Chemotherapy

Prof. Naveed Iqbal Ansari

Initially the term was used by Ehrlich at
the beginning of the 20th Century to
describe the use of synthetic chemicals
to destroy infective agents

In the recent years it has been

broadened to the use of antibiotics &
cancer chemotherapy
 Molecular basis of
chemotherapy

Chemotherapeutic agents are

chemicals that are intended to
be toxic for the pathogenic
organisms but innocuous for
the host
 Biochemical reactions
as
potential Targets
Class I reactions
Mechanism to obtain energy from glucose or
some alternative carbon source
Class II reactions
To synthesize Amino acids & Growth factors
Class III reactions
To make own macromolecules-proteins, RNA,
DNA, polysaccharides & Peptidoglycans
 Class I reactions
These are not promising targets
There is no marked difference between
bacteria & human cells to obtain energy
from glucose

Even if glucose pathway is blocked

bacteria can use alternatives as
aminoacids & lactate
 Class II reactions
Aminoacids (except essential aa),
nucleotides, phospholipids, amino-sugars,
carbohydrates & vitamins are all
synthesized by humans therefore can not
become target
Folate is not synthesized by humans
Sulfonamides, trimethoprim (infection)
methotrexate (cancer)
Pyramidine & purine analogs
5-FU, Methotrexate, Flucyticine
 Class III reactions
Peptidoglycans constitutes the cell wall
-lactam antibiotics, Cycloserine, vancomycin
Proteins
Ribosomes
Human 60S & 40S

bacterial 50S & 30S

Cloramphenicol, tetracyclines, aminoglycosides

Nucleic acid
Inhibit the synthesis of nucleotides
Alteration of base pairing property of template
By inhibiting either DNA or RNA polymerase
Inhibition of DNA gyrase
Direct effect on DNA
Formed structures of the cells
Cell membrane
Antifungals
DNA
Bleomycin for cancer
Intracellular organelles
Microtubules:
Albendazole intestinal worm
vinca alkaloids for cancer
Food vacuoles
Chloroquine

Muscle fibres
Anthelmintics: piperazine, pyrantel
Antimicrobials
Infectious Microbes Are Living Entities
With a Nearly Unlimited Ability to Adapt
Microbes Tiny Organisms

Reproduce approximately every 30 minutes

Constant mutation
Constant migration
Constant adaptation

Basic building blocks of many virulent diseases

Their predators: antibiotics and antivirals
We must stay a step ahead with:
Surveillance
Testing
New strategies (research, development, distribution)
Micro-organisms
Microbes are everywhere.
There are more of them
on a person's hand than
there are people on the
entire planet!
Microbes are in the air we
breathe, the ground we
walk on, the food we eat
they're even inside us!
We couldn't digest food
without themanimals
couldn't, either. Without
microbes, plants couldn't
grow, garbage wouldn't
decay and there would be
a lot less oxygen to
breathe.
 Classification
Common Shapes:
spheres - (cocci).
rods - (bacilli).
spirals - (spirilla).
Intermediate Shapes:
short rods - (coccobacilli).
commas - (vibrii).
Rare shapes:
squares
stars
irregular
Cocci
Bacilli
Spirals
 Gram-Positive Aerobes
COCCI BACILLI
clusters - Bacillus sp.
Staphylococci
Corynebacterium sp.
pairs
S. pneumoniae Listeria monocytogenes
chains - group and Nocardia sp.
viridans
streptococci
pairs and chains -
Enterococcus sp.
 Gram-Negative Aerobes
COCCI BACILLI
Moraxella catarrhalis E. coli, Enterobacter sp.
Neisseria gonorrhoeae Citrobacter, Klebsiella sp.
Neisseria meningitidis Proteus sp., Serratia
Haemophilus influenzae Salmonella, Shigella
Acinetobacter,
Helicobacter
Pseudomonas aeruginosa
 Anaerobes
Above Diaphragm Below Diaphragm
Peptococcus sp. Clostridium
Peptostreptococcus sp. perfringens,
Prevotella tetani, and
difficile
Veillonella
Bacteroides fragilis,
Actinomyces
disastonis,
ovatus,
thetaiotamicron
Fusobacterium
 Other Bacteria
Atypical Bacteria
Legionella pneumophila
Mycoplasma pneumoniae or hominis
Chlamydia pneumoniae or
trachomatis
Spirochetes
Treponema pallidum (syphilis)
Borrelia burgdorferi (Lyme)
Common Bacterial Pathogens
by Site of Infection
Certain bacteria have a propensity
to commonly cause infection in
particular body sites or fluids
Bacteria by Site of Infection
Are We Making Progress to Eliminate
Infectious Microbes?
Antimicrobials

Control symptoms
Destroy organisms
Eradicate diseases
 Antimicrobials
Antimicrobials
The chemicals to kill or control the
growth of micro-organisms

Antibiotics
Chemicals obtained from living organism
to kill or control the growth of micro-
organisms
 History of Antimicrobials
Time line of events

1932, 1952, 1956, Linezolid

Sulfonamides Erythromycin Vancomycin becomes
discovered discovered introduced available
1900 2000

1980s,
1928, 1962,
1940s: Penicillin Fluorinated
Penicillin Quinolones
becomes commercially Quinolones
discovered discovered
available and available
Cephalosporins are
synthesized
 How to choose an
antimicrobial
Antibiotic may be Proper?
diagnosis
chosen before results
of the culture are
available based on
some preliminary
information
Site of infection and
likely causative
organism
Gram-stain result
(does result
correlate with
potential organism
above)
Minimal inhibitory concentration
lowest level stopping growth

e. g. zone of inhibition around a

disk impregnated with antibiotic
How antimicrobials act
 How antimicrobials act
1. Inhibit cell wall synthesis causing cell lysis
2. Interfere with cell membrane increasing
permeability, allowing leakage
3. Inhibit protein synthesis by binding to
ribosomal subunits
4. Interfere with nucleic acid synthesis
Interfere with metabolism, replacing PABA used to
synthesize folic acid.
Interfere with nucleic acid production, preventing
reproduction.
 Inhibit bacterial cell wall

-lactam antibiotics
Penicillins
Cephalosporins

Cycloserine
Vancomycin
Bacitracin
 Cell Membrane

Polymyxins & Colistin

Antifungals
Nystatin
Amphotericin B
Imidazole antifungal agents
 Protein synthesis inhibitors

Chloramphenicol, clindamycin &

erythromycin bind to 50S subunit

Aminoglycosides & tetracyclines bind

to 30S subunit
Protein Synthesis
Inhibiting Nucleic acid synthesis
DNA & RNA formation

By acting on formed structures

Microtubules
albendazole
Food vacuoles
chloroquine
Muscle fibres
piperazine
 Effects of Antibiotics
Bacteriostatic
Inhibits bacterial cell growth, host
immune system must help fight the
microbe

Bacteriocidal
Kills bacteria, effective when host
immune system is compromised
 Resistance to drugs
1. Alteration in membrane permeability
Membrane transport or pores
Antimicrobials cannot cross
tetracyclines, quinolones, aminoglycosides

2. Alteration of target
Bacterial ribosomes altered by DNA mutation
Antimicrobial agent no longer binds
erythromycin, rifamycin, antimetabolites
 Resistance to drugs
3. Development of enzymes
lactamase which inactivates
penicillin & cephalosporins;

Staphylococci, Streptococci, Gonococci

Gram negative enzymes against

aminoglycosides & chloramphenicol

4. Enzyme alteration
Sulfonamide resistant bacteria have ability
to acquire needed PABA when drug is present
 Resistance to drugs
5. Metabolic pathway alteration
By-pass reaction inhibited by antimicrobial
agent
Sulfonamide resistant bacteria can by-pass
production of Folic acid and use ready made
folic acid from environment
 Factors contributing to
resistance
Widespread use of antibiotics

Antibiotics being used when they are

not needed

Levels of drugs less than therapeutic

 Limiting Drug Resistance
1. Maintain high levels - antibiotic in
patient kill or inhibit pathogen
Take ALL of prescription. Do not stop when
symptoms subside.

2. Two antibiotics more effective than one

Synergistic effect e.g C0-Trimoxazole

3. Restrict antibiotic use; bacterial

infections only, not viral; narrow spectrum
NO ANTIBIOTICS IN ANIMAL FEED.
CDC 50 M of 150 M outpatient prescriptions no
need
 Factors contributing to
treatment failures
Selection of inappropriate antibiotic
Inadequate drug blood levels
Course of treatment too short
Bacterial resistance
Poor adherence to dosing regimen
Others
A 26-year-old female with a 2-week history of
urinary urgency and frequency presents to
her primary care physician for evaluation.
Urinalysis reveals nitrates, leukocytes and
red blood cells. The physician selects a
quinolone antibiotic for treatment of a
presumed urinary tract infection. Which of
the following organisms would be most
sensitive at the lowest drug concentration?
(A) Escherichia coli
(B) Haemophilus influenzae
(C) Neisseria gonorrhoeae.
(D) Pseudomonas aeruginosa
(E) Staphylococcus aureus
A 22-year-old sexually active man
presents to the ambulatory care clinic
with dysuria, penile discharge and a
swollen right knee. A joint aspirate of
his right knee reveals many neutrophils
as well as some gram negative
diplococci. Which is the best choice to
treat his condition?
(A) Ceftriaxone.
(B) Cephalexin
(C) Dexamethasone
(D) Meropenem
(E) Penicillin G
A 22-year-old African American man who is a
college student plans to travel to Africa for a
semester of study abroad. A university
student health physician prescribes
chloroquine for malaria prophylaxis starting 2
weeks before the trip. Soon after starting the
regimen, the patient develops scleral icterus.
What is the most likely underlying cause for
the icterus?
(A) Biliary sludging
(B) Chloroquine simply turns tears yellow; this is
not true icterus
(C) Drug interaction
(D) Enzyme deficiency.
(E) Hepatotoxicity of chloroquine
A 3-year-old girl presents to the emergency
department with a history of recurrent UTIs with
costovertebral angle tenderness, high fever, and
dysuria. A urine culture grows gram-negative
lactose-fermenting rods. The physician suspects E.
coli pyelonephritis. Ciprofloxacin is highly effective
against E. coli in vitro, but the physician chooses not
to use it in this case. Why would she choose not to
prescribe ciprofloxacin?
(A) Ciprofloxacin is bacteriostatic, not bactericidal
(B) Ciprofloxacin is contraindicated in patients younger
than 18 years old.
(C) Ciprofloxacin is effective against E. coli in vitro, but
not efficacious in vivo
(D) Ciprofloxacin is nephrotoxic and should not be used to
treat kidney infections
(E) The physician should prescribe ciprofloxacin in this
case
A 21-year-old man presents to the ambulatory care
clinic with an erythematous, swollen, painful left
elbow. History is significant for untreated impetigo on
his left forearm. A joint aspirate reveals gram-
positive cocci in clusters. The physician begins
empiric treatment with vancomycin while the
organism is cultured. It is found to be methicillin
susceptible. Methicillin is not widely used, but which
of the following is an equivalent drug that could be
used to treat this mans infection?
(A) Amoxicillin
(B) Ampicillin
(C) Oxacillin.
(D) Penicillin G
(E) Penicillin V
A 23-year-old woman who underwent a
laparoscopic appendectomy is later found to
have a wound infection. A culture grows
methicillin-resistant Staphylococcus aureus
(MRSA). What is the principle mechanism this
strain uses to avoid the bactericidal properties
of methicillin and methicillin-related drugs?
(A) Changes a D-alanine peptidoglycan residue to
a D-glycine so methicillin cannot bind
(B) Has altered PBPs that methicillin cannot bind.
(C) Prevents methicillin from entering the cell
(D) Pumps methicillin out of the cell
(E) Uses a -lactamase break down methicillin
A 25-year-old man presents to the emergency
department with severe abdominal pain,
rigors, and a temperature of 39C. For the
past 2 days, he has suffered from right lower
quadrant pain and only came to the hospital
when it suddenly worsened. The physician
suspects ruptured appendicitis and administers
imipenem with cilastatin. Cilastatin blocks
which of the following enzymes to increase
imipenems efficacy?
(A) Bacterial efflux pump
(B) CYP3A4
(C) Dehydropeptidase.
(D) Organic anion transporter
(E) Penicillinase
A 73-year-old man with overwhelming
sepsis requiring intravenous fluid
support, pressors, and antibiotics is now
beginning to improve clinically. The
rationale against the use of a
bacteriostatic antibiotic in this patient
includes which of the following?
(A) Arrest growth of bacteria.
(B) Cause cell death of pathogens
(C) Removal of viable organisms
(D) Requirement for lower doses of
medication
A 55-year-old woman is hospitalized for
treatment of osteomyelitis. The infectious
organism is found to be susceptible to
gentamicin so she is started on a once daily
dose of intravenous gentamicin. Which of
the following symptoms may be a signal to
the physician to stop gentamicin therapy?
(A) Eosinophilia
(B) Headache
(C) Nausea
(D) Salivation
(E) Tinnitus.
A 48-year-old man who is obese and a
chronic alcoholic is hospitalized for
spontaneous peritonitis. He begins a
course of gentamicin as part of an
empiric antibiotic regimen. Which of the
following medications should the
physician avoid prescribing while this
patient is taking gentamicin?
(A) Diazepam
(B) Disulfiram
(C) Fomepizole
(D) Furosemide.
(E) Omeprazole
A 23-year-old woman presents to her
primary care physician with dysuria and
urgency. Urine is positive for leukocyte
esterase and nitrites. Her physician
prescribes co-trimoxazole for her UTI.
How does co-Trimoxazole inhibit bacterial
growth?
(A) Inhibition of cell wall synthesis
(B) Inhibition of DNA gyrase
(C) Inhibition of nucleotide synthesis.
(D) Inhibition of ribosomes
(E) Inhibition of RNA synthesis
A 21-year-old woman college student complains of
a skin lesion near her knee on the inside of her
thigh. She recently returned from a trip to Africa
where she played a handmade goatskin drum.
The lesion is painless with a black center. The
physician suspects cutaneous anthrax and
prescribes oral ciprofloxacin. Which of the
following should this patient avoid taking with
ciprofloxacin?
(A) Alcohol
(B) Grapefruit juice
(C) Milk.
(D) St. Johns wort
(E) Ciprofloxacin does not interact with any
of these substances
A 8-month-old female infant is brought to the
emergency department by her parents. She is
febrile, tachycardic and hypotensive. Sepsis is
suspected and the physician wants to give
chloramphenicol but is worried about gray baby
syndrome. Why does chloramphenicol
sometimes cause gray baby syndrome in
infants?
(A) Chloramphenicols narrow spectrum
means Empiric therapy is often ineffective
(B) Clindamycin, not chloramphenicol, causes
gray baby syndrome
(C) Decreased absorption from the intestines
(D) Decreased conjugation in infant liver.
(E) Decreased excretion by infant kidneys
A 16yr old boy presents to the ambulatory
care clinic with a persistent dry cough. He
had cleaned out a barn attic that was full
of bats about 2 weeks ago and has had the
cough for 5 days. The physician suspects
histoplasmosis. Which would be the best
treatment for this patient?
(A) Albendazole
(B) Griseofulvin
(C) Ketoconazole.
(D) Nystatin
(E) Penicillin G
A 71-year-old man with osteomyelitis is
treated with aminoglycosides. Blood
cultures are drawn and reveal resistance
to this antibiotic class. What is the most
likely reason for this to occur?
(A) Increased hepatic transaminase
activity
(B) Increased phosphodiesterase
activity
(C) Presence of plasmid-associated
synthesis of acetyltransferase.
(D) Uptake of drug into oxygen-
dependent transport system
A 27-year-old man hospitalized following a
kidney transplant develops a high fever,
tachycardia, and hypotension. Blood
cultures grow Candida albicans. He is
started on amphotericin B and flucytosine.
Which of the following describes part of
flucytosines mechanism of action?
(A) Disruption of microtubules
(B) Inhibition of ergosterol synthesis
(C) Inhibition of protein synthesis
(D) Inhibition of thymidylate synthase.
(E) Pore formation in the fungal cell
membrane
A 37-year-old woman with urinary
frequency, urgency and pelvic pain
presents to her primary care physician.
She has an allergy to quinolones and
penicillin. Urinalysis reveals nitrates,
leukocytes, and blood. What is the most
appropriate treatment for this patient?
(A) Azithromycin
(B) Cefazolin
(C) Clarithromycin.
(D) Erythromycin
(E) Levofloxacin
The rationale behind the lack of
use of the antibiotic
tetracyclines in modern day
medicine relates to which of
the following?
(A) Altered targets
(B) Efflux.
(C) Enzymatic activation
(D) Permeability
A 52-year-old man with recurrent
Pseudomonas infections now has another
infection. Culture and sensitivity now
indicate that this pathogen is not
sensitive to chloramphenicol. What is the
most likely reason for development of
resistance?
(A) Facilitated drug penetration to cell
membrane
(B) MDR gene
(C) Reduced membrane permeability.
(D) Thickened cell membrane
(E) Undesirable pH
A 54-year-old man with tuberculosis is
maintained on a multidrug regimen
including cycloserine. He complains of
intermittent chest pressure and dyspnea
but this does not limit his daily activities
On a cellular level, which of the following
amino acids is blocked by this agent?
(A) D-alanine.
(B) D-aspartate
(C) D-glutamate
(D) Para-aminobenzoate
(E) Uracil
A 34-year-old man with a history of
recurrent tuberculosis on a multidrug
regimen, including isoniazid. He
presents to his primary care physician
complaining of paresthesias of his
hands and feet. What is the most likely
explanation for this finding?
(A) Diabetes mellitus
(B) Lumbar disc disease
(C) Peripheral neuritis.
(D) Spinal cord compression
(E) Urinary tract infection
A 35-year-old woman with a history of world
travel is found to have a hookworm infection.
She has begun on therapy with mebendazole
therapy orally and now returns home for
follow-up. Which of the following statements
regarding the pharmacodynamics of this
agent is correct?
(A) Best results are obtained with
intravenous doses
(B) Hepatic first-pass metabolism is
achieved.
(C) Low-fat meals enhance absorption
(D) Side effect profile is unfavorable
(E) Use in pregnancy is preferred
A 34-year-old man is hospitalized with
seizures, headache and vomiting. CT
scan of the brain reveals
cysticercosis. What is the most
appropriate treatment for this
patient?
(A) Albendazole.
(B) Niclosamide
(C) Prednisone
(D) Tetracycline
(E) Watchful waiting
A 4-year-old boy is hospitalized on the
pediatric service with cough, runny nose,
and chest pressure. Concern for
respiratory syncytial virus is brought up by
the treating physician. Treatment with
zanamivir is undertaken. Which of the
following underlying conditions can worsen
bronchospasm in this patient?
(A) Adenoiditis
(B) Asthma.
(C) Floppy tongue syndrome
(D) Pharyngitis
(E) Tracheitis
A 29-year-old man with recurrent herpes viral
infections of the scrotum and penile shaft
presents to his primary care physician
because the medication is not working for
him. He takes oral acyclovir for these
outbreaks. Physical examination reveals
active genitourinary herpes disease. What is
the most likely explanation for the resistance
to this medication?
(A) Deficient DNA synthase
(B) Deficient RNA polymerase
(C) Deficient RNA transferase
(D) Deficient thymidine kinase.
(E) Deficient uracil synthase
A 52-year-old female presents with facial
wrinkling that has not been satisfactorily
treated with creams. She requests
information on botulinum toxin A at an
acquaintances recommendation.
Botulinum toxins mechanism of action is
most similar to which other bacterial
toxin?
(A) Cytolethal distending toxin
(B) Heat-labile enterotoxin
(C) Heat-stable enterotoxin
(D) Shiga toxin
(E) Tetanospasmin.
A 24-year-old male soldier has just
returned from a duty tour in Iraq. He
complains of a 3-cm diameter
nonhealing ulcer on his left forearm. He
report having an insect bite there while
in Iraq. Which of the following drugs
would be best for this patient?
(A) Primaquine
(B) Praziquantel
(C) Prednisone
(D) Nifurtimox
(E) Sodium stibogluconate.
A 27-year-old man presented to the clinic for
routine abroad trip preparation. He is traveling to
the Caribbean in 1 month. Antidiarrheals and
antimalarials are prescribed. It is noted that the
patient has a history of epilepsy, latent TB and
has contracted malaria once on a prior trip. His
vaccines are up to date and he has no allergies.
What medication is contraindicated for this
patient?
(A) Chloroquine
(B) Diphenoxylate
(C) Doxycycline
(D) Loperamide
(E) Mefloquine.
A 4-year-old boy is brought by his mother to the
clinic complaining of perianal itching. He spends
the weekdays at a daycare center. The mother
also brings a strip of adhesive tape from the
night before which she had stuck to the childs
perianal area as the doctor had ordered on the
phone. Microscopic examination of the tape
revealed small, white, round worms. Which is
the best treatment for this child?
(A) Fluconazole
(B) Mebendazole.
(C) Metronidazole
(D) Nifurtimox
(E) Praziquantel
A 63-year-old woman presents with a
productive cough, shortness of breath,
and fever and chills. Past medical
history is significant for chronic renal
disease. After a standard dose of which
of the following drugs would you expect
to see the greatest increase in serum
drug concentration?
(A) Cefepime.
(B) Cyclosporine
(C) Doxycycline
(D) Erythromycin
(E) Nafcillin
A 3-month-old male infant is brought to the emergency
department by his parents following a 30-min seizure
at home. In the emergency department, the child is
not seizing and is afebrile. Prenatal history is
insignificant except for a few apparently mild illnesses
experienced by his mother. They own three cats. A
CT scan of the infants head reveals intracerebral
calcifications and mild ventricular hypertrophy. The
infant is given pyrimethamine for toxoplasmosis.
Which of the following describes pyrimethamines
mechanism of action?
(A) Inhibition of dihydrofolate reductase.
(B) Inhibition of dihydropteroate synthetase
(C) Inhibition of nucleic acid synthesis
(D) Membrane depolarization
(E) Ribosome inhibition
A 19-year-old college student man presents to the
student health service with a 2-week history of
headache, malaise, sore throat, and dry cough, which
has become productive over the last 4 days. He
states that several of his dorm mates have
complained of similar problems in the last few weeks.
Pulmonary auscultation reveals scattered coarse
rhonchi bilaterally. What is the best treatment for this
patient?
(A) Cephazolin
(B) Ciprofloxacin
(C) Oral erythromycin.
(D) Intravenous erythromycin
(E) Observation alone
A 24-year-old primigravid womans water breaks at 39
weeks gestation. Twenty-four hours later, she is having
regular contractions 3 min apart. Her labor lasts 8 h. At
the hospital, she gives birth to a baby boy, who initially
appeared healthy. Within the next 12 h, the baby boy
begins to have temperature fluctuations, difficulty
breathing, and reduced movements. You suspect
neonatal sepsis, so IV ampicillin is started. Which
additional antibiotic could be given simultaneously to
have a synergistic effect in controlling this infection?
(A) Amoxicillin
(B) Cephalexin
(C) Gentamicin.
(D) Penicillin G
(E) Penicillin V
An 18-year-old male college student presents
to the emergency room with a fever of 103F
and stiff neck for the past 3 h. After a lumbar
puncture and Gram stain, the diagnosis of
meningococcal meningitis is established.
Unfortunately, his college did not require
students to have the meningococcal vaccine.
What prophylaxis should be given to his close
contacts in the dorm?
(A) Benzathine penicillin G
(B) Ceftriaxone
(C) Penicillin
(D) Rifampin.
(E) Trimethoprimsulfamethoxazole
A 28-year-old man presents to the
emergency department with diarrhea for
the past 2 days. He went on a camping
trip 10 days ago. His loose stools are foul
smelling and have been associated with
abdominal pain and nausea. Stool analysis
shows cysts. What is the most appropriate
treatment?
(A) Clindamycin
(B) Ivermectin
(C) Metronidazole.
(D) Praziquantel
(E) Sulfadiazine
A 8-year-old boy presents to the clinic with an
extremely itchy rash for the past 2 days. He
is the fourth student from his class to
present with the same symptoms. The rash is
across his hands, wrists, and elbows
bilaterally. Small erythematous papules with
obvious burrows, which look like insect bites,
are aligned in 8-cm segments. What is the
most appropriate treatment?
(A) Diphenhydramine
(B) Doxycycline
(C) Lindane
(D) Permethrin.
(E) Topical corticosteroid
A 47-year-old man with a history of spina bifida
presents to the emergency department with a
fever. His temperature was 102F orally. He
has a neurogenic bladder secondary to his
spina bifida. A urinalysis showed an infection,
and culture grew out vancomycin-resistant
Enterococcus. He is started on Linezolid. What
is the mechanism of resistance of bacteria to
vancomycin?
(A) Acetylation of vancomycin
(B) b-Lactamase cleavage of -lactam ring
(C) D-ala replaced by D-lac in the cell wall.
(D) Decreased uptake by bacterial cell
(E) Methylation of rRNA
A 58-year-old man is hospitalized in the
medical intensive care unit with a
methicillin-resistant bacterial infection.
He has begun on a course of
intravenous daptomycin. Which of the
following laboratory studies needs to be
carefully monitored in this patient?
(A) Creatinine
(B) Hemoglobin
(C) Hematocrit
(D) Hepatic transaminases.
(E) Sodium
A 78-year-old alcoholic male with mild Alzheimer disease
and poor dental hygiene is to have his remaining teeth
extracted. Because of his Alzheimers disease, he is
not a candidate for dentures. He also has a history of
mitral valve stenosis with mild cardiac insufficiency.
His current medications include captopril, digoxin and
furosemide. Which of the following medications would
be the most appropriate for prophylaxis prior to his
dental procedure?
(A) Amoxicillin.
(B) Co-trimoxazole
(C) Imipenem
(D) Tetracycline
(E) Vancomycin