Infectious Disease Part 3
Which of the following medications require patient counseling for risk of photosensitivity? A Vfend B Vigamox C Keflex D Augmentin XR E Unasyn
A
A 32 year old critically-ill patient with diabetes is admitted to the intensive care unit with respiratory compromise and acute kidney injury. She is diagnosed with pulmonary Aspergillosis. Which of the following antifungal agents would be most appropriate to initiate? A Vfend B Flucytosine C Zosyn D AmBisome E Cancidas
A - The drug of choice for Aspergillosis is voriconazole. Amphotericin B is an alternative, but should be avoided in the setting of acute kidney injury due to its nephrotoxicity potential.
Choose an acceptable treatment option for daily suppressive therapy for a herpes simplex genital infection: A Acyclovir 400 mg PO BID B Ganciclovir 250 mg PO BID C Valganciclovir 500 mg PO daily D Famciclovir 2,000 mg PO daily E Foscarnet 50 mg IV daily
A - This therapy can reduce herpes recurrences.
A first year medical resident is rounding with the internal medicine team and asks the pharmacist for a hint on how to keep the azole antifungals straight. Which of the following are true regarding the azole antifungals? (Select ALL that apply.) A Increased LFTs are a possible adverse effect. B All are hepatically cleared, except fluconazole. C All have significant drug interactions that should be reviewed when ordering/dispensing. D All can prolong the QT interval, except isavuconazonium. E All are associated with phototoxicity.
A, B, C, D - All azoles are moderate-strong 3A4 inhibitors and most have other significant enzyme and drug interactions. Fluconazole requires renal dose adjustment. Cresemba can cause a short QT interval. Voriconazole is notable for phototoxicity.
Which of the following is/are active agains Zygomycetes (Mucor, Rhizopus species)? (Select ALL that apply.) Amphotericin B deoxycholate B Amphotericin B liposomal C Voriconazole D Cresemba E Posaconazole
A,B,D,E - Voriconazole is active against Aspergillus but not Zygomycetes.
Select the correct dose of oseltamivir for the treatment of influenza in an adult: A 75 mg BID for ten days B 75 mg BID for five days C 75 mg daily for ten days D 75 mg daily for five days E 75 mg BID for fourteen days
B
TY comes to the pharmacy to pick up her prescription for Valtrex for treatment of her recurrent herpes simplex virus. Which of the following statements would be best to include during patient counseling? A This medication is very effective and will cure her herpes infection. B She should start therapy within one day of symptom onset to experience maximum benefit from the drug. C This medication should be taken with food. D It is safe to continue sexual contact with her partner when she has symptoms or a herpes outbreak. E This product is effective only when she has developed genital lesions.
B - Antivirals used to treat herpes simplex virus decrease the duration of the infection. Antivirals should be started within 24 hours of symptom onset of a recurrence for maximal benefit and sexual contact should be avoided when symptoms or lesions are present.
FR is a 20 year old female who presented to the university health clinic with fatigue and a sore throat. She was found to have tender, swollen lymph nodes on exam. She was diagnosed with infectious mononucleosis. Which of the following is true regarding this illness? A It is sexually transmitted and her partner should be notified and treated. B It is caused by Epstein-Barr virus and is primarily spread by saliva (e.g., kissing, sharing food or drinks). C It is treated with amoxicillin. D She should have received the EBV vaccine as an adolescent. E It is rare and should be reported to the CDC.
B - Infectious mononucleosis is often called "mono" and is common. Most people will become infected with EBV at some point in their life. There is no vaccine or treatment available and it is self-resolving.
Itraconazole is used for a variety of fungal infections including blastomycosis, histoplasmosis, aspergillosis and onychomycosis. Itraconazole cannot be used with certain drugs. Which of the following drugs is contraindicated with the use of itraconazole? A Cetirizine B Quinidine C Zafirlukast D Azithromycin E Amphotericin B
B - Itraconazole is a strong 3A4 inhibitor. Use with certain drugs has been associated QT prolongation and ventricular arrhythmias.
The pharmacist is on rounds with the internal medicine team. They are discussing a patient who has oral candidiasis due to a recent chemotherapy treatment. The infection is very painful for the patient and is considered moderate to severe. Which of the following is the best regimen to recommend for this patient? A Clotrimazole troches 10 mg PO 5 times per day B Fluconazole 200 mg IV daily C Posaconazole 400 mg PO BID D Amphotericin B 15 mg/kg IV BID E Itraconazole 200 mg PO daily
B - Patients with severe and painful oral candidiasis will not tolerate taking medications orally without analgesics. Localized treatment with clotrimazole is used for mild infections only, in patients without immunosuppression. The most appropriate therapy would be an antifungal given intravenously until oral medications are tolerated. Fluconazole has appropriate activity and the amphotericin dosing is too high.
DS has just received a prescription for oseltamivir (Tamiflu). He has been feeling incredibly weak from the flu for the past five days and is hopeful the medicine will offer some relief. Mr. Stuart has asthma and has been wheezing since he became ill. Choose the correct statements. (Select ALL that apply.) A It would be preferable for him to receive zanamivir. B Oseltamivir effectiveness may be decreased. C A patient who has influenza and is a candidate for a neuraminidase inhibitor will need 10 days of therapy. D A patient who has influenza and is a candidate for a neuraminidase inhibitor will need 5 days of therapy. E It would be preferable for him to receive amoxicillin.
B, D - To be most effective oseltamivir should be started within 48 hours of symptom onset. Patients who are candidates should receive 5 days of therapy.
Which of the following are potential treatment options for the management vesicular genital lesions caused by a first episode of Herpes Simplex Virus-2 (HSV-2) in a non-HIV positive patient. (Select ALL that apply.) A Valcyte 900 mg PO twice daily x 5 days B Famvir 250 mg PO three times daily x 10 days C Valtrex 1 g PO daily x 5 days D Foscavir 90 mg/kg IV Q12H x 14 days E Zovirax 400 mg PO three times daily x 7-10 days
B, E - The preferred options for first episode of HSV-2 genital lesions include acyclovir 400 mg PO three times daily (or 200 mg 5x/day) OR Valtrex 1 g PO twice daily OR Famvir 250 mg PO TID. The duration of HSV-2, first episode, should be 7-10 days.
RS, a 23 year-old male with poorly controlled asthma, currently is presenting with a sudden onset of headache, dry cough and fever (temperature 101.9 degrees F) illness for approximately 24 hours. A rapid test reveals influenza B. If indicated, which antiviral agent would be most useful to initiate? A Antiviral therapy is not indicated as too much time has passed since the onset of the patient's symptoms. B Famvir C Tamiflu D Relenza E Flumadine
C - Antivirals are most effective when started < 48 hours after symptom onset. Tamiflu is the best option in this case. Relenza should not be used in patients with breathing problems, including asthma and COPD. Adamantanes have not been recommended as influenza monotherapy for several years due to resistance.
A patient with severe renal impairment (creatinine clearance approximately 25 mL/min) is in the hospital for treatment of an infection. Blood cultures are positive for Candida krusei. Which of the following medications is best to treat the patient's infection? A Tigecycline 100 mg IV x 1; then 50 mg IV every 12 hours B Amphotericin B deoxycholate 3 mg/kg IV daily C Caspofungin 70 mg IV x 1, then 50 mg IV daily D Fluconazole 200 mg IV daily E Ketoconazole 400 mg PO daily
C - Caspofungin is effective against Candida species such as C. krusei and C. glabrata. Fluconazole is not active against C. krusei. Infuse caspofungin slowly, over 1 hour. Echinocandins do not require dose adjustment in renal impairment.
LT is a 37 year-old female who presented to the ED on 10/2 with fever, fatigue and generalized aches. She receives chronic parenteral nutrition due to a non-healing enterocutaneous fistula. She had come to the ED one day prior and blood cultures x2 were drawn, but she refused admission at that time. Her past medical history is significant for Crohn's disease. She is noted to have a Hickman central catheter at the right chest for TPN administration. The site is red and warm. Medications Remicade 5 mg/kg IV every 8 weeks Prednisone 20 mg PO daily Ciprofloxacin 500 mg PO BID (currently on day 6 of 10 for Crohn's exacerbation) Flagyl 500 mg PO BID (currently on day 6 of 10 for Crohn's exacerbation) Vitals: Height: 5'4" Weight: 112 pounds BP: 108/65 mmHg HR: 78 BPM RR: 17 BPM Temp: 102.8°F Pain: 4/10 Labs 10/2: Na (mEq/L) = 138 (135 - 145) K (mEq/L) = 3.6 (3.5 - 5) Cl (mEq/L) = 100 (95 - 103) HCO3 (mEq/L) = 27 (24 - 30) BUN (mg/dL) = 20 (7 - 20) SCr (mg/dL) = 1.8 (0.6 - 1.3) Glucose (mg/dL) = 112 (100 - 125) Ca (mg/dL) = 8.7 (8.5 - 10.5) Mg (mEq/L) = 1.3 (1.3 - 2.1) PO4 (mg/dL) = 2.4 (2.3 - 4.7) Albumin (g/dL) = 3.6 (3.5 - 5) Tests: Blood cultures x2 from the previous ED visit reveal C. albicans. Plan: Start an antifungal. To the OR to remove the central venous catheter and place a peripherally inserted central line on the left side. Question: Which of the following would be an appropriate treatment for LT's bloodstream infection? A Voriconazole 6 mg/kg IV Q12H x1, then 4 mg/kg IV Q12H B Fluconazole 800 mg IV Q24H C Fluconazole 200 mg IV Q24H D Amphotericin B deoxycholate 0.5 mg/kg IV Q24H E Isavuconazonium 372 mg IV Q8H x6 doses, then 372 mg PO Q24H
C - Fluconazole at a dose reduced for her renal function is the most reasonable choice for C. albicans. The broader spectrum of voriconazole is not needed for Candida spp. Also, the solubilizing agent in IV voriconazole can accumulate in renal impairment and can further worsen kidney function. The broad spectrum of amphotericin B is not needed and risk of nephrotoxicity is undesirable in this patient with elevated SCr. Isavuconazonium (Cresemba) has tolerability issues and the broad spectrum is not necessary.
JW is receiving oseltamivir (Tamiflu). Choose the correct mechanism of action for oseltamivir. A Binds to the ribosomal subunit in viral RNA B Stimulates phagocytosis C Inhibits neuraminidase D Prevents viral shedding E Inhibits hemagglutinin
C - Hemagglutinin and neuraminidase are proteins on the surface of the influenza virus. Oseltamivir is a neuraminidase inhibitor, which stops the virus from budding off and spreading to other cells.
A 32 year old female who is receiving chemotherapy for acute leukemia is diagnosed with mucormycosis via tissue culture and will being therapy with IV isavuconazonium. The nurse contacts the pharmacist asking what he needs to know, as he has never administered the drug before. Which of the following is an important point regarding this medication? A This medication requires light protection during administration. B This medication is not compatible with PVC containers and will be supplied in a glass bottle. C This medication requires a filter for administration. D This medication requires PTT monitoring. E This medication can prolong the QT interval.
C - Isavuconazonium (Cresemba) is a prodrug of isavuconazole. It does not contain a solubilizing agent as with voriconazole and posaconazole, so a filter is required for administration, to prevent any particulates (undissolved drug) from entering a patient's bloodstream. This agent can shorten the QT interval, which is unique within the azole class (all the other agents are associated with prolonged QT).
A patient is receiving itraconazole for treatment of an aspergillosis infection. Which of the following statements regarding itraconazole therapy is correct? A The oral capsule and oral solution can be used interchangeably. B The oral capsule is best if administered on an empty stomach. C The oral solution should be administered on an empty stomach D St. John's wort will have no effect on itraconazole levels. E This medication is safe to use in heart failure patients.
C - Itraconazole capsules and solution are not bioequivalent and are not interchangeable. The oral solution should be taken on an empty stomach and the oral capsules should be taken after a meal. Use of itraconazole is not recommended for treatment of onychomycosis in patients with heart failure.
Which of the following statements is incorrect with regard to amphotericin B? A Lipid formulations were formulated to reduce the risk for infusion reactions and nephrotoxicity. B It is a fungicidal agent with broad antifungal spectrum of activity. C Liposomal amphotericin B requires lower doses than conventional amphotericin B dexoycholate. D It is compatible with D5W only. E It is commonly associated with nephrotoxicity and electrolyte abnormalities.
C - Lipid-based amphotericin B doses are higher than conventional, ranging from 3-6 mg/kg/day. To help prevent dosing errors, amphotericin B deoxycholate (conventional) carries a boxed warning to confirm any dose exceeding 1.5 mg/kg/day.
A patient is being discharged home from the hospital. The patient was getting fluconazole 400 mg IV daily for the treatment of his fungal infection. The physician would like to continue with oral fluconazole therapy. What is the equivalent oral dose? A 800 mg B 600 mg C 400 mg D 200 mg E 100 mg
C - The fluconazole IV to oral ratio is 1:1.
A patient is picking up a new prescription for Vfend at the pharmacy. Which of the following counseling points regarding Vfend are correct? (Select ALL that apply.) A This medication should be taken with meals, preferably breakfast and dinner. B This medication can cause lymphomas with prolonged use. C This medication can cause visual changes; care is advised when driving and driving at night should be avoided. D This medication can damage the liver and liver function tests may need to be monitored. E This medication is associated with many drug interactions.
C, D, E - Visual disturbances (abnormal vision, color vision change and/or photophobia) occur in about 20% of voriconazole-treated patients. Voriconazole is taken on an empty stomach 1 hour before or 1 hour after meals. Check for drug interactions; there are many.
SF developed a white film on her tongue and throat. One month prior, a Symbicort inhaler was prescribed for her asthma. When asked, she stated that she isn't always able to rinse her mouth each dose. Which of the following drugs could be used to treat for oral candida (thrush)? (Select ALL that apply.) A Fluconazole, taken by injection B Ketoconazole, taken orally C Nystatin suspension, swish and swallow D Bactrim E Clotrimazole lozenges
C, E - Topical agents are useful for treating mild, localized Candida infections of the mouth
Which of the following agents would be considered inappropriate monotherapy for treatment of herpes zoster? (Select ALL that apply.) A Valacyclovir 1,000 mg PO TID for 7 days B Famciclovir 500 mg PO TID for 7 days C Valganciclovir 1,000 mg PO TID for 7 days D Acyclovir 800 mg PO 5x daily for 10 days E Acyclovir cream topically 5x daily for 7 days
C, E - Valganciclovir (Valcyte) is used for cytomegalovirus (think of Valcyte for cytomegalovirus). Herpes zoster is treated with systemic antivirals.
Antiviral agents active against cytomegalovirus (CMV) include which of the following: A Valganciclovir, valacyclovir, acyclovir B Atazanavir, valganciclovir, foscarnet C Foscarnet, acyclovir, cidofovir D Valganciclovir, foscarnet, cidofovir E Acyclovir, valacyclovir, ganciclovir
D - Ganciclovir, valganciclovir, foscarnet and cidofovir are indicated for CMV. Others listed are indicated for HSV (acyclovir, valacyclovir, famciclovir) or HIV (atazanavir).
Which of the following statements is correct with regards to voriconazole? A It binds to ergosterol in the cell membrane altering cell membrane permeability. B Its spectrum of activity includes many Candida and many molds, but excludes Aspergillus. C It is a hepatic enzyme inducer reducing the levels of the induced drug. D It is associated with hepatotoxicity and ocular toxicity. E It must be taken with food, preferably a high fat meal.
D - Azoles act by inhibiting the production of ergosterol. It is a hepatic enzyme inhibitor, not an inducer. Voriconazole is the drug of choice for Aspergillosis. Patients should be counseled to take voriconazole on an empty stomach.
GP is receiving amphotericin B deoxycholate for treatment of mucormycosis. Which of the following side effects are most likely to occur with treatment? A Hyponatremia, hypocalcemia, hypokalemia B Hyponatremia, hypokalemia, chest tightness C Hypocalcemia, hyperkalemia, leucopenia D Hypomagnesemia, hypokalemia, rigors E Hyperkalemia, hypermagnesemia, hypotension
D - Common side effects associated with amphotericin B deoxycholate include hypomagnesemia, hypokalemia, fever, chills, rigors, headache, hypotension, and nephrotoxicity.
DD has developed candidemia after 3 weeks in the intensive care unit. She is currently being treated with micafungin. Which of the following statements is correct regarding micafungin? A Micafungin is available orally and can cause pulmonary edema. B Micafungin is known to cause embryofetal toxicity. C Micafungin requires premedication prior to administration. D Micafungin infusions can cause histamine-related symptoms. E Micafungin is an azole antifungal agent.
D - Micafungin, an echinocandin, can cause histamine-mediated symptoms such as rash, pruritus, facial swelling, flushing, and hypotension. To decrease the potential of a histamine reaction, infuse over 1 hour. Micafungin is only available intravenously.
A 20 year old male with HIV/AIDS is admitted to the medicine floor for a work-up of sepsis. Blood cultures are performed and reveal germ-tube positive yeast which is identified as Candida albicans. The patient will require several weeks of medication and the team wishes to avoid sending him home with an IV line and asks if there is an acceptable agent to treat Candida albicans that is available in both intravenous and oral formulations. Which agent could be recommended? A Flucytosine B Micafungin C Nystatin D Terbinafine E Fluconazole
E - Fluconazole is the drug of choice for Candida albicans bloodstream infections (candidemia). Micafungin has activity against Candida albicans, but is only available in injectable form. The other agents are not appropriate and are not available in both IV and PO forms.
Lisa Bates is a 42 year-old female admitted to the oncology unit on 12/15 because of a suspected problem with her central line. She recently received chemotherapy and is taking prophylaxis with posaconazole suspension due to prolonged neutropenia and mucositis. On hospital day 5, the central line has been replaced and her mucositis is resolving to the point that she can swallow tablets. The patient mentioned to the nurse that she dislikes measuring out the liquid doses. After discussing it with the patient, the prescriber completes the discharge medication reconciliation and changes her posaconazole to the tablets. Which of the following is/are true regarding posaconazole dosage forms? A Posaconazole suspension and tablets should be taken on an empty stomach to improve bioavailibility. B Posaconazole tablets require a 25% dose increase when converting from intravenous therapy. C Posaconazole injection requires a higher dose than the suspension. D Posaconazole injection and suspension have nearly identical bioavailability. E Posaconazole suspension has lower bioavailability than the tablets.
E - The suspension has lower bioavailability than the tablets and injection. The FDA received numerous reports of serious medication errors and in January 2016 required changes to the label and the packaging to indicate that the dosage forms are not equivalent and should not be substituted at equal doses. The tablets and injection have similar bioavailability and a 1:1 IV to PO ratio, but it they are not 1:1 with suspension. Both oral forms should be taken with food.
DE is a 61 year-old male who experienced a painful, blistery rash on his neck and upper chest. He was diagnosed with shingles and prescribed valacyclovir 1 gram TID for 7 days. Which of the following counseling points on valacyclovir is correct? A It must be taken with food. B This medicine often causes a rash; if the rash appears severe contact a physician immediately. C If the patient feels better, he do not need to continue the medication for the full 7 days. D Since he has had a shingles attack, he is not a candidate for the shingles vaccine. E He may experience headache, and possible nausea, from using this medicine, but it is usually mild.
E - Valacyclovir is taken without regard to meals. In addition to headache, some patients get nausea. Otherwise, drugs in this class are generally well-tolerated.
