Antimicrobial Agents😍

Classification Based On Activity

• CIDAL:
• These kill the microoganisms.
• These must be used to treat infections in immunocompromised person.
• Examples: BE VA F A
• Time dependent killing
• BEta lactams
• VAncomycin
• Concentration dependent killing
• Fluroquinolones
• Aminoglycosides
• Mnemonic: Amina (Aminogly) Beta (Betalactam) ne Fluvannapo (Fluro) Vanil (vanco) kondu poi konnu
• Others
• Metronidazole

• STATIC:
• These inhibit the growth of microorganisms.
• These cannot be relied upon if there is immunosuppression.

Classification Based on Mechanism of Action

• Chloramphenicol S/E
• Dose related:
• Hypoplastic Anemia
• Thrombocytopenia
• Leukopenia
• Idiosyncratic
• Aplastic anemia

CELL WALL SYNTHESIS INHIBITORS

A. BETA LACTAMS

1. Penicillins

2. Cephalosporins

3. Carbapenems

4. *Monobactams

• Mnemonic: Beta → Monu () → Pencil (), car (), safe ()

1. Penicillins

S/E

• Hypersensitivity

• AIN

• AIHA -Warm type

Penicillin G (Benzyl Penicillin)

• Limitations:
• Not effective orally [Acid labile]
• Short acting [Due to rapid tubular secretion]
• Narrow spectrum
• Resistance
• Allergy

1. Acid Resistant / Oral Penicillins

• Mnemonic: VODKA

• V → Penicillin V (Phenoxymethyl Penicillin)

• O → Oxacillin

• D → Dicloxacillin

• K → Cloxacillin

• A → Ampicillin, Amoxycillin

• Mnemonic: Oxa → Cloxa → Dicloxa → Ampi → Amox

NOTE:

• Amoxicillin → maculopapular rash

2. Prolong duration of action

• a. Probenecid competes with Penicillin for transporters in PT
• ↑↑ Duration of action of Penicillin.

• b. Depot Preparations
• IM route only
• Benzathine Penicillin G
• Longest acting Penicillin
• Procaine Penicillin G
• Mnemonic: Protect (Procaine) pencil → carry in benz (benzathine)

3. Spectrum of Penicillins

• Mainly against gram positive bacteria.

• Not effective against most gram negative bacilli.

• Against Extended (Wide) Spectrum beta-lactamases
• Wide city → I Am (Ampi, Amox) going Slow (Zlo) in Car (Car) with Piper
• A → Ampicillin, Amoxycillin
• Ci → Carbenicillin
• Ty → Ticarcillin
• M → Mezlocillin
• A → Azlocillin
• P → Piperacillin
• All of these are effective against Pseudomonas except ampicillin and amoxycillin.
• Mnemonic: Repeat with me → Car ticar azlo mezlo Pipe Ampi

4. Solving problem of resistance

Antibiotic Resistance

Types

• Enzyme mediated
• Aminoglycosides
• β-lactamase
• Chloramphenicol
• Amina () Betakk () Enzyme vach Choru () koduth

• Altered target
• MRSA
• PBP → PBP2a
• VRSA
• D-ala → D-lac
• Macrolides
• Linezolid

• Efflux pump
• Tetracyclines

β-lactamase

• BLA gene transmitted/coded via plasmids

• Enzyme by bacteria

• Bind to penicillin-binding proteins (PBPs) or transpeptidases on S. aureus

• break the structure of penicillin at β-lactam ring.
• ⇒ breakage.

• Transfer: Transduction > Conjugation

• Ex: H. influenza Resistance to Ampicillin
• d/t production of beta lactamase

β Lactamase Inhibitors

• Clavulanic acid, sulbactam and tazobactam
• ⛔ β-lactamase

• Combinations are:
• Clavulanic Acid + Amoxycillin
• Sulbactam + Ampicillin
• Tazobactam + Piperacillin

Penicillinase

• Specific β-lactamase

• Produced by Staphylococcus aureus

• Acts mainly on penicillin's

Penicillinase Resistant Penicillins

• Mnemonic: Put CONDOM over pencil to protect it
• C → Cloxacillin
• O → Oxacillin
• N → Nafcillin
• D → Dicloxacillin
• O M → Methicillin [Most resistant]

• Mnemonic: Oxa Cloxa Dicloxa + M and N

Methicillin resistance

• Resistance is due to altered Penicillin Binding Proteins.
• mecA gene
• PBP → PBP2a
• which has a lesser affinity for antibiotic binding.

• Diagnosis of methicillin resistance
• Cefoxitin disc diffusion agar/Oxacillin.
• Latex agglutination for PBP2a.
• ELISA / PCR for MecA.

• MRSA treatment
• DOC for MRSA : Vancomycin.
• All β-lactams are ineffective
• except 5th gen cephalosporins.
• 5th Gen:
• Ceftibiprole
• Ceftaroline
• (With “rol”)
• Against MRSA, VRSA
• Daptomycin

---

• Say Mercy Mercy (MRSA)
• Valentines (Panton Valentine toxin A/w MRSA) dayil → game (γ hemolysin) played
• with Hymen (Synergohymentrophic toxin) doing PV (PV toxin)

---

Vancomycin resistance

• Vancomycin-resistant enterococcus (VRE).

• VanA gene.

• Mechanism:
• Peptidoglycan precursor changes from
• D-ala-D-ala → D-ala-D-lactate / D-ala-D-serine.

Vancomycin resistance	MIC	ㅤ
VRSA (Vancomycin-resistance S. aureus.)	>16 µg/ml vancomycin.	ㅤ
VISA (Vancomycin-intermediate S. aureus.)	>4-8 µg/ml vancomycin.	Lesser resistance.

• VRSA Drugs
• DOC for VRSA : Daptomycin.
• Lung surfactant → break down Daptomycin
• DOC for VRSA pneumonia : Linezolid.
• Linezolid has good lung penetration
• Streptogramins
• Quinpristin + Dalfopristin

5. Allergy

• Skin testing done by intradermal injection of drug.

• Cross Allergy
• If allergic to one penicillin, all β lactams can cause allergy
• except monobactam.

Indications of Penicillins

• Penicillins are First Line Drugs in
• L → Listeria (DOC is ampicillin)
• A → Actinomycosis
• S → Syphilis
• Benzathine Penicillin → Penicillin G → IM → 2.4 MU
• Primary, secondary, early latent → 1 dose
• Late Latent, tertiary → 3 doses
• T → Tetanus
• M → Meningococcus?
• AN → Anthrax ?
• BTR-Fluroquinolones
• Mastitis - Cloxacillin

2. Cephalosporins

• Order
• Remember order 1, 4, 5 →
• 1 → A (cefA) → 1st gen → except cefaclor (2nd gen)
• 4 → PQ → Pi, qui → 4th gen
• 5 → R → Rol → → 5th gen
• 3rd → ending with me, one, ten → except cefuroxime (2nd gen)

• Cefuroxime is 2nd generation

• Cefazolin is DOC for surgical prophylaxis.

• 5th generation are effective against MRSA.

A. Cephalosporins secreted in bile

• Safe in renal failure.

• Include:
• Cefoperazone
• Ceftriaxone

• Antimicrobial Agents That are Secreted in Bile
• Mnemonic: “One”, Lion (Lincosamide), Tiger (Tige), Dog (Doxy), giRaffe (Rifampicin)
• Safe in — “one” Cefoperazone
• Ceftriaxone
• The --- Tigecycline
• R --- Rifampicin
• E --- Erythromycin
• N --- Nafcillin
• A --- Ampicillin
• L --- Lincosamides [Clindamycin]
• Disease --- Doxycycline

B. Anti-Pseudomonal Cephalosporins

• Include:
• Cefepime
• Cefpirome
• Cefoperazone
• Ceftazidime

• Mnemonic: Pseudomanas → Pime/Dime, Perome, Perazone

• Ceftazidime [Most effective anti-Pseudomonal cephalosporin].

D. Hypoprothrombinemia ( Prothrombin)

• Methylthiotetrazole (MTT) or N-methylthiotetrazole (NMTT) group found in some cephalosporin antibiotics
• Include:
• Cefoperazone
• Moxalactam (latamoxef)

• MOA:
• ⛔ vitamin K epoxide reductase

• C/F:
• Clinically significant bleeding when starting on Cephalosporin in patient on anticoagulant therapy or having Vit K deficiency

• Avoided in hemophilia patients.

• Reversible with vitamin K1 (phytonadione).

• Mnemonic: Molakkum (Moxalactam) Perinum (Perazone) vendiyulla Kallum (Alcohol) yudhavum (War farin)

E. In Pregnancy

• Cephalosporins > Amoxicillin

3. Carbapenems

Imipenem

• Spectrum:
• Effective against:
• Gram-positive
• Gram-negative
• Anaerobes
• Pseudomonas

• Always given with: Cilastatin
• Reason: Cilastatin inhibits dehydropeptidase enzyme in kidney
• Prevents Imipenem degradation

• Side Effect:
• Seizures
• Contraindicated in:
• Epileptic patients

• DOC
• Enterobacter
• Acinetobacter

• Ipen (Imipenem) lasts with Seal (Cilastin)

• NOTE:
• 2 antibiotics C/I in seizure
• Imipenem
• FQs
• I'm (Imipenem) epileptic Queen (FQ)

Other Carbapenems:

• Meropenem

• Ertapenem

• Doripenem

• Faropenem
• Cilastatin not required.
• Lesser risk of seizures.

4. Monobactam

• Only drug in the group is Aztreonam.
• Do not show cross allergy.
• Effective only against Gm -ve bacteria including Pseudomonas.
• Mnemonic: Ask Tera Naam (Aztreonam) → Because he is different from rest of the group

B. VANCOMYCIN

• It is not effective orally [Not Absorbed].

• Nomogram scale
• Matzke scale

• Adverse Effects:
• When given by IV route → releases Histamine - Red man syndrome.
• Nephrotoxic.
• Ototoxic.
• Infusion reaction
• Mnemonic: Red (red man syndrome) Van () → NO (nephrp, oto) to passenger → Maattan parayum (Matzke)

• Indications
• DOC for MRSA infections.
• Can be used for Pseudomembranous Colitis (Now DOC is fidaxomicin).
• Not effective against Pseudomonas.

Pseudomembranous colitis

 

• It is a type of superinfection.m

• MC bacteria involved: Clostridium difficile.

• Cause:
• Long-term use of antibiotics.
• Alters gut flora.

• Clinical features: Watery diarrhoea.

• Diagnosis:
• Toxigenic culture: Culture media: 100% sensitivity
• Cefoxitin cycloserine fructose agar (CCFA).
• Cefoxitin cysteine yeast extract agar (CCYA).
• Detection of toxins via ELISA and PCR.

• MC antimicrobials implicated are:
• 3rd Gen. Cephalosporins > Clindamycin > Ampi or Amoxycillin > FQ.

• Accordion sign — Thick edematous bowel.

• Treatment:



• DOC :
• Oral Fidaxomicin (Low chances of relapse).
• Alternative :
• Oral vancomycin
• Oral Metronidazole.
• Monoclonal Ab against toxin :
• Bezlotoxumab.

PROTEIN SYNTHESIS INHIBITORS

• Drugs inhibit protein synthesis by binding to 30S or 50S.

• It is rememberred as buy AT - 30, SELL @ 50
• Aminoglycosides and Tetracyclines bind at 30S ribosomes.
• Rest all
• bind at 50S ribosomes.
• streptogramins,
• Erythromycin group,
• Linezolid
• Lincosamides

Aminoglycosides

• Drugs
• Streptomycin
• Gentamicin
• Amikacin

• General Properties
• Not effective orally [Not absorbed].
• Active mainly on Gm -ve [Including Pseudomonas].
• Not effective on anaerobic bacteria.
• Cidal drugs (Only protein synthesis inhibitors which are cidal).
• These are nephrotoxic, ototoxic and can cause neuromuscular blockade.
• Not given in pregnancy
• DOC
• plague
• Tularemia

Tetracyclines

• Drugs
• Demeclocycline
• Doxycycline
• Minocycline

• Adverse Effects
• K – Kidney Failure – All are C/I except Doxycycline
• A - Anti-anabolic
• P – Phototoxic
• I – Insipidus diabetes (Inhibit ADH release)
• L – Liver Failure C/I
• D – Dentition and Bone problems
• (C/I in pregnancy and children < 8 years)
• E – Not to be given after Expiry [Risk of Fanconi Syndrome]
• V – Vestibular dysfunction

• Uses
• Tetracycline → Rub (scrub) cheythitt erinjapo → 4 adich → Cricket (Rickettsia) → Koladich (cholera)
• Kapil Dev → SriLnka kk
• S – SIADH [Demeclocycline]
• R – Rickettsia [DOC], Scrub typhus (DOC: Doxy)
• I – Granuloma lnguinale
• L – LGV
• N – Atypical pNeumonia
• [DOC – Macrolides]
• K – Cholera [DOC]
• A– Luminal Amoebiasis
• [DOC For amoebiasis → Metronidazole]

• Resistance: Due to development of efflux pumps.

Macrolides

• Drugs
• Erythromycin
• Clarithromycin
• Roxithromycin
• Azithromycin

• Motilin agonist - prokinetic

• Cause Jaundice

• CYP inhibitors

• QT prolongation
• last 2 are also seen with
• Ketoconazole
• Fluroquinolones

• Indications
• DOC for
• C: Chancroid, Corynebacterium
• L: Legionella
• A: Atypical Pneumonia
• P: Pertussis

• Mnemonic: Macro → Hulk → Clap (CLAP) and throw (thromycin)

• Avoided in pregnancy

• Risk of CHPS

Nail pigmentation causing drugs

• Phenothiazines
• Chlorpromazine
• Used for DM and DI
• S/E: SIADH, Disulfiram like reaction

• Chloroquine

• Minocycline

• Queen meena for magazine → put nail lacquer

Minocycline:

• Given for acne

• Leads to blue-black pigmentation on acne scars

• Black thyroid

• Due to deposition of iron chelates with minocycline

• Also leads to lupus-like reaction

• Mnemonic: Meena de mugath blue black vann

Linezolid

• Act specifically on 23s subunit

• DOC for VRSA pneumonia.

• Now approved for TB also.

• BMS

• Serotonin syndrome

• It is a static drug, so not reliable in immunocompromised patients.

Tedizolid

• active against gram-positive organisms

• good oral bioavailability

• Use
• MRSA
• VRE (Vancomycin-Resistant Enterococcus)

Lincosamides (Clindamycin)

• Secreted in Bile, so safe in renal failure.

• Causes Pseudo membranous colitis.

• Used in anaerobic bacterial infections.

• DOC for lung abscess and brain abscess.

Antibiotic resistance mechanisms

ANTIMETABOLITES

A. Sulfonamides/Sulfa Drugs

• Drugs: 
• Sulfadoxine,
• Sulfasoxazole,
• Sulfamethoxazole,
• Sulfadiazine,
• Dapsone.

• Adverse Effects
• A – Aplastic anemia
• B - Bilirubin displacement → Cause Kernicterus in newborn
• C - Crystalluria
• R - Rash
• A – Acetylation
• S – SLE
• H – Hemolysis in G6PD deficiency

• Mnemonic: Sulfikar () Pavam (PABA) kuttiye (kernicterus, hemolysis) ABC () padipichapo rash () vannu

• Mechanism:
• Structural analogs of PABA (para-aminobenzoic acid)
• Act as competitive inhibitors of folic acid synthase enzyme

• Limitation:
• Ineffective in presence of pus
• Pus contains PABA
• Competes with drug → reduces efficacy

B. Combinations

• 1. Cotrimoxazole
• Trimethoprim (T) + Sulfamethoxazole (S).
• Ratio for best bactericidal activity → 1: 20 (T:S).
• Ratio in tablet to attain this ratio → 1: 5 (T:S).
• Cotrimoxazole is DOC For
• P → Pneumocystis jiroveci
• N → Nocardia
• B → Burkholderia cepacian
• Cyclospora
• Isospora
• Mnemonic: Co try me → No (Nocardia) bug (Burkholderia) will cause Pneumonia (Pneumocystis)

• 2. Sulfadoxine + Pyrimethamine
• Indicated in Parasitic infections
• Malaria
• Toxoplasmosis
• North east people → Not SP (Swayam pongi)

DNA GYRASE INHIBITORS

• DNA Gyrase
• Introduces negative supercoils and helps in replication.

• DNA gyrase Inhibitors
• inhibit replication → preventing uncoiling.

• The drugs are fluoroquinolones.

Fluoroquinolones

• Drugs: 
• Norfloxacin,
• Ofloxacin,
• Ciprofloxacin,
• Levofloxacin,
• Moxifloxacin.

• General Properties
• Oral cidal drugs.
• Wide spectrum [Effective against Gm +ve as well as Gm -ve].
• C/I in pregnancy and children (<18 yrs) [Cause cartilage and tendon damage].
• Induce seizures [Avoided in Epilepsy].
• C/I in Renal Failure Exception
• P – Pefloxacin
• M – Moxifloxacin
• T – Trovafloxacin
• Not effective in UTI.
• Safe in renal failure.
• Avoided in liver disease.
• Mnemonic:
• Nalu dick for queen → condition, no pregnancy and children (C/I in pregnancy and children)
• Fuck Queen → Cartilage and tendon damage ayi → seizure vann
• maximum (moxifloxacin) Pee (Pefloxacin) Thrownout (trovafloxin)
• Shwasam kittilla → OMGGGGG (Ofloxacin, moxifloxacin, gatifloxacin)

• Respiratory FQ
• Mnemonic: OMG → active against so manyyyy
• O – Ofloxacin
• Levofloxacin
• L Isomer of Ofloxacin
• Long acting
• highest bioavailability
• M – Moxifloxacin
• G – Gatifloxacin
• These are active against respiratory infections caused by
• Gm +ve bacteria
• Gm -ve bacteria
• Atypical bacteria
• Mycobaterium TB

• DOC
• Meningococcal
• Anthrax
• UTI
• Travelers Diarrhea

DRUGS NOT EFFECTIVE AGAINST PARTICULAR BACTERIA

• Ente (Enteric) Aanu (Anaerobic) Aamina (Aminoglycoside) → He restricted her

• She bacame active → when kallanmare (pseudomonas) tthurathi

Note

• Gram negative → Aminoglycosides, Macrolides
• Mnemonic: Amina and macro are negative people

TUBERCULOSIS FIRST LINE DRUGS

• H → Isoniazid

• R → Rifampicin [RCIN]

• Z → Pyrazinamide

• E → Ethambutol

• S → Streptomycin (Not first line now)

• Mycins and Pyrazin

• avoid Z & S in pregnancy

• Kanamycin also avoided like streptomycin

• HRZ

• Ethiyapo → Ethambutal

Isoniazid (INH)

• Activated by: Catalase-peroxidase enzyme (Kat G) of mycobacteria

• Mechanism: Inhibits mycolic acid synthesis

• SHIP Drug → Acetylation phase 2

• Adverse Effects:
• Pyridoxine (Vitamin B6) deficiency
• leads to peripheral neuropathy
• Slow acetylators
• Use pyridoxine for prophylaxis and treatment
• Hepatotoxicity
• Fast acetylators
• SLE
• INH (3 letters) ⇔ SLE

• Mnemonic:
• INH = Isoniazid causes Neuropathy and Hepatotoxicity

Rifampicin

• Mechanism:
• Inhibits RNA polymerase (binds to β-subunit)
• Blocks transcription

• MAXIMUM CIDAL ACTION

• ATT + ART → Replace wth Rifabutin (minimum inducer)
• Rifabutin → S/E: Pseudojaundice, uveitis

• Administration: Give on empty stomach

• Excretion: Secreted in bile → safe in renal failure

• Enzyme inducer → P450 CRAP GP

• Drug Interactions:
• Warfarin → switch to Heparin
• OCPs → switch to alternative contraception

• S/E
• Pulmonary syndrome,
• orange urine

• Other Uses:
• Leprosy
• Effective against:
• Gram-positive bacteria (including MRSA)
• Gram-negative bacteria (including Pseudomonas)

Other First-Line Drugs

• Pyrazinamide:
• Causes gout
• Avoid with Hepatotoxic drugs like Voriconazoles
• Mnemonic: Pyri - Uri - fatty

• Ethambutol:
• Arabinogalactan synthesis inhibitor
• Causes red-green color blindness
• Optic neuritis
• Also causes Gout
• Mnemonic: E - Eye

SECOND LINE DRUGS

A. Cidal Drugs

B. Other static drugs

• 1. Cycloserine
• Causes neuropsychiatric adverse effects

• 2. Ethionamide
• Hepatotoxic, Hypothyroidism

• 3. PAS
• Causes hypothyroidism

• 4. Thioacetazone
• Never given in HIV patients

• Mnemonic: Thii (Thioacetazone) Passcheyth (PAS) Cycle (Cycloserine) il ethi (ethambutal, ethionamide) → static ayi ninnu

C. Drugs used for other conditions, now approved for TB

• 1. Linezolide
• Also used for VRSA

• 2. Clofazimine
• Also used for multibacillary leprosy

TREATMENT OF TUBERCULOSIS (NTEP)

• Drug Sensitive TB: 2 HRZE + 4 HRE.
• H: Isoniazid
• R: Rifampicin
• Z: Pyrazinamide
• E: Ethambutol

---

• "I REST" or "I RESP" (Isoniazid, Rifampicin, Ethambutol, Streptomycin, Pyrazinamide)
• Doses: Table of 5, 10, 15, 15, 25

---

• Drug Resistant TB

Type	Resistance Pattern
Rifampicin resistance	• Resistant to R only; • sensitive to H
MDR	• Resistant to H + R • MD Likes HR girl
Pre-XDR	• Resistant to H + R + FQ • Pre → three → HR Fuck
XDR	• Resistant to H + R + FQ + • One of Bedaquiline or Linezolid • Any group A drugs ↳ (Levofloxacin, moxifloxacin, bedaquiline, linezolid) • H () R () Fuck (FQ) → Lie (Linezolid) Bed (Bedaquiline)
TDR	• Resistance to all 1st & 2nd line drugs

• High-priority TB-HIV district:
• Co prevalence > 10%

• For TB with HIV
• First start treatment of TB (ATT).
• After 2 weeks, start treatment of HIV (ART).
• D/t IRIS → Immune Reconstitution Inflammatory syndrome
• TB flare up
• Use Rifabutin instead of Rifampicin
• If TB meningitis
• After 4 weeks
• If Disseminated TB
• After 2 months

• Both → Butin

• Prophylaxis → Pentin

Regimen Class	Intensive Phase (Months)	Intensive Phase (Drugs & Doses)	Continuation Phase (Months)	Continuation Phase (Drugs)	Frequency
DSTB	2	HRZE, 56	4 Total = 6	HRE, 112	Daily
DRTB	ㅤ	ㅤ	ㅤ	ㅤ	ㅤ
H mono/poly DRTB	6	ZERO, 180	Total = 6	-	Daily
Shorter MDR	4-6 (5)	CHOBZEE	5 Total = 5+5 = 10	COZE	-
Longer MDR For XDR TB - total 20 months	18-20 (20)	L2 C2 B	Total = 20	-	-

Shorter MDR CHOBZEE	Shorter MDR COZE	Longer MDR
• C: Clofazimine	• C: Clofazimine	• L: Levofloxacin, Linezolid
• H: Isoniazid (High dose)	• O: Levofloxacin	• C: Cycloserine, Clofazimine
• O: Levofloxacin	• Z: Pyrazinamide	• B: Bedaquiline
• B: Bedaquiline	• E: Ethambutol	ㅤ
• Z: Pyrazinamide	ㅤ	ㅤ
• E: Ethambutol	ㅤ	ㅤ
• E: Ethionamide	ㅤ	ㅤ

Newer regime:

• BPaLM regime x 6 months
• Approved for Longer MDR in Aug 2024
• B: Bedaquiline
• Pa: Pretomanid
• L: Linezolid
• M: Moxifloxacin

New drugs

• 1. Bedaquiline
• ATP synthase inhibitor
• QT prolongation
• Bedil () kidakkan with cutee () → Need ATP ()

• 2. Delamanid
• Group C drug

• 3. Pretomanid
• Free radical → mycolic cell wall injury
• QT prolongation
• Preman Free time () il → mathilu polichu () → with a cutee ()

• Bed () il Premam () → Cute → QT prolongation

MDR has 2 resistance

1. R Resistance

2. H resistance



• D/t
1. kat G gene mutation
2. INH a/b mutation
• Single gene mutation : Shorter/longer MDR.
• Double gene mutation : Longer MDR.

• Bedaquiline resistance
• atpE gene

Special Situations

• TB in pregnancy:
• 2HRE + 7 HR
• Pregnancy → 9 months (2 months HER, 7 months in HR)
• Avoid Streptomycin, Bedaquilin, Petromanid
• NO Preman () in My () Bed () during pregnancy

Prophylaxis/TB Preventive Therapy (TPT)

TPT Regimens

Drugs	Duration	Indication	Frequency	Total doses
H (Isoniazid)	6 months	6H Standard • (In < 13 years)	Daily	180
HP (Isoniazid + Rifapentine)	3 months	3 HP • Preferred in PLHIV <13 • 3 → w → WEAK (CHILDREN) WEEKLY ()	Weekly	12
HP	1 month	1 HP • Preferred in PLHIV >13 • 1 → D → aDult → Daily	Daily	28

• Contact with Drug-Resistant TB (DR-TB):
• 4R 6O

• Both → Butin

• Prophylaxis → Pentin

LEPROSY

Tablet	Dosage >14 yr	Dosage 10-14 yr	Duration
Rifampicin	600 mg monthly	450 mg monthly	Paucibacillary: 6 months (Completed within 9 months)
Dapsone	100 mg daily	50 mg daily	Multibacillary: 12 months (Completed within 18 months)
Clofazimine	300 mg monthly + 50 mg daily	150 mg monthly + 50 mg on alternate days	ㅤ

• Lepra Reactions



• DOC for both type 1 and type 2 Lepra reaction is steroids
• MDT for leprosy should continue.

---

Clofazimine:

• Prescribed in leprosy patients

• Typically leads to ichthyosis

• Also reddish-brown pigmentation

• Forms crystals deposited in skin

• Presence indicates regular medication

• Mnemonic: clofaziMeeen → Icthyosis

---

ANTI-HIV DRUGS

• Cobicitat
• Potentiate gravis

• Ritonavir
• Potentiate Navirs

• Stem live for 120 years

• Fourty1 - Fuviritide - Fusion inhibitor

• Marannu poi to attach - CCR5

• CD4 - Bali

GHRH Analogue

• Tesamorelin
• HIV related atrophy

 

1. Fusion Inhibitors

• Maraviroc
• Coreceptor antagonist
• Binds with CCR-5.
• Given orally.

• Enfuvirtide
• Binds with GP 41 of Virus
• Envelope and Fusion of Virus with T cell is Inhibited.
• Given subcutaneously.
• Fusion Inhibitor

• Mnemonic:
• Virus → Fuse (Enfuvirtide) cheyyan vannu
• but Cell → Marannoi (Maraviroc)

2. Reverse Transcriptase Inhibitors(RTI)

• Inhibit reverse transcriptase (RNA dependent DNA polymerase).

• May be competitive (NRTI) or Non-competitive (NNRTI).

A. Competitive RTI

• NRTI (Nucleotide or side RT inhibitors) → Competitive inhibition

Nucleoside RTI:	Nucleotide RTI:
• Zidovudine • Lamivudine • Stavudine • Didanosine • Zalcitabine • Emtricitabine • Abacavir	Tenofovir
Mnemonic: - Vudine - Citabine - Abacavir	ㅤ

• Adverse Effect

Drug	Side Effect	Mnemonic:
Lamivudine	SAFEST	ㅤ
Zidovudine	Bone Marrow Suppression	ㅤ
Abacavir	Myocardial Infarction (MI)	Abba had MI
Zalcitabine	Aphthous ulcers in mouth	Zaluva ↑↑ → ulcer in mouth
Emtricitabine	Pigmentation of palms and soles	Tried sitting (in fresh painted seat) → got Paint in palm and soles
Didanosine	Highest risk of pancreatitis	Did a sin → alcohol → pancreatitis
Stavudine	Highest risk of peripheral neuropathy	Stoveil vachapo polliyath arinjilla → d/t peripheral neuropathy
Tenofovir	Nephrotoxic	ㅤ
Atazanavir	Min Lipodystrophy	Attack → run → no obesity
Indinavir	Radiolucent Stones and Jaundice	Indinn people → stones and jaundice
Tipranivir	IC Bleed	Tip idichu → IC bleed

Zidovudine:

• Given to HIV positive patients

• Typically leads to pigmentation of nails & skin

• Also Bone marrow suppression

• If hand only → Emtricitabine

• Mnemonic: Zidovudine → Seed in hand → Hyperpigmentation

B. Non-Competitive RTI (NNRTI):

• Efavirenz
• Teratogenicity
• Vivid dreams
• E fav child → bad dream (vivid dream) something will happen to child (teratogen)

• Nevirapine

• Delavirdine

• Mnemonic:
• N N nnu keeekkumbo Nee Virappeen (Nevirapin), Efaa virappeen ()
• Competition ENDS → Deal (Dela) New (Nevi) Failures (Efa)

3. Integrase Inhibitors

• Can be given orally.

• One of the first line drugs for HIV now.

• Drugs include:
• Raltegravir
• Elvitegravir
• Dolutegravir

4. Protease Inhibitors

• Drugs:
• Ritonavir
• Lopinavir
• Amprenavir
• Fosamprenavir
• Atazanavir
• Saquinavir
• Nelfinavir
• lndinavir

• Properties of Protease Inhibitors
• Substrates of CYP3A4.
• Inhibitors of CYP 3A4.
• Strongest is ritonavir
• Boosts the effect of other protease inhibitors
• Cause lipodystrophy syndrome.
• ↑ Glucose
• ↑ Lipids
• Insulin resistance
• Weight gain
• Rx : Tesamorlion

• Note:
• Mnemonic: AIDS ullapo Protein kazhichal LDS varum
• so given only in PEP for short term like me

CLINICAL MANAGEMENT OF HIV

1. Treatment of HIV

First line ART (FLART):

• HAART = Highly Active Anti Retro Viral Therapy

• Indicated for all HIV-positive patients, regardless of CD4 count

• Lifelong therapy

• Minimum 3 drugs from minimum 2 groups

• Viral load > CD4 count for monitoring treatment efficacy

First-line regimen:

• 2 NRTIs + 1 NNRTI / Integrase Inhibitor

Common combinations:

• T + L + D

Age	Weight	Regimen	ㅤ
Age >10 yrs	Weight >30 kg	TLD	ㅤ
Age 6-10 yrs	Weight 20-30 kg	ALD	Aldi
Age <6 yrs	Weight <20 kg	AL + LPV/r	ALL

• T: Tenofovir

• A: Abacavir

• L: Lamivudine

• LPV: Lopinavir

• r: Ritonavir

• D: Dolutegravir

Prophylaxis

Post-exposure prophylaxis (PEP):

• In needle stick injury
• TLD:
• T300, L300, D50 x 28 days as 1 OD tablet
• Started within 2 hrs
• Maximum: <72 hr

Pre-exposure prophylaxis of HIV

• Beneficiaries:
• Spouses of HIV +ve patients
• Habitual sex worker clients

• Regimen:
• Tenofovir + Emtricitabine
• Mnemonic:
• Take a TEa (tenofovir, emtricitabiune)
• Before going to Lena every 6 months

• Lenacapavir
• Novel first in class PrEP
• MOA: HIV capsid inhibitor
• Inhibiting capsid assembly & nuclear import of viral DNA
• 900 mg S/c every 6 months
• t1/2 = 38 days

Prevention of opportunistic infection:

• Pneumocystis jirovecii pneumonia (PJP) infection
• Cotrimoxazole preventive therapy
• Dose:
• Double strength.
• 800 mg Sulfamethoxazole + 160 mg Trimethoprim

Started:

• At CD4 <350/mm3

• Given for minimum 6 months

• Stopped when CD4 >350/mm3
• On 2 occasions 6 months apart

Cotrimoxazole prophylaxis

Age group	Indication
HIV-exposed infants > 4–6 weeks	All infants
Children < 5 years	All children
Children > 5 years	CD4 < 350 and/or WHO stage 3 or 4
Adults and pregnant women	CD4 < 350 and/or WHO stage 3 or 4
HIV + TB coinfection	All patients
Malaria endemic area	Children and adults regardless of CD4 count or stage

Prevention of Mother to Child Transmission

• Mother on ART with Nevirapine:
• Zidovudine (AZT) for 6 weeks to prevent archived resistance

• Baby exposed to HIV +ve mothers:
1. Risk of transmission Low:
• <1000 copies/mL viral load,
• Nevirapine x 6 weeks
2. Risk of transmission High:
• Exclusive breastfeeding:
• Zidovudine + Nevirapine x 12 weeks
• Replacement feed:
• Zidovudine + Nevirapine x 6 weeks in child
1. 1000 copies/mL viral load
2. Mother not on ART
3. Unknown viral load
4. Newly Dx HIV +ve within 6 wks of delivery

• Cotrimoxazole prophylaxis from 6 weeks to 18 months

• Early infant diagnosis is done at 6 weeks by DNA-PCR
• If negative → screen every 6 months → till 2 years

• Confirmatory testing is done at 18 months by DNA-PCR

• Children with HIV
• Failure to thrive

ANTI-INFLUENZA DRUGS

ANTI-HERPES VIRUS DRUGS

• HSV-1:
• Mucocutaneous Herpes
• Herpes Encephalitis

• HSV-2:
• Genital Herpes

• VZV:
• Chicken pox

• DOC for all of them is ACYCLOVIR.

• CMV
• Ganciclovir is DOC
• Ganciclovir resistance
• d/t UL97 phosphotransferase gene mutation
• Use Foscarnet
• Foscarnet resistance → d/t UL 54 gene
• cyto meGa → Ganciclovir

DRUGS FOR COVID-19

• Caused by Novel corona virus.

• Most cases are self-limiting.

• Important drugs
• 1. Steroids
• Only life saving drugs in COVID-19 pneumonia
• Safe in children
• Increase the risk of infections like mucormycosis
• 2. Remdesivir
• Avoid in children
• Inhibit RNA dependent RNA polymerase
• Given intravenously
• Effective in first 10 days of illness only
• Given with steroids (or baricitinib)
• Only US-FDA approved drug for COVID-19 pneumonia
• 3. Monoclonal antibodies against spike protein
• Drugs include Bebtelovimab
• Indicated for OPD treatment of Covid
• Decrease risk of hospitalization
• Baby tell Vimal Covid vannu

ANTIFUNGAL DRUGS

1. TOPICAL ANTIFUNGAL DRUGS

• Used for dermatopytosis
• e.g. azoles

• Used for steroid induced oropharyngeal candidiasis
• e.g. nystatin, clotrimazole

• Drugs for dermatophytosis:
• Azoles
• Sertaconazole
• Has anti-inflammatory and anti-pruritic activity
• Settan best → scratches and cures fever
• Miconazole
• Ciclipirox
• Terbinafine
• Both for Fungal Nail infection → Nail Lacquer
• Has Widespread resistance
• Mnemonic: Tere bina wide aytt sqeeze ayi

2. SYSTEMIC ANTIFUGAL DRUGS

DRUG	MECHANISM
Azoles	MECHANISM • ⛔ lanosterol 14-α- demethylase • ⛔lanosterol -> ergosterol synthesis USE • DOC for Candidasis ↳ Fluconazole. • DOC for Invasive Aspergillosis ↳ Voriconazole Very (Voriconazole) Invasive Aspergillosis Azole → assholes → dont knw how to cross lane (lanosterol) Lanosterol - ergosterol
Amphotericin B & Nystatin	MECHANISM • Bind to ergosterol and create pores USE • Mucormycosis (DOC). • Cryptococcal meningitis (DOC). • Kala azar (DOC - LAMB). LAMB → muttanaadu (mucor) → idichu thorannu Pore (create pore) idakki → Cryptil keri Cryptil (Cryptococcal) kidannu Karuthu (Kala azar) Poi
Allylamines / Terbinafine	MECHANISM • ⛔squalene epoxidase • ⛔lanosterol -> squalene conversion USE • Dermatophytosis (DOC). Tera bina () → sqeeze (squalene) hogaya → dermat fight () hogaya
Griseofulvin	MECHANISM • ⛔mitotic spindle USE • Dermatophytosis → Tinea capitis ("spindle il grease ozhich karakkam")
5-Flucytosine	MECHANISM • ⛔ Fungal DNA Polymerase USE • With AMB for cryptococcal meningitis CAUTION • Not given with Alcohol • Disulfiram like reaction
Caspofungin (Echinocandins)	MECHANISM • ⛔ β glucan synthesis • Cell wall inhibitor USE • Systemic Candidasis ↳ Initial treatment ↳ Not Nephrotoxic • Aspergillosis CAspo → Candida and Aspergillo - inhibit candy

Notes	Antifungals
Azole useful in mucor	Posaconazole / Isavuconazole
Azole with antipruritc/ anti-inflammatory action	Sertaconazole
Antifungal causing heart failure	Itraconazole

Itraconazole

• DOC
• Histoplasmosis
• Sporothrix
• Blastomyces

---

AMB

• Side effects
• Nephrotoxic
• Liposomal AMB is less nephrotoxic.
• (Cryptococcal, Mucor uses AMP)
• Infusion reaction
• RTA type 1
• Hypokalemia
• BM suppression

---

Voriconazole

• Take on an empty stomach
• (also for ATT drugs)
• Fatty meals ↓ absorption

• Metabolized by cytochrome P450 enzymes

• Transient visual changes

• Monitor blood levels
• Especially in liver disease
• Helps titrate dosage

• Avoid combination with pyrazinamide

• DOC for Aspergillus

ANTI-PARASITIC DRUGS

MALARIA

ACT Components:

• Artesunate: 4 mg/kg

• Sulfadoxine: 25 mg/kg

• Pyrimethamine: 1.25 mg/kg

• Artemether: 20 mg

• Lumefantrine: 120 mg

• Mnemonic: NES → Not SP (swayam pongi)

• Mixed Infection
• (P. falciparum + P. vivax)
• Rx: ACT-AL/ACT-SP + Primaquine x 14 days

In Pregnancy:

Complicated / Cerebral Malaria

• IV Quinine

• IV Artesunate

Primaquine

• DOC for Radical Cure For P. vivax

• Given for 14 days

• Tafenoquine is single dose radial cure of P. vivax malaria

• Contraindication (C/I) of Primaquine:
• Pregnancy
• Infants
• G6PD deficiency

Vaccines

• Mosquirix RTS

• S/AS01

Prophylaxis

Indicators

• Incidence → x 1000

• Rate → x 100

• Annual Parasite Incidence (API):

Category	API (State)	API (District)	Classification
3	>1	-	Intensified malaria control
2	<1	Some : >1	Pre-elimination area
1	<1	All : <1	Elimination area
0	0 or negligible	-	Prevention of re-establishment

• Count 3 - 2 - 1 - 0 → kill the mosquito
• Assesses the burden of malaria
• Impact indicator
• Total no of confirmed cases x 1000
  Total population
• Confirmed cases:
• Slides positive OR
• Rapid diagnostic kit positive (Approved only in NES)

• Annual Blood Examination Rate (ABER) (> 10%):
• No of slides examined x 100
  Total population
• Indicator for prevalence of fever
• Operational indicator

• Slide Positivity Rate (SPR):
• No. of slides positive x 100
  No. of slides examined
• Best during outbreak

• Recent Malarial Transmission Indicator:
• Infant Parasite Rate (IPR)

• Number of slides examined → always 100

• Spleen Rate
• Number of children from 2 to 10 years showing enlargement of the spleen.
• Measure of endemicity of malaria.
• Holoendemic pattern - seen during 2- 10 years

---

• Targets
• Annual Parasite Incidence (API): < 1/1000
• Annual Blood Examination Rate (ABER): > 10%
• Microfilaria Rate: < 1%

Chloroquine Toxicity Manifestations

• Erythema Multiforme

Chloroquine Toxicity	Ocular Manifestations
1. Pre-Maculopathy	ㅤ
↳ Early /Reversible	• Normal vision (peripheral) • Central scotoma (blind spot)
2. Maculopathy	ㅤ
↳ Advanced / Irreversible	• Bull's eye lesion maculopathy • ↓↓↓ visual acuity hit Bulls eye (Bulls eye maculopathy) when u get the Queen (Chloroquine)

Bull's eye lesion maculopathy

---

• Seen in
• Chloroquine toxicity
• Stargardt’s disease

---

Vortex Keratopathy / Cornea verticillata

• Whorl like/Spindle pattern

• Also seen in Queen () Ami () Tame () with Netram () in Indian () Fabric () dress
• Chloroquine
• Amiodarone
• Tamoxifene
• Netarsudil (Rho kinase ⛔),
• Indomethacin
• Fabry’s disease
• Phenothiazines

• NOT Methotrexate

AMOEBIASIS

USES OF METRONIDAZOLE

• Mnemonic: GUPTA

• G - Giardiasis, Gardnerella vaginalis (bacterial vaginosis)

• U - Ulcer (Peptic ulcer)

• P - Pseudomembranous colitis

• T - Trichomoniasis

• A - Amoebiasis, Anaerobic bacterial infections

Anaerobic Infections

• Supradiaphragmatic: Clindamycin

• Infradiaphragmatic: Metronidazole

• Bacteroides: Metronidazole, Clindamycin

• Hulk (macrolides) and Amina (aminoglycosides) → Negative

Statement: In the case of a patient hospitalized for community-acquired pneumonia, a combination of beta-lactams and azithromycin is administered as therapy. What is the reason for using this combination in medical practice? It effectively targets both Gram-positive bacteria and anaerobic organisms.

Antibiotic Killing Patterns