Professional Documents
Culture Documents
Keri McLean !
Intercalating in MRes in Clinical Science (Eye and Vision)!
1
Aim
‘Ten
ways
to
kill
a
pa0ent’
-‐
summary
of
Dr
Fitzgerald’s
lecture.
Possible
exam
ques0on.
Narrow
therapeu0c
index
drugs
Inducers
and
inhibitors
of
cytochrome
P450
An&-‐arrhythmics
Vaughan-‐Williams
classifica0on
of
An0-‐arrhythmic
drugs
An&bio&cs
• Gram
+/-‐
bacteria
and
common
organisms
of
infec0on
• Mechanism
of
ac0on,
side
effects
• Rough
guide
to
an0bio0cs
2!
Ten
ways
to
kill
a
pa&ent…CAUTION!
Methotrexate
and
trimethoprim
(both
block
dihydrofolate
reductase
causing
severe
bone
marrow
depression)
Allopurinol
and
azathioprine
(Increases
6
mercaptopurine
leading
to
severe
bone
marrow
depression)
4!
Narrow
Therapeu&c
Index
These
drugs
need
to
be
monitored
Digoxin
Amiodarone
Lithium
Methotrexate
Warfarin
Carbamazepine
Theophylline
P
henytoin
C
arbamazapine
Can cause
failure of COCP
B
arbiturates
R
ifampicin
A
lcohol
(chronic)
S
ulhonylureas
6!
Cytochrome
P450
Inhibitors
Reduces
drug
metabolism/breakdown
=
increased
effect
of
other
drugs
metabolised
by
CYP450.
Immediate
effect!
S
odium
valporate
I
soniazide
C
iprofloxacin
K
etoconazole
E.g. Macrolide antibiotics
(inhibitor) and warfarin (reduced
F
luconazole
metabolism)
A
lcohol
(Acute)
C
ime&dine
E
rythomycin
S
ulphoamides
.
C
hloramphenicol
O
meprazole
M
ethronidazole
(Grapefruit
juice)
7!
An&-‐arrhythmic
drugs
Vaughan-‐Williams
classifica&on:
9!
Beta-‐blockers:
Block
beta-‐adrenoreceptors
=>
reduce
exer0onally-‐induced
rise
in
HR
and
reduce
cardiac
contrac0lity.
Reduces
systolic
BP
and
myocardial
demand
for
O2.
Blocking
Beta1
receptors
=
-‐ve
inotropic
and
-‐ve
chronotropic
Blocking
Beta2
receptors
=
peripheral
vasoconstric0on
and
bronchospasm.
Propranolol
is
non-‐selec0ve
and
bisoprolol
is
rela0vely
B1
selec0ve
Indica&ons:
angina,
arrhythmia,
heart
failure
(bisoprolol
and
carvedilol
S/E:
Bradycardia
(verapamil
and
dil0azem),
reflex
tachycardia
11!
Digoxin:
Blocks
Na+/K+
pump.
Used
to
slow
pulse
in
fast
AF.
Weak
+ve
inotrope
S/E:
• GI
disturbance
• Dizziness
• Arrhythmias
• Rash
Toxicity:
• Blurred
or
yellow
vision
(xanthopsia)
• Abdominal
pain
• Arrhythmias
Contraindica&ons:
• Complete
heart
block
and
second
degree
heart
block
• VT
/
VF
Interac&ons:
• Risk
of
hypokalaemia
with
diure0c
=>
arrhythmias
• Risk
of
AV
block
and
symptoma0c
bradycardia
with
beta-‐blockers
12!
Superventricular
tachycardia
(SVT)
ECG features:
P waves absent or inverted after the QRS!
Narrow complex (QRS <120ms) tachycardia (>100bpm)!
13!
Superventricular
tachycardia
(SVT)
Treatment:
!
ECG
features:
Ventricular
rate
approx
150bpm
(due
to
2:1
block,
atrial
rate
~300bpm)
‘Saw-‐tooth’
baseline
Treatment:!
!1) Carotid massage!
2) IV adenosine to block AV node and reveal flutter waves !
3) DC Cardioversion or amiodarone!
! 17!
Ventricular
Tachycardia
ECG
features:
Tachycardia
with
broad
QRS
complexes
Treatment:
Correct
hypokalaemia
and
hypomagnesia
IV
amiodarone
DC
Shock
Maintenance
oral
amiodarone
! 18!
Ventricular
fibrilla&on
Defibrillator
19!
Bacteria
Blue/Purple Red/pink
20!
Bacteria
Gram +ve cocci Gram -ve cocci
Staphylococci! Neisseria meningitidis!
Streptococci! Neiserria gonorrhoea!
Enterococci! Moraxella catahalis!
Acinetobacter!
Gra!
Gram -ve rods
Bacteroides!
E.coli!
Gram +ve rods Klebsiella!
Enterobacter!
Clostridia (Anerobe)! Proteus!
Salmonella!
Listeria! Shigella!
Pseudomonas!
Bacillus! Haemophilis!
Helicobacter, Campylobacter!
! Legionella!
21!
22!
Sulphonamides, trimethoprim, quinolone
and nitroimidazoles: Inhibit nucleic acid
synthesis
23!
Trimethoprim
Binds to bacterial dihydrofolate reductase and
irreversibly inhibits production of dihydrofolate, which is a
precursor for the synthesis of thymidine = inhibits
bacterial DNA synthesis!
!
Indication: UTI
24!
Quinolones: ciprofloxacin, levofloxacin!
Inhibits type I (DNA gyrase) and type IV topoisomerases
required for bacterial DNA replication, transcription, repair
and recombination!
!
Indication: UTI, GI infections, bronchopulmonary
infections, typhoid, gonorrhoea and anthrax
Cipro- is active against E. coli, Pseudomonas aeruginosa,
salmonella and campylobacter
26!
Penicillins, cephalosporins and
!
vancomycin: inhibit cell wall synthesis
27!
Penicillins: benzylpenicillin, flucloxacillin,
ampicillin, amoxicillin, Co-amoxiclav !
!
Beta-lactem binds to and inhibits the transpeptide required to
form peptidoglycan cross-links within the bacterial cell wall =
defective cell wall synthesis => cytolysis!
!
Indication: Tonsillitis (Pen V), Pneumonia (amoxicillin), cellulitis
(flucloxacillin), meningitis (BenPen), endocarditis, Rheumatic
Fever (Pen V), Osteomyelitis!
Amoxicillin is broad spectrum
S/E: Urticarial rash, anaphylaxis, GI disturbance, Antibiotic-
associated colitis, Steven-Johnston syndrome
Contraindicated : Hypersensitivity
Beta-lactamases produced by bacteria breakdown Beta-lactem
ring and give resistance.
28!
Cephalosporins: 1st gen: cefalexin; 2nd gen:
cefuroxime; 3rd gen: cefotaxime, ceftriaxone!
Carbapenems: meropenem, piperacillin!
Contraindicated : Hypersensitivity
29!
Glycopeptide antibiotics: Vancomycin
and teicoplanin!
Inhibit bacterial cell wall synthesis by streakily and irreversibly
blocking the elongation of peptidoglycan chains = bactericidal !
!
Contraindicated : Hypersensitivity
31!
Aminoglycosides: Gentamicin,
neomycin, streptomycin
!
!
Block protein synthesis by binding to bacterial 30s ribosome
subunit. Prevents tRNA attachment and mRNA translation is
disrupted!
!
Indication: Septicaemia, biliary tract infection, acute
pyelonephritis and prostatitis, endocarditis, adjunct in Listeria
meningitis
32!
Macrolides: Erytheromycin,
azithromycin and
!
clarithromycin!
Inhibit bacterial RNA-dependent protein synthesis by reversibly
binding to 50S subunit of ribosomes within the organism = affects
growth either bacteriostat or bactericidal !
!
Indication: RTI, campylobacter enteritis, Pertussis, skin and soft
tissue, otitis media, Helicobacter pylori
P450 inhibitor
33!
Tetracyclines: Doxycyclin,
tetracycline, ! oxytetracyclin!
Active uptake resulting in inhibition of protein synthesis. Binds to
30s ribosomal subunit and inhibits aminoacyl tRNA and mRNA
ribosomal complex formation!
!
P450 inhibitor
34!
Chlorampheicol
Inhibit transpeptidation.!
!
35!
Nitrofurantoin
Metabolites damage a number of macromolecules within
bacterial cells including ribosomal proteins and DNA =
bactericidal !
!
36!
‘4 Cs’ for antibiotic causes of Clostridium difficile
Cephalosporin
Clindamycin
Co-amoxiclav
Ciprofloxacin
37!
Tuberculosis treatment: RIPE
38!
EBV and amoxicillin reaction: Don’t prescribe
for tonsillitis
39!
Rough guide to antibiotics
Upper RTI Common organisms Antibiotic
Streptococcus pneumonia
Community acquired pneumonia! Haemophilus influenzae! Amoxicillin 5 days!
Mycoplasma pneumoniae!
Meningococcal disease: !
!
In the community give IM benzylpenicillin!
!
Then 3rd generation cephalosporin i.e. IV Ceftriaxone!
!
If patient under 3months old cover for Listeria with
addition of Ampicillin !
43!