents used for other allergy prone places (nose, throat, skin, etc) are often used in the eyes as well. Important to differentiate if symptoms are in the eye or the surrounding skin. IMPORTANT EXCEPTION - Topical steroid preparations are typically not prescribed in primary care. We leave to to the ophthalmologist.

inhaled anticholinergics precautions and c/i

Known hypersensitivity Not used for acute bronchospasm Ipratropium bromide is pregnancy category B and tiotropium is pregnancy category C. Not approved for use in children Expert Panel 3 guidelines state ipratropium may be used in children as an adjunct to beta agonist (albuterol) therapy in acute exacerbations of asthma.

salmeterol

LABA Salmeterol is more selective for beta2 receptors than albuterol and has minor beta1 activity. 12 hour half-life

the basics of skin

Largest organ in the human body Structural support Immunological barrier Primary or Secondary? Skin conditions may be primary (Skin itself) or secondary (skin involvement as a result of a systemic condition)

AOM initial observation 48 hrs

Low-risk patient Over 2 years of age Mild otalgia Temperature less than 39 degrees Celsius Adequate pain management is essential. Children's acetaminophen or ibuprofen usually work well. "Safety net" prescription WASP: "Wait and See Prescription"

nicotine lozenge

Lozenge slowly dissolves in mouth. Advise not to chew lozenge. Dose: 1 lozenge every 1 to 2 hours Use 4 mg if patient smokes within 30 minutes of waking. Patient should not eat or drink while lozenge is in mouth. Wean after 6 weeks of abstinence.

MMRV (MMR +varicella) vaccine: whats is called?c/I?adrs? when give it?

MMRV (ProQuad) Similar to MMR: Contraindications the same as MMR Use caution in patients with a history of cerebral injury, seizures, or where physiological stress due to fever should be avoided ADRs: fever greater than 102oF (21.5% vs. 14.9% with MMR); increased risk of febrile seizures May administer on same schedule as MMR Use MMR + varicella for first dose and MMRV for second dose due to fever Informed consent includes risk of fever and febrile seizures

Community-Acquired Pneumonia in Pregnant Women

Main pathogens are S. pneumoniae, H. influenzae, M. pneumoniae, and viruses. Macrolides Pregnancy category B: erythromycin, azithromycin Pregnancy category C: clarithromycin Comorbid conditions or recent antibiotics: β-lactam plus a macrolide

Why is oral ketoconazole NOT the drug of choice for fungal infections? What are the alternative options?

Many fungal infections are localized, with candida infections commonly found on the skin and mucosal tissues in oral, intestinal and vaginal areas. This being said for local infections, topical agents are preferred since they require less monitoring, don't carry a risk of GI upset as some oral antifungals do, and only need to be given until the affected area is healed (or 48hours after healed). Whereas oral ketoconazole needs to be taken for a minimum length of 4 weeks and require monitoring of liver function prior to therapy initiation and monthly while receiving therapy. Some alternative therapies include Nystatin (Mycostatin, Nilstat) and Gentian violet solution for oral candida, Nystatin (Mycostatin, Nilstat, Nystex) for cutaneous candida, Clotrimazole (Lotrimin, Mycelex) for dermatophyte skin infections, Fluconazole (Diflucan), Miconazole (Micatin, Monistat-Derm, Micatin) along with many other creams, lotions, solutions and oral tablets that require less monitoring and have shorter duration than ketoconazole.

ocular anti-allergic drugs

Mast cell stabilizers: iodoxamide (Alomide) and cromolyn sodium (Crolom) Antihistamines: levocabastine (Livostin), antazoline (Vasocon-A, Antazoline-V), ketotifen (Zaditor), pheniramine (Naphcon-A), emedastine (Emadine) Pharmacodynamics: Mast cell stabilizers limit hypersensitivity reactions by inhibiting the degranulation of sensitized mast cells. Antihistamines block the H1 histamine receptors. Precautions Hypersensitivity Products that contain benzalkonium chloride may affect soft contacts. ADRs: blurred vision, eye discomfort, tearing Drug interactions: none Clinical use and dosing Allergic conjunctivitis(occurs in response to variety of allergens): ophthalmic H1 blockers Vernal conjunctivitis(primarily in spring b/c of an allergen): mast cell stabilizers for up to 3 months Patient education Administration Use of eye medication ADRs Transient stinging and burning. headache is most common with h1

Oral contraceptives (yaz / estrostep / ortho tri-cyclen)

May be used as second line agents in female patients Significant adverse affects (nausea/weight gain/bleeding) No smoking!! (increased risk of thromboembolism)

penicillins: ADRs

May cause serious immediate allergic reactions Reactions occur within 2 to 30 minutes of administration Patients may be given desensitization therapy Rash: maculopapular rash occurs 9% of time that is not allergic in origin, appears 7 to 10 days into treatment GI: diarrhea, nausea/vomiting, addition of clavulanate increases risk of diarrhea Fungal overgrowth C. difficile colitis Most are thought to be safe in pregnancy

Live attenuated influenza vaccine (LAIV) examples

Measles, mumps, and rubella vaccine (MMR) Oral poliovirus vaccine Rotavirus vaccine-Rotavirus not very effective in kids, good handwashing is usually adequate Varicella virus vaccine Herpes zoster vaccine Typhoid Yellow fever vaccine Bacillus Calmette-Guérin vaccine

Meningococcal Vaccine: what is the organism? forms of it, C/I, ADRs, who gets it?

Meningococcal polysaccharide vaccine (MPSV) groups A, C, Y and W-135 (Menomune A/C/Y/W-135) is used to prevent meningococcemia and meningitis caused by Neisseria meningitidis serogroups A, C, Y, and W-135. MCV4 (Menactra, Menveo) is a tetravalent meningococcal conjugate vaccine that also provides protection against serogroups A, C, Y, and W-135. Contraindications: febrile illness, see age guidelines for each ADRs: local reaction Dosing MCV4 at age 11 to 12 years with booster at age 16 years (or if in group living situation) MCV4 functional asplenia, travelers to high-risk areas, lab workers MCV4 unvaccinated college freshmen or military recruits MPSV adults over age 55 years

asthma in pregnant patients

Monitor asthma symptoms at each prenatal visit. Inhaled beta-agonists are drug of choice during pregnancy. Inhaled corticosteroids are the long-term drug of choice, if needed. Avoid medication as much as possible Some people have worsening symptoms towards end of pregnancy due to increased blood volume, increased pressure on diaphragm, more allergy problems during pregnancy

Anthelminthics: Monitoring & patient education

Monitoring: Assess for the eradication of the helminth Roundworms, hookworms, ascariasis, trichuriasis, and whipworms; stool samples are obtained before and 1 to 3 weeks after treatment for proof of cure Patient education: Albendazole and mebendazole are given with a high-fat meal Ivermectin is taken on an empty stomach Albendazole should not be taken if pregnant and back-up contraception should be used for 1 month after taking

Systemic Azoles and Other Antifungals: monitoring &patient education

Monitoring: Ketoconazole: aspartate amino transferase, alanine aminotransferase, alkaline phosphatase, and bilirubin before and every 3 to 4 months Patient education: Instruct to take with food. Discourage alcohol use. Educate regarding signs of liver toxicity.

clindamycin when do you stop it? ADRs

Monitoring: Stop medication if significant diarrhea occurs Patient education: Finishing therapy ADRs: diarrhea

antivirals monitoring & patient education

Monitoring:Rash for resolution Temperature Blood urea nitrogen and creatinine high-risk patients Patient education:Drug started at earliest sign of infection Good hydration Educate regarding symptoms of renal failure, encephalopathic changes, blood dyscrasias

antivirals for influenza: monitoring & patient education

Monitoring:Renal function in elderly and debilitated patients Older patients: evaluate for confusion, hallucinations, and cognitive impairment Patient education:Take full course of therapy. ADRs Advise annual influenza vaccination

Metronidazole and Nitazoxanide: monitoring & patient education

Monitoring:Resolution of symptoms Signs of leukopenia Patient education: Administration Metallic taste with metronidazole Avoid alcohol if taking metronidazole or tinidazole due to disulfiram-like reaction Concurrent treatment of partner if sexually transmitted infection

Anti-retroviral Treatment (ART)

More than 20 U.S. Food and Drug Administration-approved ART drugs Treatment of HIV disease is a dynamic, rapidly changing arena HIV medications are always used in combination to reduce the amount of HIV in the blood

acne vulgaris

Most common skin condition in the u.s.a. Adolescent males Adult females Treatment Soaps and avoidance of oily skin products 1%-10%Benzoyl peroxide preparations (o.t.c creams, gels, lotions etc...)

treatment of tinea infections

Most infections respond to o.t.c. topical antifungals Usually application of topical antifungals 1-2 times daily for 2-4 weeks Refractory cases may require oral antifungals (tinea capatis may also require oral antifungals) Any tinea infection may take weeks to clear, and treatment should continue for up to a week following the resolution of symptoms...

pneumonia antibiotic choices for kids over 5yo

Mycoplasma or other atypical most likely Azithromycin: 10 mg/kg on day 1 and 5 mg/kg on days 2 through 5 Clarithromycin: 15 mg/kg per day in two divided doses (maximum 1 g/day) Erythromycin: 40 to 50 mg/kg/day Mycoplasma pneumoniae is the most common cause of community-acquired pneumonia and accounts for 20% of pneumonia cases in the general population, 9-16% of cases in early-school-aged children, 16-21% of cases in older children, and 30-50% of cases in college students

viral conjunctivitis

NO antibiotics Can occur with symptoms of a cold, flu, or other respiratory infection Usually begins in one eye and may spread to the other eye within days Discharge from the eye is usually watery rather than thick Usually caused by an adenovirus, herpes simplex virus, or herpes zoster Treatment: watchful waiting, comfort measures like compresses If herpes keratitis is suspected, refer to ophthalmologist

allergic conjunctivitis

NO antibiotics Usually occurs in both eyes Can produce intense itching, tearing, and swelling in the eyes (Itchy eyes are the hallmark of an allergic issue and usually not part of viral or bacterial conjunctivitis) May occur with symptoms of allergy, such as an itchy nose, sneezing, a scratchy throat, or asthma The patient may have atopy (increased likelihood of allergies)

URI symptoms

Nasal congestion Rhinorrhea Malaise Scratchy or sore throat The nasal discharge typically starts out thin and clear and thickens, then may progress to a green or yellow color. This does NOT indicate that a bacterial infection is present. Generalized muscle aches can be present Adults usually don't have a fever (Remember there is a range in normal body temperature and that fluctuates through the day/night. An elevated temperature is usually considered a fever when >100.5 F) Children may have low-grade fever

Gonococcal conjunctivitis: RFs, treatment

Newborns and in sexually promiscuous teenagers and adults Treatment: parenteral antibiotics (ceftriaxone) and sterile saline irrigations

smoking cessation: rational drug selection

Nicotine replacement therapy Antidepressant Bupropion Nicotine receptor partial agonist Varenicline

Lyme disease describe how you would decide to treat the following (include drug, amount and duration): An adult tick attached to female adult for less than 12 hours.

No treatment needs to be done since the tick must be attached for at least 36 hours to cause Lyme disease. If the tick is still attached it should be removed with tweezers and pulled straight out. The bite area should be washed with soap and water or rubbing alcohol after removal.

live attenuated vaccines: c/I, drug interactions

Not administered to immunocompromised patients Usually not given if patient has febrile illness- only TRUE contraindication. Fever >101. if they have a mild cold you still give it If patient needs two live vaccines Give both the same day (use different arms)OR Administer at least 4 weeks apart Not administered in pregnancy Pregnancy should be avoided for 1 month after vaccination. Drug interaction Antiviral drugs

oral polio vaccine

Not used in the United States since 2000 Effective, easy to administer Virus lives in gastrointestinal (GI) tract for 4 to 6 weeks after administration (can be shed in diapers, exposing caregivers) Rare risk of vaccine-associated paralytic poliomyelitis Patient and household contacts Still used throughout the world

Six "families" of HIV antiretroviral drugs

Nucleoside reverse transcriptase inhibitors Nonnucleoside reverse transcriptase inhibitors Protease inhibitors Fusion inhibitors Integrase strand transfer inhibitor CCR5 antagonists

contact dermatitis treatment

Often does not require treatment (just relief of pruritus and hydration) Astringents (calamine lotion) Apply as needed Topical steroids (hydrocortisone) Apply 2-4 times a day Antihistamines (diphenhydramine) Topical or oral Benadryl (25-50 mg q 6-8hrs)

principles of HIV therapy

Ongoing HIV replication leads to immune system damage and progression to AIDS Plasma HIV ribonucleic acid (RNA) and CD4 T-cell levels must be regularly measured (every 3 to 6 months) Treatment decisions should be individualized based on the risk of disease progression as indicated by plasma HIV RNA levels and CD4 measurements Goal of therapy should be the maximum achievable suppression of HIV replication Most effective way to achieve sustained suppression of HIV replication is the combination of effective anti-HIV medications

Antivirals for Influenza: pharmacodynamics &pharmacokinetics

Only reduces symptoms by a day, doesnt make you better in 24hrs pharmacokinetics & pharmacodynamics: Pharmacodynamics:Oseltamivir (Tamiflu), peramivir (Rapivab), zanamivir (Relenza) are used to treat influenza A and B Sensitivity varies by year Resistance to amantadine and rimantadine is common, no longer recommended for influenza Pharmacokinetics:Oseltamivir is well-absorbed after oral administration Zanamivir is inhaled, 4% to 17% absorbed Peramivir is administered IV

ophthalmic anti-inflammatory drugs

Ophthalmic NSAIDs Flurbiprofen (Ocufen), suprofen (Profenal), diclofenac (Voltaren ophthalmic solution), nepafenac (Nevanac), ketorolac (Acular) Corticosteroid ophthalmic agents (almost NEVER prescribed by anyone but an ophthalmologist) Pharmacodynamics Ocular NSAIDs have analgesic, antipyretic and anti-inflammatory activity Topical steroids exert an anti-inflammatory action, that can lead to complications if not used cautiously by opthalmology

asthma outcome evaluation

Optimal outcome is thought of as being able to do most/all activities of daily living with few/none asthma symptoms. Refer to an asthma specialist: If achieving and/or maintaining control is elusive If immunosuppressive therapy being considered Any adult who requires step 4 therapy or child who requires step 3 therapy

Otic Anti-Infectives

Otitis externa (OE) is a painful, inflammatory condition of external auditory canal. See article from the American Family Physician (Acute OE: An Update) http://www.aafp.org/afp/2012/1201/p1055.html and also Up-to-Date article on External otitis: Treatment (2015) Pharmacodynamics Combination products with corticosteroid and antibiotic Hydrocortisone reduces the inflammation caused by OE and hence aids in pain management precautions and contraindications Perforated tympanic membrane (TM) May cause superinfection

topical retinoid patient education

Patients should be instructed to keep taking this medication even if it causes an initial worsening because this is due to "comedones that were previously under the skin being extruded" and their skin will improve 6-8 weeks into therapy Patients should also be told to avoid contact of these agents with the eyes and mucous membranes since it can cause stinging, burning or itching, and to avoid sun exposure/ wear sunscreen since they can increase photosensitivity. Topical retinoids are pregnancy category C. Some other side effects include skin irritation, redness, and peeling if too much is applied. Patients should not use ant harsh toners, astrigents, scrubs or cleansers while on topical retinoid therapy because they increase irritation. Some examples of these drugs include Tretinoin (Retin-A), Adapalene (Differin) and Adapalene and benzoyl peroxide (Epiduo).

Ophthalmic Anti-Infectives

Pharmacodynamics Bacteriostatic or bactericidal Pharmacokinetics Generally penetrate only the ocular fluid and tissues Minimal systemic absorption Precautions and contraindications Hypersensitivity Adverse drug reactions (ADRs) Local irritation Super-infection with prolonged use Bacitracin may cause blurred vision Sulfacetamide ophthalmic preparations may cause a hypersensitivity reaction in patients who have previously exhibited sensitivity to sulfonamides. Aminoglycosides may cause localized ocular toxicity. Fluoroquinolones may cause a white crystalline precipitate to form in the superficial portion of the cornea. Drug interactions No drug interactions reported for ophthalmic preparations of bacitracin, gentamicin, tobramycin, polymyxin B, azithromycin and erythromycin Sulfacetamide is incompatible with silver-containing preparations

Anthelminthics: pharmacodynamics & ADRs

Pharmacodynamics: Intestinal nematodes are treated with mebendazole, pyrantel,and thiabendazole Tissue nematodes are treated with mebendazole, thiabendazole, albendazole, or ivermectin In the United States pinworms are common: 50 million cases per year ADRs: Nausea, vomiting, diarrhea, transient abdominal pain Mebendazole may cause transient neutropenia Ivermectin may cause Mazzotti reaction

Antimycobacterials: pharmacodynamics & pharmacokinetics

Pharmacodynamics: Isoniazid (INH) and ethambutol inhibit synthesis of mycolic acids Rifampin binds to the beta subunit of mycobacteria DNA-dependent RNA polymerase and inhibits RNA synthesis Ethambutol inhibits synthesis of arabinogalactan, an essential component of mycobacteria cell walls Resistance develops rapidly to monotherapy Cross-resistance with INH and ethionamide Pharmacokinetics: Well-absorbed orally Metabolism of isoniazid is highly variable and dependent on acetylator status.

Metronidazole and Nitazoxanide: pharmacodynamics &pharmacokinetics

Pharmacodynamics: Metronidazole treats both parasitical and bacterial infections Active against Trichomonas vaginalis, Entamoeba histolytica, H. pylori, Clostridium, C. difficile Nitazoxanide is used to treat Giardia lamblia and Cryptosporidium Tinidazole is active against amebiasis, giardiasis, and trichomoniasis Pharmacokinetics:Metronidazole is well-absorbed when taken orally

Systemic Azoles and Other Antifungals: pharmacodynamics

Pharmacodynamics: Polyene macrolides: amphotericin B and nystatin Azoles have broad spectrum activity: butoconazole, clotrimazole, ketoconazole, minonazole, terconazole, tioconazole, fluconazole, itraconazole Allylamines active against yeast and dermatophytes: naftifine, terbinafine Nuclear acid synthesis inhibitors: flucytosine Griseofulvin

Sulfonamides, Trimethoprim, Nitrofurantoin: pharmacodynamics & ADRs, who c/I in?

Pharmacodynamics: Sulfonamides block folic acid synthesis, trimethoprim inhibits DNA synthesis, nitrofurantoin may inhibit acetyl coenzymes. Inhibit both gram-positive and gram-negative bacteria E. coli, S. pyogenes, S. pneumoniae, H. influenza, and some protozoa Resistance an issue ADRs: GI - anorexia, n/v, diarrhea, stomatitis; rashes, increased hypersensitivity reactions, photosensitivity; CNS - headache, dizziness, drug interactions Avoid in G6PD deficiency

Macrolides, Azalides, Ketolides: pharmacodynamics & pharmacokinetics

Pharmacodynamics: erythromycin Inhibits RNA-dependent protein synthesis Weak bases, activity increases in alkaline media Atypical and intracellular organisms commonly resistant to beta-lactam antibiotics are often susceptible Cross-resistance seen to all in class Pharmacokinetics: well-absorbed from duodenum Potent inhibitors of CYP 450 3A4 Combination with statins may increase risk for myopathy Exhibit enterohepatic recycling, which can lead to buildup in the system and can cause n/v; tissue levels are higher than serum levels

Lincosamides: Clindamycin (Cleocin): pharmacodynamics & pharmacokinetics

Pharmacodynamics: inhibits protein synthesis No gram-negative activity Gram-positive activity: corynebacterium acnes, gardnarella vaginalis, some methicillin-resistant Staphylococcus aureus (MRSA) Pharmacokinetics: oral dosing completely absorbed, not affected by gastric acid

Lipoglycopeptides: Vancomycin: pharmacodynamics, pharmacokinetics, ADRs

Pharmacodynamics:Vancomycin, telavancin (Vibativ), dalbavancin (Zeven) Used for severe gram-positive infections, such as MRSA-resistant to first-line antibiotics Inhibits cell wall synthesis Pharmacokinetics:Poor oral absorption, given IV ADRs: Ototoxicity (transient or permanent) Nephrotocity "Red Man" syndrome if infused too fast -dilation issue

Systemic Azoles and Other Antifungals: pharmacokinetics, ADRs and drug interactions

Pharmacokinetics: Absorption of itraconazole is enhanced by food Absorption of griseofulvin is enhanced by fat Fluconazole is an inhibitor of CYP 450 3A4 and 2C9 Itraconazole is an inhibitor of CYP 450 3A4 Ketoconazole is an inhibitor of CYP 450 3A4 ADRs: All of the azoles and terbinafine have been associated with hepatotoxicity Drug interactions: Multiple due to CYP 450 3A4 inhibition

fluoroquinolone: pharmacokinetics & ADRs

Pharmacokinetics: Well-absorbed; take on empty stomach for best absorption ADRs: Black Box warning for tendonitis/ tendon rupture.Elderly at higher risk Can have delayed onset, 120 days to months after administration GI: pseudomembranous colitis Central nervous system (CNS): sleep disorders, dizziness, acidosis Renal/hepatic failure Cardiovascular: angina, atrial flutter Avoid in pregnancy Do not prescribe to children less than 18 yo

Pneumococcal Conjugate Vaccine: what organism? C/I, who gets it? ADRS, drug interactions

Pneumococcal 13-valent conjugate vaccine (Prevnar) targets the 13 most common strains of invasive pneumococcus in infants. Contraindications: moderate to severe febrile illness, give 10 to 14 days before splenectomy, organ transplant, or chemotherapy. No PPV in children less than 2 years or PCV in adults ADRs: local reaction, mild systemic effects Drug interactions: immunosuppressants (give 10 to 14 days before)- need a break from drug before giving vacicne Dosing Four doses given at 2, 4, 6, and 12 to 15 months of age Immunocompromised adults 19 years of age or older get one dose Adults over 65 years of age get one dose Give PCV13 1 year after PPV

pneumonia overview

Pneumonia develops when an organism invades the lung parenchyma and the host defenses are depressed. Bacterial pneumonia results when the lung's primary defense mechanisms are altered by a viral infection or immunological problems. Chronically ill patients of all ages are more prone to pneumonia.

pneumonia patient education

Pneumonia might be bacterial, viral, or mycoplasmal. Education regarding antibiotic prescribed Hydration, smoking cessation, and rest Symptoms of worsening status should be described. Patients should be told to expect clinical improvement in 48 to 72 hours, however cough and fatigue may not completely resolve for 7-14 days.

Pneumococcal Polysaccharide Vaccine: organism? c/I, ADRs, who gets it?

Polyvalent pneumococcal polysaccharide vaccine (PPV) 23 purified capsular polysaccharides from Streptococcus pneumoniae. Contraindications: moderate to severe febrile illness, give 10 to 14 days before splenectomy, organ transplant, or chemotherapy. No PPV in children less than 2 years ADRs: local reaction, mild systemic effects Drug interactions: immunosuppressants (give 10 to 14 days before) Dosing All adults over age 65 years Persons 2 years to 65 years with chronic cardiac or pulmonary disease, chronic liver disease, or alcoholism, diabetes mellitus, cerebrospinal fluid leaks Persons 2 years to 65 years with asplenia Immunocompromised persons Smokers age 19 years to 65 years Asthma patients age 19 to 65 years 12 to 24 months after bone marrow transplant PPV is given to children 2 months after last pneumococcal conjugate vaccine (PCV) dose.

prevention of TB

Positive TB test but no signs of active TB Drug therapy INH alone for 6 to 9 months Monitor monthly. Directly observed therapy may be necessary. Successful treatment is determined by absence of disease. Patient education is critical to successful treatment.

ophthalmic anti-inflammatory drugs: precautions, C/I, ADRs, rational drug selection, patient education

Precautions and contraindications Referral to an ophthalmologist is warranted for patients who appear to need corticosteroid therapy ADRs Eye discomfort or tearing Ocular H1 histamine blockers may cause headache Naphazoline may precipitate narrow-angle glaucoma Ocular corticosteroids may cause Glaucoma (elevated intraocular pressure - IOP) with optic nerve damage, loss of visual acuity and field defects, cataract formation, secondary infection of the eye, exacerbation of existing infections, and perforation of the globe Rational drug selection Vernal conjunctivitis: ocular NSAIDs Ophthalmic corticosteroids should only be prescribed by an ophthalmologist. Patient education Administration Use exactly as prescribed for length of therapy advised ADRs Transient stinging and burning

Buproprion (Zyban)

Precautions and contraindications Seizure disorders, bulimia, and anorexia nervosa Neurological disorders Reduce dose in renal dysfunction. Avoid in pregnancy. ADRs Insomnia (40%) Dizziness (10%) Dry mouth (10%)

nicotine replacement therapy Precautions and contraindications

Precautions and contraindications: Pregnancy Gum is pregnancy category C. Transdermal patch is pregnancy category D. Contraindicated: Immediately after a myocardial infarction Immediately after a stroke If a patient will not stop smoking while wearing a patch

Macrolides, Azalides, Ketolides: precautions & c/I, ADRs, drug interactions

Precautions and contraindications: Most are safe in pregnancy and children ADRs :Dose-related GI: n/v, abdominal pain, cramping, diarrhea... rare but moreso with erythromycin Skin: urticaria, bullous eruptions, eczema, Stevens-Johnson syndrome Drug interactions:Inhibitors of CYP 3A4

smoking cessation therapies: patient variables

Pregnancy :Nicotine replacement products not recommended Bupropion (Zyban) not recommended Varenicline (Chantrix) not recommended BUT...these patients need to quit! Children:Not used Adolescents: Early identification and support for quitting Patch has some evidence for use (prescription needed).

TB treatment patient variables

Pregnancy and lactation Treat with INH and RIF. Pyridoxine 25 mg/day is administered. Increased risk of INH-induced hepatitis Pediatric patients May use gastric lavage if unable to get sputum. May progress to miliary TB or central nervous system disease. Treat with INH and RIF. Pyridoxine 25 mg/day is administered. HIV-positive May not have positive PPD. Extrapulmonary TB is common. Treatment is same as for uninfected adults (four drug therapy).

smoking cessation patient education

Proper dosing Removal of patch at appropriate time Proper dosing of gum and inhaler Advise on OTC products. Monitor for ADRs. NEVER smoke while wearing a patch.

AOM patient education

Proper use of the prescribed antibiotic. Take the entire course. Don't skip or miss doses. The predicted course of the infection once antibiotics are started Follow up in 2 to 3 days if no improvement. Pain control PRN Help patients and parents understand the importance of hand-washing and how to maintain healthy immune function.

Haemophilus B Conjugate Vaccine: which species? C/I, ADRs, who gets it?

Protects against invasive H. flu Contraindications: allergy to components of vaccine, moderate to severe illness, only given to children younger than age 6 years ADRs: injection site pain and redness Dosing: depends on vaccine used ActHib or Pentacel: 2 months, 4 months, 6 months, 12 to 15 months (booster dose) PedvaxHIB or Comvax: 2 months, 4 months, 12 to 15 months (booster dose) If first dose given after age 15 months, then child only needs one dose.

Immune Globulin (IG) Serums

Provide passive immunity to infectious diseases Derived from the pooled plasma of adults, processed by cold ethanol fractionation Contraindications: Do not give within 3 months of live vaccine ADRs: mild local and systemic reactions Drug interactions: live virus vaccines Dosing: depends on IG serum used

cholera vaccine (travel vaccine)

Provides active immunity against cholera The vaccine is 50% effective in reducing disease in endemic areas Discontinued production in United States

rabies vaccine

Rabies vaccine (Imovax, RabAvert) inactivated rabies virus Contraindications: moderate to severe illness ADRs: mild local and systemic reactions, serum sickness may occur (6%) Drug interactions: chloroquine (Aralen), immunosuppressants, rabies IG (RIG) Dosing Pre-exposure vaccine day 0, day 7, and either day 21 or day 28, booster every 2 yrs Post-exposure prophylaxis days 0, 3, 7, and 14, with RIG given on day 0

smoking cessation therapies: nicotine

Rapidly absorbed Act on nicotine receptors in the brain and central nervous system Each puff maintains blood levels. Tolerance develops. Withdrawal syndrome if discontinued

malignant otitis externa

Rare but potentially lethal infection caused by P. aeruginosa Risks for this condition include: Chemotherapy Diabetes Weakened immune system OE is often caused by bacteria that are hard to treat, such as pseudomonas. Symptoms may include continued drainage that smells foul, fever, pain deep in the ear/head, loss of hearing and/or voice, and trouble swallowing. OE extends and invades the surrounding tissues, causing osteomyelitis of the base of the skull and purulent meningitis Treatment: parenteral antibiotics, such as an aminoglycoside and carbenicillin for 4 to 6 weeks, WITH surgical debridement

Provider responsibility to patients traveling to foreign countries

Read the information and explain it to your patient. Discuss risk and explain that some or all of the office visit and the vaccines and medications might not be paid for since travel is a choice and not considered a medical necessity. Explain what could happen if they choose to not have some vaccinations or take anti-malarial medications, for example.

causes of antimicrobial drug resistance

Recent use and overuse of antibiotics for non-bacterial illness Overuse of broad-spectrum antibiotics-zpac is overused because its easy once a day dosing Age younger than 2 years or older than 65 years Daycare center attendance Exposure to young children Multiple medical comorbidities Immunosuppression Every antibiotic class has resistant organisms Local resistance patterns can be identified by monitoring the antibiogram of the local laboratory Vaccination with pneumococcal vaccine has decreased resistance

prevention of AOM

Reconsider daycare attendance. (I find this an odd statement. Most families do not have an option for one parent to stay home or to afford a "nanny" for their children so that they can avoid daycare. Additionally, the "germ-fest" will just be delayed until preschool or kindergarten) Breastfeed for the first 6 months of life. EXCELLENT! Avoid "bottle propping" or supine bottle feeding Avoid any exposure to tobacco smoke and if that isn't possible, reduce exposure. Vaccinate

asthma goals of therapy

Reduce impairment: Prevent chronic symptoms. Reduce use of inhaled short-acting beta agonists. Maintain normal or near-normal pulmonary function. Maintain normal activity levels. Meet patient/family expectations of asthma care. Reduce risk: Prevent recurrent exacerbations and minimize emergency department (ED) visits and hospitalizations. Prevent loss of lung function. Provide optimal therapy with minimal adverse drug reactions (ADRs).

pneumonia goals of treatment

Return to baseline respiratory status. Fever should resolve in 2 to 4 days. Leukocytosis resolves by day 4 of treatment. Chest x-ray may take 4 weeks or more to return to normal.

TB rational drug selection

Risk stratification High risk: children under age 4 years, HIV/AIDS patients, transplant patients, foreign-born patients Drug therapy principles Treatment regimens must contain multiple drugs to which the organisms are susceptible. The drugs must be taken regularly as prescribed. Drug therapy must continue for a sufficient period of time. Two phases of treatment: Initiation phase is for first 2 months. Continuation phase lasts 4 to 7 months. Follow Centers for Disease Control guidelines for 6 month or 9 month regimen. Drug-resistant TB Determined by susceptibility testing Treat with at least two drugs that TB is sensitive to based on susceptibility testing. If a patient is resistant to multiple first-line drugs (isoniazid - INH, rifampin - RIF, ethambutol - EMB, pyrazinamide), then at least three new drugs that the organism is susceptible to should be administered.

rotavirus vaccine: name, how is it administered? c/I, adrs, when is it given?

RotaTeq and Rotarix Orally administered and replicates in small intestine Contraindicated: immunocompromised, febrile illness ADRs: mild GI upset, no risk of intussusception in newer vaccines Administer to infants with first dose by age 14 weeks, 6 days and last dose by 8 months. Rotarix (RV1): Give at age 2 months, 4 months. RotaTeq (RV5): Give at age 2 months, 4 months, 6 months.

pneumonia common adult pathogens

S. pneumoniae Patients with underlying lung disease Non-typeable Haemophilus influenza and Moraxella catarrhalis Staph aureus: frequent co-pathogen with influenza Mycoplasma pneumoniae Viral pneumonia

Common Pediatric Pneumonia Pathogens

S. pneumoniae is the most common cause of bacterial pneumonia in patients of all ages. Increase in viral pneumonia with PCV7 vaccine Infants 4 to 16 weeks Consider chlamydia. Over 5 years through adolescence Consider mycoplasma. Community-acquired methicillin-resistant staphylococcus aureus Virus

sinusitis patient education

Saline nasal spray or drops- Liquefies secretions Decreases crusting near the sinus ostia Sinus rinses- Facilitates drainage and unblocks thick secretions Topical decongestants- Decrease tissue edema and nasal resistance, probably enhances drainage of secretion from sinus ostia Nasal Corticosteroids- Helpful in chronic sinusitis No evidence for use in acute sinusitis, but may help manage symptoms in some patients

asthma special situations

Seasonal allergies Start long-term control medications at least 1 month before allergy season starts. Cough variant asthma Trial of bronchodilator Same stepwise management Exercise induced asthma (EIA) Most people with asthma have an exercise induced component Treatment Short-acting beta agonist 15 minutes before exercise (2 to 3 hours) Salmeterol lasts 10 to 12 hours (cannot use if using as long-term care medication) Mask or scarf over mouth if EIA is cold-induced Leukotriene modifier may help

Keratolytics (sulfur/salicylic acid)

Second line (not as effective as other topical agents)

albuterol

Selective beta2 agonist with minor beta1 activity, short acting. Levalbuterol is where the (S)-isomer from racemic albuterol is removed. It is thought to have fewer side effects.-less of an increased HR, can still happen Increased HR can be when med. Starts lasts 5-10 mins should go away

herpes zoster vaccine: whats it for? how reduced of risk? c/I, drug interactions, who gets it?

Shingles caused by reactivation of varicella Zoster vaccine (Zostavax) Reduces risk of developing herpes zoster 51.3% Reduces risk of post-herpetic neuralgia by 66.5% (reduced severity in 57%) Contraindications: neomycin or gelatin allergy, immunocompromised, pregnancy, acute illness, age younger than 60 years Drug interactions: high-dose steroids, antivirals Administer one dose for all patients age 60 years or older (insurance may prevent this until age 65)$235/vaccine. Most insurances don't cover it until 60yo. Has to be kept frozen

Beta2 Receptor Agonists

Short-acting beta agonists Albuterol (ProAir, Ventolin, Proventil) Pirbuterol (Maxair ) Levalbuterol (Xopenex) Long-acting beta agonists Salmeterol (Serevent) Formoterol (Foradil) Indacaterol (Arcapta Neohaler) Arformoterol (Brovana)

The Expert Panel 3 Guidelines recommend ongoing monitoring of the following:

Signs and symptoms Pulmonary function Quality of life and functional status History of asthma exacerbations, pharmacotherapy Patient-provider communication Patient satisfaction

Lyme disease describe how you would decide to treat the following (include drug, amount and duration): An adult tick attached to a male adult for over 36 hours with no evidence of erythema migrans.

Since this patient has met the criteria that the tick has been attached for at least 36 hours, assuming that the tick has been removed within 72 hours, the bite took place in New England, and a male adult was bit, prophylactic dosing is appropriate in this case. This would involve a 1X dose of Doxycycline 200 mg po

Lyme disease describe how you would decide to treat the following (include drug, amount and duration): An adult presents with a rash suspicious for erythema migrans with no other neurological or cardiac symptoms.

Since this patient has the erythema migrans they are symptomatic for a early localized, early disseminated bite. Since about "80% of patients with Lyme disease will have this sign within three to 30 days after a tick bite, about seven days after the tick bite on average" initiation of treatment can be done based on clinical findings and blood testing isn't necessary to confirm diagnosis of early Lyme disease since it may not come back positive for 2-6 weeks. Treatment would involve one of the following: Doxycycline 100 mg po bid x 14 days , Amoxicillin 500 mg po tid x 14 days or Cefuroxime axetil 500 mg po bid x 14 days.

TB monitoring

Sputum cultures monthly until negative Chest x-ray at completion of therapy to document baseline post-TB chest x-ray Monitor for adverse drug reactions Baseline liver enzymes, bilirubin, creatinine, complete blood count, platelet Baseline ophthalmology exam if treating with EMB Monitor for hepatitis if on INH monthly. Monitor for peripheral neuropathy if on INH.

TB outcome evaluation

Sputum evaluation monthly TB-free after 2 months of treatment Patient compliance

Mild intermittent asthma

Step 1 therapy Use short-acting beta2 agonists as needed for symptoms. Patients have symptoms when exposed to triggers (upper respiratory infections, weather conditions, allergens, chemical inhalants, etc). Exercise can be mild intermittent. Need an annual flu shot.

Mild persistent asthma

Step 2 therapy Treat with one long-term control medication daily. Low-dose inhaled corticosteriods are the mainstay for all age patients. Cromolyn or a leukotriene modifier are alternatives. See dosage chart for low-dose schedule of each inhaled corticosteroid. Use beta agonists as needed; if using 2 days or more per week, then step up in therapy.

Moderate persistent asthma

Step 3 therapy Treat w medium-dose inhaled corticosteroids Or low-dose inhaled steroids plus long-acting beta agonists (adults) Alternative: medium-dose inhaled steroid plus leukotriene receptor modifier May use short-acting beta agonists. Exacerbations may require oral corticosteroids.

Severe persistent asthma

Step 4 therapy Medium-dose inhaled corticosteroids plus long-acting beta agonist Or medium-dose inhaled corticosteroid and a leukotriene modifier or theophylline(theophylline not used in years) Step 5 therapy High-dose inhaled corticosteroids plus long-acting beta agonists Step 6 therapy High-dose inhaled corticosteroids plus long-acting beta agonists and oral corticosteroids Severe persistent asthma requires consultation with asthma specialist.

Hordeolum

Sty Caused by S. aureus Treatment: usually hot compresses several times daily until the "pimple-like" lesion drains is adequate, but antibiotic eye drops or ointment can be used for slow to clear, very large or uncomfortable episodes.

Commonly Used Topical Occular Antibiotics

Sulfonamides are broad-spectrum compounds with good corneal penetration, but the development of resistance during treatment is common. Sulfonamides have a synergistic effect when combined with trimethoprim, effective in MRSA or Nocardia keratitis and in B henselae conjunctivitis. Macrolides are active against gram-positive cocci and bacilli, and a few gram-negative organisms such as Neisseria; resistance is rising due to mutations, and overuse. Corneal penetration and penetration of the ocular-blood barrier is generally poor because of poor solubility. Erythromycin ointment is well tolerated and commonly used for blepharitis for its gram-positive coverage. Newer macrolides can increase efficacy against some pathogens such as Mycobacteria and Chlamydia. Topical ophthalmic azithromycin is commercially available for the treatment of conjunctivitis.

impetigo

Superficial bacterial infection (staph or strep) Most Common in ages 2-5 Non-painful, blisters/crusting of ruptured blisters Treatment : mild: topical mupirocin moderate - severe : ORAL PENICILLIN (S. AUREUS MAY BE RESISTANT) FIRST GEN CEPHALOSPORIN MACROLIDES Risk of post-strep Glomerularnephritis higher than in pharyngitis

URIs treatment

Symptomatic care Fluids, antipyretics if indicated. Remember that a fever has a purpose...it is part of the immune response to "fight" the illness. Unless a patient has pain or the fever is high enough to cause achiness, I encourage people to avoid "treating the fever" Nasal bulb suctioning in infants Decongestants in older children and adults No antibiotics No difference in clinical outcomes Patients will ask, even insist on getting an antibiotic prescribed

stages of HIV

Symptomatic primary HIV infection approximately 2 to 4 weeks after infection: Flu-like viral syndrome develops with fever, lymphadenopathy, pharyngitis, rash, and myalgias Asymptomatic infection: No abnormal physical findings Symptomatic HIV infection : Development of common infections Advanced HIV disease/AIDS: Severe immunosuppression, CD4 T lymphocytes (CD4 cell) count less than 200 cells/mm3

decongestants

Systemic sympathomimetics- Pseudoephedrine Phenylephrine Topical decongestants- Phenylephrine (Neosynephrine) Oxymetazoline (Afrin) They can have rebound when used for more than a couple of days in a row) Action: vasoconstriction of capillary vessels, theoretically decreasing congestion Adverse drug reactions Tachycardia Hypertension Anxiety/restlessness/irritability NOT for kids, death can occur

ocular lubricants

Tear-like lubricants for the relief of dry eyes and eye irritation "Artificial tears" Pharmacodynamics Balanced solution of salts to maintain ocular tonicity, buffers, and preservatives Clinical use and dosing Dry eye syndrome: Instill three or four times/day

oral antibiotics

Tetracycline (250/500 mg twice daily) Erythromycin (250/500 mg twice daily) May result in gi upset

tetracyclines: pharmacodynamics, pharmacokinetics, c/I, drug interactions

Tetracycline and doxycycline Pharmacodynamics: Bind reversibly to the 30S subunit of the bacterial ribosome Pharmacokinetics Food decreases absorption Milk and calcium decrease absorption Precautions and contraindications Do not prescribe to pregnant women, lactating women, or children less than age 8 years Drug interactions: many

recommended immunizations

The CDC Advisory Committee on Immunization Practice (ACIP) sets the recommended vaccine schedule. Children age 0 to 6 years Children 7 to 18 years Adult schedule Catch-up schedule Guidelines for vaccinating pregnant women

beta agonists rational drug selection

The Expert Panel 3 says any short-acting beta agonist can be used in adults. Age Only albuterol and metaproterenol are approved for use in children younger than 4 years. Albuterol is the safest to use in infants. Cost Albuterol is the least expensive.

the common cold

The common cold is caused by viral pathogens, most commonly rhinovirus, along with: Parainfluenza and Influenza Adenovirus Respiratory syncytial virus Coronavirus Enteroviruses Children get six to eight "colds" a year More if in daycare/school and more when first placed in daycare/school Adults average 2.5 upper respiratory infections (URIs) per year Lasting at least 7 to 9 days, often with a post-viral cough lasting longer Significant runny nose and cough on days 1 to 4 are symptoms predictive for viral origin. The vast majority are viral in nature with NO bacterial pathogen Bacterial rhinosinusitis complicates only about 2% of cases Very commonly treated with antibiotics, even though not indicated.

What are the predominant organisms associated with cellulitis?

The predominant organisms associated with cellulitis area Streptococcus pneumoniae, S. aureus and in children H. influenzae

asthma in pediatric patients

Three categories of wheezing in children younger than age 5 years Transient early wheezing Persistent early-onset wheezing Late-onset wheezing/asthma The Expert Panel 3 Guidelines provide treatment categories for 0 to 4 years and 5 to 11 years. Stepwise approach is similar in adults and children, but not the same. Some medications not approved or should not be used in children. Long-acting beta agonists should not be prescribed singly, need to be combined with an inhaled corticosteroid. RSV, bronchiitis are RFs for kids for asthma since reactive airway

inactivated influenza virus: how many strains? C/I, ADRs, drug interactions, how frequent and who gets it?

Three strains of influenza: two type A and one or two type B Strains change annually based on predicted circulating strains and can vary in effectiveness Contraindications: anaphylaxis to eggs or influenza vaccine, Guillain-Barré syndrome within 6 weeks of influenza vaccine, febrile illness ADRs: local reaction, mild systemic effects Drug interactions: immunosuppressants, theophylline, phenytoin, warfarin Dosing: annual vaccine to all persons 6 months or older Patients younger than 9 years get two doses the first year. High-dose flu vaccine for age more than 65 years FluBlok or Flucelvax may be used in patients with egg allergies.

Common Pediatric Skin Conditions (Infectious): Fungal

Tinea Candida

otic analgesics

Topical anesthetics are used in the ear to treat pain associated with otitis media Local anesthetic antipyrine and benzocaine (Auralgan) is used to provide pain relief. This is not always available Analgesic eardrops are instilled into the affected ear three to four times daily or up to once every 1 to 2 hours as needed for pain. HOWEVER, patients must understand that this medication is used ONLY after the ear has been evaluated and treated for any infection. Using this in an infected ear, can result in worsening infection and TM rupture since the patient will not feel worsening pain as much.

topical antibiotics action and preps

Topical antibiotics control acne by decreasing the free fatty acids that P.acnes produces and thus decreases sebum production. Benzoyl peroxide is a topical medication that can come in OTC or prescription form it also comes in forms combined with other topical antibiotics to increase efficacy. Other topical antibiotics include Erythromycin (Staticin, Akne-Mycin, A/T/S, Eryderm, Erymax, Ery-Sol, T-Stat, Erygel), Benzoyl peroxide/ clindamycin (Benzaclin, Duac), Benzoyl peroxide/ erythromycin (Benzamycin), Clindamycin (Cleocin, Clinda-Derm, C/T/S), Tetracycline (Topicycline), Metronidazole (Metro-Gel, Noritate).

Ophthalmic Diagnostic Products

Topical fluorescein sodium is used in the office to detect corneal epithelial defects or abrasions. How to instill fluorescein. Pharmacodynamics Fluorescein is a yellow, water-soluble dibasic acid xanthine dye It produces an intense fluorescent green color in alkaline (pH 0.5) solution A corneal abrasion or corneal epithelial defect will uptake the dye and appear bright green under ultraviolet light It does not stain an intact cornea Clinical use and dosing of fluorescein Detection of corneal epithelial defects Instill 1 or 2 drops of fluorescein 2% solution into the eye or use fluorescein strips moistened with sterile water Use Wood's lamp to detect defect Remove excess stain with sterile saline rinse can put contacts in 1 hour later

topical retinoids action, c/i

Topical retinoids prevent the formation of micromedones by altering the abnormal keratinization process of acne that leads to the formation of these. Vitamin a derivatives Not for use in young children or during pregnancy. adapalene, Tretinoin, tazarotene ,retinol ,alitretinoin, and bexarotene. These come in cream, gel, and liquid forms

mild-moderate psoriasis treatment

Topical steroids & moisturizers Topical retinoids / vitamin D Topical tacrolimus

nicotine patch

Transdermal absorption 16-hour and 24-hour patches Slow onset, steady state once at peak Dose of patch is determined by number of cigarettes the patient smokes per day. Patch dose is decreased gradually. Patient cannot smoke while using patch. ADRs: Monitor for nicotine toxicity. Advise to dispose of patches safely.

oral typhoid vaccine: for which traveling countries? which age? how many doses? how often re-vaccinate?

Travelers to South or Southeast Asia, Africa, Caribbean, Central and South America Oral capsule for age 6 years and up, given 48 hours apart for 4 doses Revaccinate every 5 years

adult community acquired pneumonia

Treatment based on Infectious Diseases Society of America and the American Thoracic Society Consensus Statement (2007). I: Previously healthy with no risk factors for drug-resistant S. pneumonia II: Patients with risk factors III: Not admitted to the intensive care unit (ICU) IV: ICU patients CURB-65 criteria evaluate confusion, uremia, respiratory rate, low blood pressure, age 65 years or greater.

What are the treatment recommendations for these organisms associated with cellulitis?

Treatment is systemic broad-spectrum antibiotics that may involve an initial dose of IM or IV antibiotic followed by oral antibiotics such as dicloxacillin or a cephalosporin. Follow up should be done within 24 hours to assess if the condition is improving or worsening to decide which antibiotic is most appropriate. Oral antibiotics are typically prescribed for 7-10 days and should be taken for the full prescribed time even if symptoms resolve sooner.

HIV outcome evaluation

Treatment plans are individualized to each patient Success is determined by when the patient begins therapy and how well he or she is able to adhere to therapy

Tuberculin Purified Protein Derivative

Tuberculin PPD is used to screen asymptomatic individuals for infection with M. tuberculosis. Contraindications: tuberculin-positive reactors, immunodeficiency ADRs: In highly sensitive people, vesiculation, ulceration, and necrosis can occur at the administration site Drug interaction: live virus vaccines, Bacillus Calmette-Guérin, and immunosuppressants Dosing The test consists of injecting 5 TU of PPD intradermally Reactions are read in 48 to 72 hours Positive reading based on risk category and size of induration

TB significance & resistance

Tuberculosis (TB) is one of the world's deadliest diseases: One third of the world's population is infected with TB. TB is a leading killer of people who are HIV infected. Resistance is a growing problem. Acquired resistance to TB medications stems from inadequate or inappropriate prescribed treatment regimens or from patient noncompliance. Treatment regimens are long. Multidrug-resistant TB is becoming more of a problem.

Measles Mumps Rubella vaccine: how effective? c/I, ADRs,druginteractions, when is it given? 1st dose?2nd dose? what if infant traveling?

Two doses 99% effective in providing immunity for measles (88% for mumps) Contraindications: neomycin allergy, pregnancy, immunosuppression, febrile illness OK to give with egg allergy May give to breastfeeding women Adverse drug reactions (ADRs): fever 7 to 12 days after vaccination Drug interactions: immune globulin, high dose corticosteroids, chemotherapy Administer first dose at age 12 to 15 months Second dose given at age 4 to 6 years, or at least 4 weeks after the first dose Give one dose to any infant 6 to 12 months who will be traveling internationally Does not "count" as first dose; give a dose at 12 to 15 months - > 12 months!!!

typhoid vaccine: forms of it? c/I, ADRs, drug interactions, who gets it? how often

Two parenteral typhoid vaccines Heat- and phenol-inactivated vaccine (typhoid vaccine) Purified Vi polysaccharide (Typhim Vi) Contraindications: acute febrile illness, children less than 2 years ADRs: mild local and systemic reaction Drug interactions: immunosuppressants Dosing: one dose to travelers, lab workers, household contacts, booster dose every 2 years

nicotine replacement therapy

Use for patients who smoke more than 20 cigarettes per day, or.... Over-the-counter (OTC) drugs Gum: Nicorette Patch: Nicotrol, Nicoderm, Habitrol Lozenge: Commit Prescription drugs Nasal spray: Nicotrol NS Inhaler: Nicotrol

managing asthma exacerbations

Use oral steroids to regain control. Use a short "burst": Adults: 40 to 60 mg/day for 5 to 10 days Children: 1 to 2 mg/kg daily (maximum 60 mg/day) for 3 to 10 days If control does not continue, then a step up in therapy is warranted. NO evidence that >60mg/day will be beneficial. 60mg/day is max.dose Ellen does 40mg/day for 5 days then done, don't need to taper they'll be fine

cephalosporins: clinical use & dosing

Used for therapeutic failure in AOM First generation: strep pharyngitis, skin infections Cephalexin, cefpodoxime, cefixime can be prescribed as second-line drugs for urinary tract infection (UTI). Ceftriaxone and cefixime used for general condition gonococcus (GC)/chlamydia Cefpodoxime, cefuroxime, or parenteral ceftriaxone followed by oral cefpodoxime are used for community-acquired pneumonia

ophthalmic vasoconstrictors

Used to provide temporary relief of redness of the eye due to minor eye irritants Pharmacodynamics Sympathomimetic agents that act by constricting the conjunctivae blood vessels precautions and contraindications Hypersensitivity Narrow angle glaucoma ADRs Transient stinging and burning Temporary blurred vision Increased IOP Rebound congestion or redness can develop with frequent or extended use. Drug interactions Oxymetazoline or tetrahydrozoline: no interactions Naphazoline: tricyclic antidepressants, maprotiline Monoamine oxidase inhibitors Beta blockers

bacterial conjunctivitis: general

Usually begins in one eye and sometimes spreads to the other eye More commonly associated with discharge of pus, especially a yellow-green color Sometimes occurs with an ear infection or other URI issues

beta2 agonists ADRs

Usually transient Tachycardia and palpitations Some central nervous system (CNS) excitation effects Tremors, dizziness, shakiness, nervousness and restlessness-typically transient Headaches Salmeterol has an increased risk of exacerbation of severe asthma symptoms if the patient is deteriorating.

mass immunization

Vaccinate susceptible populations Effective in reducing vaccine preventable disease H. flu decreased 99% Pertussis decreased 93% Hepatitis A decreased 91% Disease numbers increase when vaccination rates go down Ex in Vermont, parents have chosen not to vaccinate with pertussis or alternate vaccine schedules(up to 1,000 cases last several years) The test is brutal. Most susceptible=very young and very old (moreso very young b/c they have very little lungs). All adults need Tdap booster d/t increased rate of pertussis

vaccine vs. immunization

Vaccination is the administration of a vaccine Immunization is the development of immunity to a pathogen We hope that vaccination will lead to immunity to a pathogen Vaccines for viral infections are either attenuated live viruses or inactivated viral particles.

treatment of candida infections

Vaginal candida infection very common (esophageal or oral may suggest immunosuppression) Vaginal candida: Usually responds to o.t.c. antifungals (topical) May use oral fluconazole Oropharyngeal/esophageal candida : Often associated with inhaled corticosteroids Any therapeutic plan must consider patients immune status (in those with immunosuppression) Oral fluconazole is agent of choice (100-200mg daily for 2 weeks) Severe cases may require iv amphotericin B

Nicotinic Receptor Partial Agonists

Varenicline (Chantix) Highly selective to the α4β2 and moderately selective to the 5-HT3 receptor Start a week before quit date. Dosing: 0.5 mg by mouth daily for the first 3 days Then 0.5 mg twice daily on days 4 to 7 On day 8 increase to 1.0 mg twice daily. Continue therapy for 12 weeks. ADRs: Nausea: 16% to 41% Neuropsychiatric symptoms Changes in behavior, agitation, depressed mood, vivid dreams, suicidal ideation, and actual suicidal behavior Pregnancy category C: Don't use! Adult use only (18 years or more)

varicella vaccine: name, how effective, c/I, ADRs, when it is given? # of doses?

Varicella virus vaccine (Varivax) Two doses 98.3% effective against getting disease May be administered post-exposure (within 3 days) Contraindications: neomycin allergy, febrile illness, immunocompromised, high-dose steroids, pregnancy ADRs: fever, rash, injection site reaction Administer first dose at age 12 to 15 months and second dose at age 4 to 6 years (most often with MMR) Adolescents and adults with no history of varicella are given two doses 4 to 8 weeks apart. It's a better option to get vaccine since if you go to a chicken pox party and get chicken pox you run risk of getting shingles later in life. Shingles vaccine makes shingles must less likely to come out when immunocompromised. More and more younger people getting shingles now

diaper rash

Very common (often candida) Treatment: Keep are clean and dry with moisture barrier ointments Antifungals(nystatin/clotrimazole/miconazole) ointments 2-4 times daily Low potency steroids (.25 - 1% hydrocortisone) Antibiotics? (to treat secondary staph/strep bacterial infections)

penicillins: pharmacokinetics

Well-absorbed from GI tract, but several are unstable in acid: dicloxacillin and amoxicillin better absorbed than ampicillin Bound to proteins with good distribution to most tissues Small amount is metabolized, most are excreted as unchanged drug in the urine Probenecid prolongs the half-life and increases risk for toxicity

smoking cessation monitoring

Withdrawal symptoms Nicotine toxicity ADRs Replacement of tobacco with other substances. Education about this and help with healthier coping strategies. Monitor patient on varenicline for neuropsychiatric changes.

asthma patient education

Written asthma action plan Overall treatment plan Specific drug therapy Drugs that are a part of treatment regimen and what they do Importance of adherence to plan Review asthma action plan at least every 6 months. Newly diagnosed asthmatics: watch them use inhaler so you know if they are doing it appropriately, Shouldn't be hitting back of throat, shouldn't be in mouth a lot educate them Don't use Albuterol every day!! (even though you feel better with it) Use long term one

what vaccines are recommended

all regular and routine vaccinations should be up-to-date (Tdap, Hep A and B, childhood vaccines, etc.) They offer the most up-to-date advice on the vaccinations specific to the risk in that part of the world as well as advice on how to prevent disease for which there is no vaccine available. They will guide you through patient counseling What to bring for OTC and prescription medications NOTE : If yellow fever is required, the Travel Clinic at UVM is the only place to get it around here. We can do the other pieces, but not that.

cephalosporins: ADRs

allergies, skin rashes, arthralgia, coagulation abnormalities, anemia, neutropenia, leukopenia, thrombocytosis, fever, seizures, renal/hepatic failure. HIGH rate of cliff

clindamycin

boxed warning for severe colitis; dermatological: rash, burning, itching, erythema; transient eosinophelia, neutropenia, thrombocytopenia

topical antibiotics side effects, patient education

common side effects include dryness, pruritis, redness, or irritation. Patients should be educated that drugs with benzoyl peroxide can cause mild irritation due to the drying effect on the skin, they can be used on kids 12 years old and older. Clindamycin should be used cautiously in patients with eczema, and should be stopped if diarrhea develops. Tetracycline can be staining to clothes and yellowing of skin can be removed by washing while Benzamycin can bleach fabrics as well.

azalaic acid

for patients who can't tolerate benzoyl peroxide or retinoids

blepharitis symptoms

gritty or burning sensation in their eyes, excessive tearing, itching, red and swollen eyelids, dry eyes or crusting of the eyelids. For some people, blepharitis causes only minor irritation and itching. However, it can lead to more severe symptoms, such as blurring of vision, missing or misdirected eyelashes, and inflammation of other eye tissue, particularly the cornea.

fluoroquinolone: pharmacodynamics

interfere with bacterial enzymes required for the synthesis of bacterial DNA Noted for extensive gram-negative activity Not recommended for children less than 18yo Increasing resistance due to overprescribing Can no longer be used for gonorrhea Resistant tuberculosis (TB)

cephalosporins: pharmacokinetics

oral formulations absorbed from GI tract, widely distributed to most tissues, some highly bound to proteins, some are metabolized to less active compounds, most excreted via kidneys, in various degrees as unchanged drug

who is at risk of fatal asthma attack?

previous severe exacerbations requiring intubation or ICU admission, 2 or more hospitalizations or 3 ED visits in past year, use of more than two short-acting beta agonist inhalers per month, worsening asthma, and low socioeconomic status (remember social determinants of health). 2 puffs per week of beta agonist or less know its GOOD CONTROL

Expert Panel 3 Guidelines recommendation for dose of inhaled corticosteroids

reduced by 25% to 50% every 2 to 3 months to lowest possible dose to maintain control. -not done a lot in practice when something is found that works but it is recommended

beta lactams: cephalosporins pharmacodynamics

structurally and chemically similar to PCNs Inhibit mucopeptide synthesis in the bacterial cell wall Four generations: First generation-Used for skin and soft tissue infections Primarily active against gram-positive bacteria, S. aureus and S. epidermidis Second generation- Active against same as first generation, plus Klebsiella, Proteus, E. coli Third generation-Used for broader indications More active against gram-negative bacteria Fourth generation-Resistant to beta-lactamase Primarily active against gram-positive bacteria

once control achieved, how frequent should patient be seen?

the patient is typically seen every 1 to 6 months to review control and ensure optimal treatment.

Describe the terms "tachyphylaxis" and "pulse dosing" in relation to topical corticosteroids.

topical corticosteroids are susceptible to developing a form of acute tolerance known as tachyphylaxis. Tachyphylaxis is defined as "a rapidly diminishing response to successive doses of a drug rendering it less effective". This is problematic when the use of topical corticosteroids is warranted for chronic conditions such as psoriasis and systemic lupus erythematus and may be used for extended periods of time for other inflammatory skin conditions such as alopecia areata, contact and atopic dermatitis. Topical corticosteroid pulse therapy involves intermittent use of superpotent corticosteroids (high or very high potency formularies) that are used less frequently than the counterpart once or twice daily dosing. Intermittent or "pulse" therapy has the benefit of minimizing adverse effects and has the best long-term outcome, particularly in patients receiving topical corticosteroids for psoriasis.