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1.10.1 Antimicrobials Lapoint.Pptx 8/20/14 Antimicrobials! Jeff Lapoint, DO! ! Michelle Burns & Michael Policastro! Antimicrobials! • Antibiotics! • Antifungals! • Anti-mycobacterials! • Antihelminthics! • Antimalarials! • Sterilants! • Antivirals! ! Antibiotics! • Beta lactams! • Vancomycin! • PCN and • Tetracyclines! cephalosporins! • Chloramphenicol! • Sulfonamides! • Dapsone! • Aminoglycosides! • Quinolones! • Ketolides/Macrolides! • Misc! 1 8/20/14 Beta-lactams! PCN Toxicity! • Jarish-Herxheimer: IM/IV Pen G! • Hoigne Syndrome: IM/IV Pen G! • Hepatitis: Amoxicillin-clavulanic acid! Cephalosporin Toxicity! • MTT side chain (N-methylthiotetrazole)! • Cefazolin " "Cefamandole! • Cefotetan " "Cefoperazone! • Cefmetazole "Moxalactam! 2 8/20/14 MTT side chain! Cephalosporin Toxicity! • Ceftriaxone: ! • Pseudolithiasis: Gall-bladder sludging! • Kernicterus 2º bilirubin displacement! • Cefaclor (ceclor): Serum sickness ! • Type III Hypersensitivity (immune complexes)! 3 8/20/14 Sulfonamides! • Hypersensitivity: Most common adverse effect! • Methemoglobinemia/Hemolysis: Rare! • Bone Marrow Suppression: Rare! Aminoglycosides! • Gentamicin, Tobramicin, Amikacin! • Neuromuscular blockade! • Chronic: ! • Ototoxicity and nephrotoxicity ! Ketolides/Macrolides! • Telithromycin: Hepatotoxicity; exacerbation of Myasthenia Gravis! • Erythromycin, Clarithromycin, Azithromycin! • QTc: Torsades de Pointes! • Drug-drug interactions! • Erythromycin: GI side effects (pro-motility)! 4 8/20/14 Vancomycin! • Ototoxicity:! • May be permanent! • Excessively high levels (60-100 mcg/mL)! • Nephrotoxicity: ! • Caution when used in combination with aminoglycosides! Tetracyclines! • Tetracyline! • Doxycycline! • Minocycline ! • Demeclocycline! • Tigecycline! Chloramphenicol! • Grey Baby Syndrome:! • Bone Marrow Toxicity: ! • Supression: anemia, leukopenia, ↓ plt! • Idiosyncratic: aplastic anemia, often fatal! 5 8/20/14 Dapsone! • Toxicity: Primary from P-450 metabolites! • RBC oxidant stress! • Methemoglobinemia "! • Sulfhemoglobinemia "! Quinolones! • Orthopedic ! • ↑ QTc! • Drug-drug! • Hepatoxicity ! • Neurotoxicity! Miscellaneous Abx! • Linezolid! • Metronidazole! • Nitrofurantoin! 6 8/20/14 Pentamidine! • Toxicity:! • Hypotension! • Hypoglycemia! • IDDM! • ↑ QTc: Torsades de Pointes! • Pancreatitis! Antituberculosis Meds! • Isoniazid (INH)! Acid! • Rifampin! • Capreomycin! • Ethambutol! • Pyrazinamide! • Cycloserine! • Para-Aminosalicylic INH! • Structurally related to nicotinic acid (niacin or Vit B3 shown on right side)! • Pyridine ring essential for antituberculous activity! • Rapidly absorbed with peak [plasma] within 2 hrs! 7 8/20/14 Glutamate! PLP! Pyridoxine! Pyridoxine! GAD! Kinase! GABA! INH Toxicity! • Acute: Triad of seizures, coma, lactic acidosis! • Chronic: Hepatitis (hepatocellular necrosis)! INH Toxicity! • Chronic: ! • Peripheral neuropathy: stocking glove distribution, progress proximally ! • Primarily sensory, although may see myalgias/ weakness! • Optic neuritis (red-green discrimination intact) ! • Increased incidence in malnourished, alcoholics, slow acetylators! 8 8/20/14 INH Toxicity cont’d! • Drug-drug: ! • inhibits 3A4 (cbz), 1A2 (theophylline), 2C9 (phenytoin/ warfarin) ! • Induce 2E1 (APAP)! • Food-drug: ! • weak MAOI activity → tyramine reaction! • serotonin syndrome reported in pts taking meperidine + INH! INH Seizure Treatment! • Pyridoxine B6: Give with GABA agonists! • Rapidly terminates seizures, reverses coma, corrects metabolic acidosis! • Give gram per gram ingested if known! • Empiric dosing is 5 grams (70 mg/kg pedi)! Rifampin! • Semisynthetic antibiotic derived from Steptomyces mediterranei! • Inhibits initial steps in RNA chain polymerization! • Greatest teratogenic effect of all TB meds! • Malformation rate 4.4%! • Anencephaly, hydrocephalus, congenital limb #! 9 8/20/14 Rifampin ! • N/V, diarrhea (only TB med to do so)! • Flushing, angioedema, periorbital/facial edema! • Reddish discoloration of body fluids! Rifampin! • CSF also affected, leading to confusion of xanthochromia! • Skin discoloration may be washed off ! • Hepatitis! • Drug-drug: Induces 3A4! Ethambutol! • 1st line in pregnancy! • Chelates metal! • Zn chelation = optic neuritis! • Shift wavelength discrimination! • Loss red/green discrimination! 10 8/20/14 Ethambutol Toxicity! • Acute: N/V, abdominal pain! • Could see optic neuropathy acute > 10 grams! Ethambutol Toxicity! • Chronic:! • Optic neuritis: unilateral or bilateral! • Loss of red-green discrimination: distinguish from INH optic neuropathy! • Contraindicated in children too young to comply with formal ophtho exam! • Peripheral neuropathy, asymptomatic ↑ uric acid! Cycloserine! • Neuro dysfunction is very common! • Sz, psychosis , contraindicated in epilepsy ! • CHF! 11 8/20/14 Capreomycin! • Hearing loss, tinnitus! • Proteinuria, electrolyte loss! • Sterile abscess at injection sites! Pyrazinamide! • Structural analog of nicotinamide! • Prodrug! • Toxicity! • Hepatitis! • Hyperuricemia! Antimalarials! • Quechuas 1st antimalaria: bark of cinchona tree! • Europe 350 years ago-quinine! 12 8/20/14 Antimalarials! • Types:! • Proguanil/ Pyimethamine/ • Quinine! Suldoxine! • Chloroquine/ • Atovaquone! hydroxychloroquine! • Artemisinin: very • Primaquine! safe, sz! • Mefloquine! Quinine! • Optical isomer quinidine! • Once widely used for malaria! • Occasionally used for chloroquine-resistant cases! • Nocturnal muscle cramps! • Sources: Tonic water, street heroin! • Abortifacient: Oxytocic activity, Preterm labor! Quinine Toxicity! • Cardiac: Na & K channel inhibition! • Metabolic: Pancreatic ATP-sensitive K+ channel blocked! • Otic: 8th nerve dysfunction → tinnitus & deafness! • Retinal toxicity! 13 8/20/14 Chloroquine/ Hydroxychloroquine! • Uses:! • Chloroquine: antimalarial! • Hydroxychloroquine: anti-inflammatory! • Toxicity: Hypotension more prominent! • Treatment: Early, aggressive management Fatality ↓ 91% to 9%! Antimalarials! • Primaquine: RBC oxidant stress! • Methemoglobinema! • Hemolysis (G6PD)! • Mefloquine: Neuropsych changes 1:200 pts! • Insomnia with odd dreams! • “Clouded consciousness”! Antimalarials:Folate Inhibitors! • Atovaquone: Rash, erythema multiformae! • Proguanil: GI, megaloblastic anemia, rash! • Pyrimethamine: N/V, SZ, megaloblastic anemia! • Dapsone! 14 8/20/14 Antivirals! NRTI’s! • Mainly undergo renal excretion EXCEPT! • Zidovudine (AZT) undergoes glucuronidation! • Abacavir metabolized by alcohol dehydrogenase! • Do not have P-450 drug interactions! NRTI’s! • Class adverse effects! • Lactic acidosis with hepatic steatosis! • body fat redistribution (lipodystrophy)! 15 8/20/14 Lipodystrophy! Dorsocervical fat pad Central Obesity! Aka “Buffalo Hump”! NRTI Adverse Effects! Zidovudine" Abacavir" Lamivudine" Emtricitabine" Hypersensitivity Bone marrow reaction: fever, suppression rash, fatigue, Generally well- (anemia/ malaise, nausea, tolerated, Hyperpigmentation neutropenia)" vomiting, headache, dry of palms and soles" Nausea" diarrhea, loss of mouth" Nail discoloration" appetite, Myopathy" pharyngitis" NRTI Adverse Effects! Stavudine! Didanosine! Tenofovir! Peripheral Pancreatitis! GI upset! neuropathy! Peripheral Flatulence! Pancreatitis! neuropathy! Nephrotoxicity! Dyslipidemia ! Diarrhea! 16 8/20/14 NRTI Lactic Acidosis! •! Treatment ?! •! L-carnitine (50 mg/kg/d 3 times a day over 2 hrs)! •! Riboflavin 50 mg/day! NNRTI’s - General! •! Hepatic metabolism-no renal dosage adjustments required! •! Many P-450 drug interactions! •! Class adverse effects:! •! increased transaminase levels! •! rash (nevirapine > delavirdine > efavirenz)! Non-nucleoside Reverse Transcriptase Inhibitors! Nevira Efavirenz! Etravirine! Rilpivirine! pine! Abnormal dreams, Insomnia! drowsiness, Depression! dizziness, Elevation Liver Elevations in confusion! s in liver failure! liver function Mood changes! function Rash tests! Elevations in tests! (7%)! Elevations in liver function serum tests! creatinine! Hyperlipidemia! •!Abnormal dreams, drowsiness, dizziness, confusion" Efavirenz! •!Mood changes" •!Elevations in liver function tests" •!Hyperlipidemia" Etravirine! •!Elevations in liver function tests" •!Liver failure" 17 Nevirapine! •!Rash (7%)" •!Insomnia" •!Depression" Rilpivirine! •!Elevations in liver function tests" •!Elevations in serum creatinine" 8/20/14 Protease Inhibitors! •! Hepatic metabolism - no renal dosage adjustments! •! Many drug interactions! PI - Class Adverse Effect! •! Hyperglycemia! •! Lipodystrophy! •! Hyperlipidemia (less with atazanavir)! •! Increased transaminases! PI Adverse Effects! Amprenavir/fos-amprenavir" GI intolerance, rash, oral paresthesias" Atazanavir" Hyperbilirubinemia" Indinavir" Nephrolithiasis, hyperbilirubinemia" Lopinavir/ritonavir" Nausea, diarrhea, pancreatitis" Nelfinavir" Diarrhea" GI intolerance, paresthesias, asthenia, Ritonavir" taste perversion, hepatitis" Saquinavir" GI intolerance" GI intolerance, hepatitis, rash, Tipranavir" intracranial hemorrhage" Darunavir" GI intolerance, rash" 18 8/20/14 Fusion Inhibitors! •! Enfuvirtide! •! Injection site reactions; erythema, cysts, and nodules at injection sites! •! Neutropenia! •! Possible increased frequency of pneumonia! Chemokine Co-receptor Antagonists! •! Maraviroc! •! Hepatoxicity: may be preceded by a systemic reaction (pruritic rash, eosinophilia)! •! Dizziness/postural hypotension! •! Increased risk of CV events (ischemia, MI)! •! Diarrhea, nausea! Integrase Inhibitors! •! Raltegravir! •! Nausea, diarrhea, flatulence! •! Elevations in amylase and liver function tests! •! Headache! •! Dizziness, abnormal dreams! •! Pruritus,
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