TUBERCULOSIS

First-line antituberculosis drugs

Drug
Isoniazid
(H)

Rifampicin
(R)

MOA
-Excellent bactericidal activity
against both intracellular and
extracellular, actively dividing M.
tuberculosis

Dosing
Children:
5mg/kg/d
ay

-Bacteriostatic against slowly

dividing organisms

Adults:
300400mg PO

-a prodrug activated by the

mycobacterial KatG
catalase/peroxidase coupled
with NADH isonicotinic acylNADH complex blocks
InhAinhibits fatty acid
synthase inhibition of mycolic
acid synthesis
-bactericidal against both
dividing and nondividing M.
tuberculosis with sterilizing
activity

Children:
1020mg/kg/
day

-exerts both intracellular and

extracellular bactericidal activity
-binds to and inhibits
mycobacterial DNA-dependent
RNA polymeraseblocks RNA
synthesis

Adults:
450600mg PO

Resistance
Amino acid changes in
either the catalaseperoxidase gene (katG) ot
InhA
Less frequently:
Alterations in kasA and loss
of NADH dehydrogenase 2
activity

Missense point mutations

in the gene coding for rpoB

Adverse effects
Drug-induced liver injury and
peripheral neuropathy
Rash, fever, anemia, acne, arthritic
symptoms, SLE-like syndrome, optic
atrophy, seizures, psychiatric symptoms

Hepatotoxicity
Orange urine, sweat, tears and contact
lenses (harmless),
rash, pruritus, thrombocytopenia,
nephritis

Pyrazinami
de (P)

-Allows treatment duration to be

shortened from 9 mos to 6 mos
and decreases rates of relapse
-more active against slowly
replicating organisms than
against actively replicating
organisms

Children:
2030mg/kg/
day

Mutation in the pncA gene

coding for pyrazinamidase

Hepatotoxicity
Hyperuricemia
Clinical gout

Missense mutations in the

embB gene that encodes for
arabinosyltransferase

Optic neuritis (reduced visual acuity,

central scotoma, loss of the ability to see
green, less commonly red)

Mutations in 16S rRNA

Ototoxicity (primarily

Adults:
1500mg/d
ay PO

-prodrug converted by
mycobacterial pyrimidase to
active form, pyrazinoic acid
fatty acid synthase I inhibition

Ethambutol
(E)

Streptomyci

-active only in acidic

environments as are found
within phagocytes or granulomas
-bacteriostatic
-provides synergy with other
drugs in the regimen
-least potent against M.
tuberculosis
-used in combination with other
agents in the continuation phase
of treatment
- inhibition of the
arabinosyltransferase involved
in cell wall synthesis which
probably inhibits formation of
arabinogalactan and
lipoarabinomannan
-has only low-level early

Children:
1520mg/kg/
day
Adults:
8001000mg/d
ay PO

Children:

bactericidal activity
-inhibits protein synthesis by
binding at a site on the 30S
mycobacterial ribosome

1018mg/kg/
day

gene or the gene encoding

ribosomal protein S12
(rpsL)

vestibulotoxicity), neuropathy, renal

toxicity

Adults:
1g IM

Duration of treatment if with involvement of lymph nodes: 6 months (4HRZE/4HR)

Extrapulmonary TB (except TB of the CNS, bone or joint for which some expert groups suggest longer therapy) should receive a regimen
containing 6 months of Rifampicin: 2HRZE/4HR
Duration of treatment if with brain involvement:
- 9-12 months
Duration of treatment if with bone and joint involvement:
- 6-9 months
CEPHALOSPORINS
1st generation: cefadroxil (PO), cefazolin(IV), cephalexin(PO), cephalothin, cephapirin, cephradine(PO)
2nd generation: Cefoxitin (IV), Cefotetan (IV), Cefuroxime (IV), Cefuroxime axetil (PO), Cefaclor, Cefamandole, Cefonicid, Cefprozil,
Ceforanide
3rd generation: cefoperazone, cefotaxime (IV), ceftazidime (IV), ceftizoxime, ceftriaxone (IV), cefixime, cefpodoxime proxetil, cefdinir,
cefditoren pivoxil, ceftibuten and moxalactam
4th generation: Cefepime (IV)
DRUGS OF CHOICE FOR DIFFERENT INFECTIOUS DISEASES
Disease
DOC
Meningitis
Penicillin G 20-24 million U/day IV q4h; ceftriaxone 4g/day IV q12h; cefotaxime 12g/day IV q4h; ampicillin

(bacterial)
Gonorrhea
Syphilis

12g/day IV q4h
Ceftriaxone 250mg IM, single dose or Cefixime 400mg PO, single dose + treatment for Chlamydia if chlamydial
infection is not ruled out: Azithromycin 1g PO, single dose or Doxycycline 100mg PO BID for 7 days
Primary, secondary or early latent: Penicillin G benzathine single dose of 2.4 mU IM (Tetracycline HCl 500mg
PO QID or Doxycycline 100mg PO BID for 2 weeks if with penicillin allergy)
Late latent, cardiovascular or benign tertiary: Penicillin G Benzathine 2.4 mU IM weekly for 3 weeks
(Tetracycline HCl 500 mg PO QID or Doxycycline 100mg PO BID for 4 weeks if with penicillin allergy)

Meningococcemia
Tetanus
Leptospirosis

Neurosyphilis: Aqueous crystalline penicillin G (18-24 mU/d IV, given as 3-4 mU q4h or continuous infusion)
for 10-14 days or aqueous procaine penicillin 2.4 mU/d IM plus oral probenecid 500mg QID both for 10-14
days
Ceftriaxone 75-100mg/kg/day max of 4g/day in one or two divided IV doses or Cefotaxime 200mg/kg/day
max 8g/day in four divided IV doses; duration of 7 days but a single dose of ceftriaxone has been successfully
treated in resource-poor settings
Metronidazole 400mg rectally or 500mg IV q6h for 7 days
Single dose of tetanus immune globulin 3000-6000 IU per IM or equine antitoxin 10000-20000 IU
Mild: Doxycycline 100mg PO BID or Amoxicillin 500mg PO TID or Ampicillin 500mg PO TID
Moderate/Severe: Penicillin 1.5 million units IV or IM q6h or Ceftriaxone 1g/d IV or Cefotaxime 1g IV q6h
Chemoprophylaxis: Doxycycline 200mg PO once a week or Azithromycin 250mg PO once or twice a week

HEPATITIS B SEROLOGY
HBsAg acute or chronic infection; protein on the surface of HBV
Anti-HBs- recovery and immunity from HBV infection; also develops in persons successfully vaccinated
IgM anti-HBc early anti-HBc indicative of acute or recent infection (6 months or less)
HBeAg- marker of viral replication and infectivity
Interpretation

Test results
(-) HBsAg
(-) Anti-HBc
(-) Anti-HBs
(-) HBsAg
(+) Anti-HBc
(+) Anti-HBs
(-) HBsAg
(-) Anti-HBc
(+) Anti-HBs
(+) HBsAg
(+) Anti-HBc
(+) IgM anti-HBc
(-) Anti-HBs
(+) HBsAg
(+) Anti-HBc
(-) IgM anti-HBc
(-) Anti-HBs

Interpretation
Susceptible
Immune due to natural infection
Immune due to Hepatitis B vaccination
Acutely infected

Chronically infected

HIV/AIDS
Some diseases of AIDS:
- Kaposi's sarcoma- a multicentric neoplasm consisting of multiple vascular nodules appearing in the skin, mucous membranes, and
viscera. The course ranges from indolent, with only minor skin or lymph node involvement, to fulminant, with extensive cutaneous
and visceral involvement.
- etc
Screening test for HIV infection
- ELISA (aka EIA- enzyme immunoassay) standard blood screening test (highly sensitive but not specific)
- P24 antigen assay- for acute HIV syndrome
- Nucleic acid testing for blood donor screening

Confirmatory test for HIV infection

- Western blot most commonly used
- HIV RNA assay- can be used to determine prognosis and evaluate treatment response
- HIV DNA PCR
- specific serologic testing for HIV-2
Note:
- positive or indeterminate EIA but negative Western blot = false positive EIA reactivity
- Western blot demonstrating antibodies to products of all three of the major genes of HIV (gag, pol, and env) is conclusive evidence
of infection with HIV
- Western blot is positive if antibodies exist to two of the three HIV proteins: p24, gp41, and gp120/160

STAGES OF DHF:
- Febrile (2-7days): viremia-driven high fever
- Critical/plasma leak phase (24-48 hours): sudden onset of varying degrees of plasma leak into the pleural and abdominal cavities
- Recovery/Convalescence/reabsorption phase (2-4 days): sudden arrest of plasma leak with concomitant reabsorption of extravasated
plasma and fluids
for more info: www.cdc.gov/dengue/clinicallab/clinical.html
WEILS SYNDROME
- severe form of Leptospirosis characterized by jaundice, renal dysfunction, and hemorrhagic diathesis
- mortality is due to hemorrhage
- findings:
o renal failure- develop during 2nd week of illness; decreased colume and renal perfusion acute tubular necrosis
o pulmonary involvement- occurs frequently; presents with cough, dyspnea, chest pain, and blood-stained sputum,
sometimes hemoptysis or even respiratory failure
o hemorrhagic manifestations- common are epistaxis, petechiae, purpura, ecchymoses; rare are severe GI bleeding, adrenal
or subarachnoid hemorrhage
o others- rhabdomyolysis, hemolysis, myocarditis, pericarditis, CHF, cardiogenic shock, ARDS, multiorgan failure

MALARIA
Cause of relapse in P. vivax and P. ovale- failure to eradicate the persistent hepatic stage
Recrudescence- recurrence of asexual parasitemia after treatment of the infection with the same species of Plasmodium that caused the
original infection due to failure to completely eradicate the parasite because of resistance (P. falciparum)
Plasmodium falciparum- can cause cerebral malaria
SIRS (Systemic inflammatory response syndrome)
- defined as 2 or more of the following:
o fever of >38C or <36C
o heart rate of >90 beats/minute
o respiratory rate of >20 breaths/minute or PaCO2 <32mmHg
o abnormal WBC (>12000/uL or <4000/uL or >10% immature band forms)
CSF FORMULAS
Bacterial infection

Cells
WBC >50/mm3, often
greatly increased

Protein
100-250 mg%

Viral, fungal, spirochetal

WBC 10-100/mm3

50-200mg%

Tuberculous infection

WBC >25/mm3

100-1000mg%

Glucose
20-50mg%; usually
lower than 50% of blood
glucose level
Normal or slightly
reduced
<50, often markedly
reduced

Other features
Gram stain shows
organisms, high opening
pressure
Special culture
techniques required,
presence of normal or
increased pressure
Special culture technique
and PCR may be needed
to detect organisms

LIGHTS CRITERIA
If any of the following is met, pleural fluid is exudate; if not, transudate.
- PF/serum protein >0.5
- PF/serum LDH >0.6
- PF LDH >2/3 upper normal serum limit
DRUGS OF CHOICE:
Multi-drug resistant typhoid: Ciprofloxacin 500mg BID PO or 400mg q12h IV for 5-7 days; Ceftriaxone 2-3g/day IV for 7-14 days;
Azithromycin 1g/day PO for 5 days
Poliomyelitis: no cure; supportive treatment
Pregnant with Measles- hyperimmune globulin
Pregnant with Hepatitis- alpha-interferon, Lamivudine
Pregnant with Varicella- Acyclovir 800mg PO 5 times a day for 7 days or Valacyclovir 1000mg PO TID for 7days
(paki-check please ng mga drugs of choice, thanks )
RABIES
Management:
-Local wound care
-All previously vaccinated patients should receive human rabies immune globulin (RIG, 20 IU/kg; 40 IU/kg for equine RIG) no later than 7
days after the first vaccine dose. The entire dose should be infiltrated at the site of the bite; if not anatomically feasible, the residual RIG
should be given at a distant site.
-Inactivated rabies vaccine should be given as soon as possible (1 mL IM in the deltoid region) and repeated on days 3, 7, and 14 for
previously unvaccinated patients; previously vaccinated patients require booster doses only on days 0 and 3.
-Preexposure prophylaxis is occasionally given to persons at high risk (including certain travelers to rabies-endemic areas). A primary
vaccine schedule is given on days 0, 7, and 21 or 28.