Infectious Disease III

GP is receiving amphotericin B deoxycholate for the treatment of mucormycosis. Which of the following side effects are most likely to occur with treatment? A) Hypomagnesemia, hypokalemia, rigors B) Hyponatremia, hypokalemia, chest tightness C) Hyperkalemia, hypermagnesemia, hypotension D) Hyponatremia, hypocalcemia, hypokalemia E) Hypocalcemia, hyperkalemia, leukopenia

A) Hypomagnesemia, hypokalemia, rigors Common side effects associated with amphotericin B deoxycholate include hypomagnesemia, hypokalemia, fever, chills, rigors, headache, hypotension and nephrotoxicity. Refer to the section(s) beginning on pg. 398

An 85-year-old man is hospitalized with a fungal infection. He has CKD stage 3 and chronic pain (on methadone). Micafungin 100 mg intravenous is given. During the infusion, the man develops a drop in blood pressure, pruritis and flushing. What is the most likely cause of this reaction? A) Micafungin is causing a histamine-release reaction. B) Acetaminophen and meperidine should have been given prior to micafungin. C) Micafungin increased the methadone levels, resulting in an adverse reaction. D) It is unlikely that this reaction is due to methadone or micafungin. E) The micafungin dose should have been really adjusted.

A) Micafungin is causing a histamine-release reaction. Micafungin, an echinocandin, can cause histamine-mediated symptoms such as rash, prutitus, facial swelling, flushing and hypotension. To decrease the potential of a histamine reaction, infuse over 1 hour. Refer to the section(s) beginning on pg. 401

RS is a 23-year-old male with poorly controlled asthma. He is currently presenting to the ED with a sudden onset of headache, dry cough and fever (temperature 101.9 degrees F). His symptoms started 24 hours ago. A rapid test reveals influenza B. Which antiviral agent would be most useful to initiate? A) Oseltamivir B) Zanamivir C) Antiviral therapy is not appropriate D) Rimantadine E) Famciclovir

A) Oseltamivir Antivirals are most effective when started ‹ 48 hours after symptom onset. Oseltamivir is the best option in this case. Zanamivir should not be used in patients with breathing problems, including asthma and COP. Adamantanes have not been recommended as influenza monotherapy for several years due to resistance. Refer to the section(s) beginning on pg. 404

DE is a 61-year-old male who is experiencing a blistery rash that wraps around the right side of his torso. He reports that the rash is tingling with shooting pain. The appearance of the rash is consistent with herpes zoster. Which medication is appropriate to treat this condition? A) Valtrex B) Diflucan C) Mycomine D) Cytovene E) Abreva

A) Valtrex DE has shingles (also called herpes zoster) and valacyclovir (Valtrex) is a recommended treatment. Refer to the section(s) beginning on pg. 408

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) Cancidas C) Flucytosine D) AmBisome E) Zosyn

A) Vfend The drug of choice for Aspergillosis is voriconazole. Isavuconazonium (Cresemba) is also indicated for the treatment of Aspergillosis. Ambisome (liposomal amphotericin B) is a less preferred alternative and should be avoided in the setting of acute kidney injury due to its risk for nephrotoxicity. Refer to the section(s) beginning on pg. 403

Which of the following medications require patient counseling for risk of photosensitivity? A) Vfend B) Mycamine C) Unasyn D) Vigamox E) Keflex

A) Vfend Vfend (voriconazole) can cause photosensitivity. The others do not. Refer to the section(s) beginning on pg. 399

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) 75 mg BID for five days The treatment dose is 75 mg twice daily for 5 days. Refer to the section(s) beginning on pg. 404

A 20-year-old male with HIV/AIDS is admitted to the medicine floor. An esophageal culture is performed and reveals germ-tube positive yeast which is identified as Candida albicans. 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) Fluconazole C) Micafungin D) Nystatin E) Terbinafine

B) Fluconazole Fluconazole is the drug of choice for esophageal candidiasis. Micafungin has activity against Candida albicans, but is only available in injectable form. Refer to the section(s) beginning on pg. 403

Which of the following counseling points are correct for Vend? (Select ALL that apply.) A) It can cause lymphomas with prolonged use. B) It can cause visual changes; care is advised when driving and driving at night should be avoided. C) It is associated with many drug interactions. D) Take with meals, preferably breakfast and dinner. E) It can damage the liver and liver function tests may need to be monitored.

B) It can cause visual changes; care is advised when driving and driving at night should be avoided. C) It is associated with many drug interactions. E) It can damage the liver and liver function tests may need to be monitored. Visual disturbances (abnormal vision, color vision changes 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. Refer to the section (s) beginning on pg. 399

Which of the following is the mechanism of action of Diflucan? A) It interferes with microtubule formation by binding tubulin. B) It decreases ergosterol synthesis and cell membrane formation. C) It inhibits the synthesis of beta (1,3)-D-glucan. D) It interferes with fungal RNA and protein synthesis. E) It binds to ergosterol in the cell membrane altering cell membrane permeability.

B) It decreases ergosterol synthesis and cell membrane formation. Diflucan is an azole. Azoles act by inhibiting the production of ergosterol, which decreases cell membrane formation. Refer to the section(s) beginning on pg. 399

Which of the following medications is contraindicated in a patient with heart failure? A) Griseofulvin B) Itraconazole C) Flucytosine D) Isavuconazonium sulfate E) Amphotericin B deoxycholate

B) Itraconazole Itraconazole use in a patient with heart failure is contraindicated because it can cause or worsen heart failure. Refer to the section(s) beginning on pg. 399

All of the following statements regarding amphotericin B are correct EXCEPT: A) The conventional formulation requires premedication to reduce infusion-related reactions. B) Lipid formulations have a greater risk for nephrotoxicity than conventional formulations. C) It is a fungicidal agent with broad antifungal spectrum of activity. D) All formulations can cause hypomagnesemia and hypokalemia. E) Doses of conventional amphotericin B >/1.5 mg/kg/day can cause cardiopulmonary arrest.

B) Lipid formulations have a greater risk for nephrotoxicity than conventional formulations. Lipid formulations of amphotericin B are associated with fewer toxicities (including decreased infusion reactions and decreased nephrotoxicity) compared to amphotericin B deoxycholate (also referred to as conventional amphotericin). 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. Refer to the section (s) beginning on pg. 398

A healthy 23-year-old woman presents to her OBGYN office complaining of a vaginal yeast infection. The patient prefers an oral treatment option. Which of the following is the most appropriate oral treatment of her yeast infection? A) One time dose of terbinafine B) One time dose of fluconazole C) Nystatin for 3 days D) Clotrimazole for 7 days E) Flucytosine for 7 days

B) One time dose of fluconazole The patient prefers an oral medication regimen to treat her vaginal candidiasis. A one time dose of fluconazole 150 mg orally is an appropriate option Refer to the section(s) beginning on pg. 399

SF was prescribed a Symbicort inhaler for her asthma. One month later, SF reports developing a white film on her tongue and throat. When asked, she stated that she isn't always able to rinse her mouth after each dose. Which of the following is the most appropriate treatment for SF? A) Bactrim B) Micafungin C) Clotrimazole lozenges D) Ketoconazole E) Terbinafine

C) Clotrimazole lozenges SF has oral thrush, a localized Candida infection of the mouth. Thrush can be avoided by rinsing the mouth after using an inhaled steroid. Topical agents are usetul for treating mild, localized Candida infections of the mouth Refer to the section(s) beginning on pg. 403

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 pathogen causes this illness? A) Herpes simplex virus 1 B) Cytomegalovirus C) Epstein-Barr virus D) Aspergillus E) Dermatophytes

C) Epstein-Barr virus Infectious mononucleosis is caused by the Epstein-Barr virus (EBV). It is spread through bodily fluids, including by kissing. Refer to the section(s) beginning on pg. 410

A 59-year-old male is admitted to the hospital with a CrCI of 35 mL/min and a fungal infection. Which of the following antifungal medications would require a dose adjustment? A) Ketoconazole B) Voriconazole C) Fluconazole D) Clotrimazole E) Isavuconazonium

C) Fluconazole Fluconazole is the only azole that requires renal dose adjustment. Refer to the section (s) beginning on pg. 399

Choose the correct mechanism of action for oseltamivir: A) Binds to the ribosomal subunit in viral RNA B) Stimulates phagocytosis C) Inhibits neuraminidase D) Inhibits hemagglutinin E) Prevents viral shedding

C) Inhibits neuraminidase 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. Refer to the section(s) beginning on pg. 404

Which of the following is a first-line treatment for dermatophytes that cause nail bed infections? (Select ALL that apply.) A) Voriconazole B) Amphotericin B C) Itraconazole D) Terbinafine E) Micafungin

C) Itraconazole D) Terbinafine Itraconazole, terbinafine and fluconazole are first-line for the treatment of nail bed infections. Refer to the section(s) beginning on pg. 403

Which of the following is a boxed warning for ketoconazole? A) Increase risk of causing heart failure B) Increased risk of death in elderly patients C) Severe hepatotoxicity D) Antabuse-like reaction when taken with alcohol E) Risk of hypoglycemia

C) Severe hepatotoxicity Ketoconazole has a boxed warning for severe hepatotoxicity that has led to liver transplantation or death. Refer to the section (s) beginning on pg. 399

Which of the following is the most appropriate administration of nystatin for the treatment of oral candidiasis? A) Administer 100 mg IV once daily. B) Allow the troche to dissolve slowly in the mouth over 15-30 minutes. C) Swish the suspension in the mouth and swallow. D) Apply the cream topically on the corners of the mouth. E) Take 1 tablet by mouth every 8 hours.

C) Swish the suspension in the mouth and swallow. Nystatin is used for the treatment of mild oral candidiasis. The suspension is swished around the mouth and held in the mouth for several minutes, then swallowed. Nystatin tablets are used for the treatment of intestinal infections. Refer to the section(s) beginning on pg. 402

DS has just received a prescription for baloxavir marboxil (Xofluza). He has been feeling incredibly weak from the flu for the past 24 hours. DS has asthma and has been wheezing since he became ill. How many days will the patient need to take this medication? A) 3 days B) 10 days C) 5 days D) 1 day E) Antiviral treatment is not appropriate

D) 1 day Baloxavir marboxil (Xofluza) is a one-time dose for influenza that is given within 48 hours of symptom onset Refer to the section(s) beginning on pg. 404

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) 200 mg B) 100 mg C) 600 mg D) 400 mg E) 800 mg

D) 400 mg The fluconazole IV to oral ratio is 1:1. Refer to the section(s) beginning on pg. 399

Which dosing instructions for the use of OTC docosanol are correct? A) Take 1 tablet daily until healed. B) Take 1 tablet five times daily at the first sign of an outbreak. C) Apply twice daily for 10 days. D) Apply five times daily at the first sign of an outbreak. E) Apply once daily for 7 days.

D) Apply five times daily at the first sign of an outbreak. Docosanol is an OTC topical treatment for herpes simplex labialis (cold sores). Refer to the section(s) beginning on pg. 407

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. Blood cultures x2 were drawn, and she was admitted to the hospital. 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) Flagy1 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) CI (mEg/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/aL) = 8.7 (8.5 - 10.5) Mg (mEg/L) = 1.3 (1.3 - 2.1) P04 (mg/dL) = 2.4 (2.3 - 4.7) Albumin (g/du) = 3.6 (3.5 - 5) WBC (cells/mm3) = 16.3 (4 - 11 x10^3) Hgb (g/dL) = 12.1 (12 - 16) Hct (%) = 36 (36 - 46%) PIt (cells/mm3) = 175 (150 - 450 x10^3) Tests: 10/2 Blood cultures x2 reveal C. glabrata. Plan: Consult pharmacy for an antifungal recommendation. Consult Surgery and infectious Diseases for the management of the infected central line. Question: Which medication is preferred to treat LT's bloodstream infection? A) Tigecycline B) Itraconazole C) Fluconazole D) Caspofungin E) Ketoconazole

D) Caspofungin Caspofungin is effective against Candida species such as C. kruse and C. glabrata, Due to growing resistance, fluconazole has limited efficacy against C. glabrata. The IDSA guidelines for the treatment of invasive candidiasis recommend initial treatment of bloodstream infections due to Candida spp with an echinocandin. Refer to the section(s) beginning on pg. 403

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) Itraconazole 200 mg PO daily B) Amphotericin B 15 mg/kg IV BID C) Clotrimazole troches 10 mg PO 5 times per day D) Fluconazole 200 mg IV daily E) Posaconazole 400 mg PO BID

D) Fluconazole 200 mg IV daily 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. Refer to the section(s) beginning on pg. 403

A patient presents with vesicular genital lesions and is prescribed a course of valacyclovir 1 gram PO BID x 10 days. Which pathogen is most likely causing the infection? A) Varicella zoster virus B) Aspergillus C) Cytomegalovirus D) Herpes simplex-2 virus E) Candida albicans

D) Herpes simplex-2 virus The patient is presenting with symptoms of genital herpes, which is most commonly caused by HSV-2. Varicella zoster virus causes chickenpox, most commonly in unvaccinated children Refer to the section (s) beginning on pg. 407

A 32-year-old female who is receiving chemotherapy for acute leukemia is diagnosed with mucormycosis via tissue culture and will begin 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 is not compatible with PVC containers and will be supplied in a glass bottle. B) This medication requires light protection during administration. C) This medication requires PTT monitoring. D) This medication requires a filter for administration. E) This medication can prolong the QT interval.

D) This medication requires a filter for administration. 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 of the other agents are associated with prolonged QT). Refer to the section(s) beginning on pg. 399

Due to the risk of life-threatening arrhythmias, coadministration of dofetilide is contraindicated with which medication? A) Amphotericin B B) Oseltamivir C) Famciclovir D) Caspofungin E) Itraconazole

E) Itraconazole Itraconazole, in combination with certain drugs, has been associated with QT prolongation and ventricular arrhythmias. See the Learning Drug Interactions chapter for more information on the effect of CYP inhibitors. Refer to the section(s) beginning on pg. 399

Which azole antifung al requires an acidic environment for absorption? A) Fluconazole B) Posaconazole C) Isavuconazonium D) Voriconazole E) Ketoconazole

E) Ketoconazole Ketoconazole requires an acidic environment for absorption. If a PPI or H2RA must be used while on ketoconazole, taking an acidic beverage (such as non-diet soda) can improve absorption by providing an acidic environment. Refer to the section(s) beginning on pg. 399

What is a 79-year-old wornan receiving intravenous acyclovir most at risk for? A) Hypertension B) Pancreatitis C) Cardiac toxicity D) Hepatotoxicity E) Kidney damage

E) Kidney damage Intravenous acyclovir can cause crystal nephropathy which can increase serum creatinine and BUN. Refer to the section(s) beginning on pg. 406

Which of the following is the most appropriate treatment for postherpetic neuralgia? A) Keppra B) Acetaminophen C) Shingrix D) Zoloft E) Lidoderm patch

E) Lidoderm patch Postherpetic neuralgia is a chronic pain that is present after a shingles outbreak. Lidocaine patches are a great treatment option for neuropathic pain from shingles. Antidepressants that are used for pain control (e.g. duloxetine, amitriptyline) can be used. Anticonvulsants like gabapentin or pregabalin can be used for postherpetic neuralgia, not levetiracetam. Refer to the section (s) beginning on pg. 408

Antiviral agents active against cytomegalovirus (CMV) include which of the following: A) Atazanavir, valganciclovir, foscarnet B) Acyclovir, valacyclovir, ganciclovir C) Valganciclovir, valacyclovir, acyclovir D) Foscarnet, acyclovir, cidofovir E) Valganciclovir, foscarnet, cidofovir

E) Valganciclovir, foscarnet, cidofovir Ganciclovir, valganciclovir, foscarnet and cidofovir are indicated for CMV. Others listed are indicated for HSV (acyclovir, valacyclovir) or HIV (atazanavir) Refer to the section(s) beginning on pg. 409