MANOR REVIEW CENTER

MODULE 6 SUPPLEMENT HANDOUT Updated APRIL 2018

Nico C. Fabian, RPh, MD
A. Blastomycosis
PHARMACEUTICAL MYCOLOGY • Gilchrist’s disease, North American Blastomycosis
• Blastomyces dermatitidis
• Fungi – eukaryotic, rigid cell walls
• Prefers men with soil contact
• All eukaryotic cells contain sterols (Ergosterol for fungi)
• Rarest systemic fungal infection
• Saphrophytes; No obligate anaerobe
• Taxonomic classification: Zygomycetes (aseptate fungi), B. Paracoccidiodomycosis
Ascomycetes (sac fungi), Basidiomycetes (mushroom), • South American Blastomycosis
Deuteromycetes (imperfect fungi) • Paracoccidioides brasiliensis
Yeast Molds • Tissue form likened to mariner’s wheel
• Prefers men
Unicellular Filamentous
Divide by budding Structural units = hyphae C. Coccidioidomycosis
Buds – blastospores Aggregates of hyphaen = • San Joaquin Valley Fever
Elongates to form mycelia • Coccidioides immitis
pseudohyphae • Prefers dark-skinned persons with soil contact
i.e. Candida, D. Histoplasmosis
Cryptococcus • Histoplasma capsulatum
• Dimorphic Fungi – grow as mold (natural reservoir, 25C at • Resides in feces birds and bats
Saboraud Dextrose agar) or as yeast (tissues, 37C on Brain • Common among cave explorers and people involved in
heart infusion agar. Example: Histoplasma capsulatum “spelunking”
• Presents as pneumonia
I. Dermatophytes
• Molds which parasitize non-living integuments V. Opportunistic Fungal Infections
o Secretes keratinase • Affect immunocompromised individuals
• Infections classified as geophilic (acute), zoophilic A. Candidiasis
(acute), or anthropophilic (milder, chronic) • Candida albicans – part of the minor normal flora
o known as ringworm infections due to the • Clinical manifestations:
formation of raised, circular lesions. - Oral thrush/Moniliasis – sore white patches in the
o commonly known as tinea (Latin for worm), mouth
and are named after the body part involved. o Management: Nystatin (binds ergosterol)
o Tinea corporis (skin), capitis (head) [kerion - Diaper dermatitis
kalbo vs. favus honey crust], manum (hands), o ManagementL Air dry or replace, Nystatin,
pedis (feet), unguium (nails), cruris (groin) Clotrimazole
[hadhad] - Candidemia – persistent fever in spite of antibiotics
• Causative agents: • Test: Beta-D-Glucan
Microsporum spp. • DOC: Fluconazole
Trichophyton T. mentagrophytes – tinea pedis (most B. Aspergillus spp.
spp. common) • Aspergillus fumigatus
T. concentricum – tinea imbricata, • Soil – where organism function as saphrophyte
“toquelau” • Aerosolizes conidia which immunocompetent breathe daily
Epidermophyton spp. but cleared by macrophages
• Diagnosis: KOH skin scrapings, Wood’s light • Inhaled leading to Allergic Pulmonary aspergillosis
(result:flourescence) o May lead to formation of fungus ball =
• Management: Topical imidazole, keep the area dry Aspergilloma
• Diagnosis: Galactomannan Ag testing; CT Scan (+) halo
II. Superficial Mycoses sign [early] and air crescent sign [late]
• DOC: Voriconazole
A. Pityriasis versicolor C. Mucormycosis
• An-an • Zygomycosis
• Etiology: Malassezia furfur (Before: Pityrosporum • Leading pathogen: Rhizopus and Mucor
orbiculare/ovale) • Common among the immunocompromised
• Hypopigmented macules • Rhinocerebral mucormycosis
• “Spaghetti and meatballs” appearance on microscopy D. Cryptococcus spp.
• Management: Selenium sulfide, Ketoconazole • Cryptococcosis – AIDS defining condition (CD4+ T cells =
controls the organism in the body)
B. Tinea nigra
• C. neoformans – most common causative agent
• Etiology: Hortaea (Exophiala) werneckii (pigmented)
• Source: pigeon droppings
• “black colonies” on culture
• Transmission = inhalation of infectious borne particles
• Brown macules on face, hand
• Meningitis – most common manifestation
C. Black Piedra • Diagnosis: CALAS, India ink
• Fungal infection of scalp hair • Management: Amphotericin B + Flucytosine; Note
• Etio: Piedraia hortae Maintenance Fluconazole
• Discrete, hard, dark brown to black nodules on the hair
– firmly attached VI. ANTI-FUNGAL AGENTS
D. White Piedra
• Fungal infection of facial, axillary, genital hair Drug MOA Remarks
• Etio: Trichosporon spp. Amphotericin B Bind to - “Queen of all antifungals”
• Soft, white to yellowish nodules loosely attached to the ergosterol - Broad-spectrum
hair leading to - DOC vs. life-threatening
increased fungal infections
III. Subcutaneous mycosis membrane - IV and liposomal
• Initiated by traumatic implantation into subcutaneous permeability preparation
tissues. - Amphotericin A =
A. Sporotrichosis relatively less clinically
• Etio: Sporothrix schenckii (thermally dimorphic fungus) important
• Horticulturists, forest rangers - Nephrotoxic
• Lymphocutaneous sporotrichosis – small, movable, non- Flucytosine Interferes with - Anti-metabolite
tender, subcutaneous nodule appears at puncture site then DNA synthesis - Narrow spectrum (not
progressively involves proximal lymphatics. used as monotherapy)
• As mold: daisy-like microconida Echinocandin Inhibits B-(1,3) - IV preparation
• As yeast: cigarette butt apearance (i.e. glucan synthase - “Cidal” vs. Candida
• Management: SSKI, Itraconazole, Fluconazole Caspofungin) - “Static” vs. Asgergillus
B. Chromomycosis - Salvage therapy vs.
• Etiology: Fonsecaea pedrosoi invasive aspergillosis
• Slow development of verrucous, cutaneous vegetations Griseofulvin Inhibits mitosis - Vs. ringworm infections
• Microscopy: copper-colored sclerotic bodies by binding to - Increased absorption if
• Management: SSKI, Itraconazole, Fluconazole microtubule taken with fatty foods
C. Mycetoma associated
• Madura foot, maduromycosis protein
• Etio: Pseudallescheria boydii Terbinafine Inhibits squalene - Vs. onchomycosis
• Draining sinuses + granules epoxidase - Allylamine
• Note True mycetoma/Eumycotic = true filamentous fungi AZOLES: Imidazole (less specific, more toxic)
i.e. Ketoconazole, Miconazole, Clotrimazole
st
IV. Systemic Mycoses Ketoconazole Inhibit 14-alpha- - 1 oral azole
• Enter via the respiratory tract sterol - Less specific vs. fungal
• Similar to TB but no person-to-person spread demethylase CYP450
For questions, suggestions, and clarification, please send an email to nicocfabian@gmail.com.
Do not be anxious about anything, but in every situation, by prayer and petition, with thanksgiving, present your requests to God. PHILIPPIANS 4:6
 MANOR REVIEW CENTER
MODULE 6 SUPPLEMENT HANDOUT Updated APRIL 2018
Nico C. Fabian, RPh, MD
- Adverse effect: • Reporting: Regular reporting information on antibiotic use
Gynecomastia, and resistance to doctors, nurses and relevant staff
decreased libido
• Education: Educating clinicians about resistance and
AZOLES: Triazole (more specific, less toxic)
optimal prescribing
Itraconazole Inhibit 14-alpha- - VS. indolent, non-
C. RESPONSIBILITIES OF PHARMACISTS IN ANTIMICROBIAL
sterol meningeal fungal
STEWARDSHIP
demethylase infections
• Promoting optimal use of antimicrobial agents
- Adverse effects:
hypertension, • Reducing the transmission of infection
rhabdomyolysis, • Educational activities
hepatotoxicity III. CDC BIOTERRORISM AGENTS
Fluconazole - Absorbed irrespective of Category A
gastric activity The U.S. public health system and primary healthcare providers must
- DOC vs. Candida be prepared to address various biological agents, including pathogens
- Adverse effect: SJS that are rarely seen in the United States. High-priority agents include
Voriconazole - DOC vs. aspergillosis organisms that pose a risk to national security because they
- Adverse effect: transient • can be easily transmitted from person to person
visual changes
Posaconazole - Vs. Rhizopus
• result in high mortality rates and have the potential for major
public health impact
- Broadest spectrum
among the azoles • might cause public panic and social disruption
• require special action for public health preparedness.
Agents/Diseases
ADDITIONAL NOTES FROM FEEDBACK • Anthrax (Bacillus anthracis)
• Botulism (Clostridium botulinum toxin)
I. PHARMACISTS IN EMERGENCY MEDICINE
• Emergency medicine is an interdisciplinary area that • Plague (Yersinia pestis)
covers medical care in an emergency room, trauma center • Smallpox (variola major)
and intensive care unit. It also provides prehospital • Tularemia (Francisella tularensis)
emergency medical service and disaster medicine.
• Viral hemorrhagic fevers, including
• Basic life support and first-aid ability are mandatory to all
the medical professionals who take care of patients.
o Filoviruses (Ebola, Marburg)
A. ROLES OF PHARMACIST
o Arenaviruses (Lassa, Machupo)
Category B
• Pharmacists are expected to play major roles as a Second highest priority agents include those that
member of the emergency medical team.
o Administration guidance • are moderately easy to disseminate;
o Analysis of intoxicating substance • result in moderate morbidity rates and low mortality rates
o Formulary management • require specific enhancements of CDC’s diagnostic capacity
o Identification of a tablet and enhanced disease surveillance.
o Inventory management Agents/Diseases
o Medication delivery
o Therapeutic drug monitoring • Brucellosis (Brucella species)
B. EMERGENCY PREPAREDNESS • Epsilon toxin of Clostridium perfringens
GENERAL PRINCIPLES • Food safety threats (Salmonella species, Escherichia
• Pharmacists should have a key role in the planning and coli O157:H7, Shigella)
execution of • Glanders (Burkholderia mallei)
o Pharmaceutical distribution and control • Melioidosis (Burkholderia pseudomallei)
o Drug therapy management of patients
• The expertise of the pharmacist should be sought in
• Psittacosis (Chlamydia psittaci)
o Developing guidelines for the diagnosis and • Q fever (Coxiella burnetii)
treatment of casualties and exposed individuals, • Ricin toxin from Ricinus communis (castor beans)
o Selecting pharmaceuticals and related • Staphylococcal enterotoxin B
supplies for national and regional stockpiles and
local emergency inventories in emergency- • Typhus fever (Rickettsia prowazekii)
preparedness programs • Viral encephalitis (alphaviruses, such as eastern equine
o Ensuring proper packaging, storage, handling, encephalitis, Venezuelan equine encephalitis, and western
labeling, and dispensing of emergency supplies equine encephalitis])
of pharmaceuticals • Water safety threats (Vibrio cholerae, Cryptosporidium
o Ensuring appropriate deployment of emergency parvum)
supplies of pharmaceuticals Category C
o Ensuring appropriate education and counseling Third highest priority agents include emerging pathogens that could be
of individuals who receive pharmaceuticals from engineered for mass dissemination in the future because of
an emergency supply in response to a disaster
• availability
• Pharmacists should be in a position to advise public health
officials on appropriate messages to convey to the public • ease of production and dissemination
• In the event of a disaster, pharmacists should be called on to • potential for high morbidity and mortality rates and major
collaborate with physicians and other prescribers in health impact.
managing the drug therapy of individual victims. Agents
• Emerging infectious diseases such as Nipah
II. PHARMACISTS AND ANTIBIOTICS
virus and hantavirus
A. LEADING CAUSES OF NOSOCOMIAL INFECTIONS
• The ESKAPE pathogens are the leading cause of
nosocomial infections throughout the world. . QUALI/QUANTI PRACTICE PROBLEMS
o Enterococcus faecium
o Staphylococcus aureus Determine the weight
o Klebsiella pneumoniae amount of NaOH MW
Molarity =
o Acinetobacter baumannii (MW: 40) pellets Liter
o Pseudomonas aeruginosa that should be
weighed to prepare weight
o Enterobacter species
0.25 L of a 0.05 M 40
B. CDC CORE ELEMENTS OF HOSPITAL ANTIBIOTIC 0.05 =
STEWARDSHIP PROGRAM solution. 0.25 L
Answer: 0.5 grams or 500 mg
• Leadership Commitment: Dedicating necessary human, A 25 gram sample 2NaHCO3 + H2S04 à Na2SO4 + 2H2O +
financial and information technology resources of NaHCO3 2CO2
• Accountability: Appointing a single leader responsible for consumed 15.00 mL
program outcomes. of 1 N Sulfuric Acid MW
N*V*
VS. Determine the (f ∗ 1000)
• Drug Expertise: Appointing a single pharmacist leader %P = x 100
responsible for working to improve antibiotic use. % NaHCO3. amount of sample
84
• Action: Implementing at least one recommended action, 1 ∗ 15 ∗
(1 ∗ 1000)
such as systemic evaluation of ongoing treatment need after %P = x 100
25 g
a set period of initial treartment Answer: 5.04%
• Tracking: Monitoring antibiotic prescribing and resistance

For questions, suggestions, and clarification, please send an email to nicocfabian@gmail.com.

Do not be anxious about anything, but in every situation, by prayer and petition, with thanksgiving, present your requests to God. PHILIPPIANS 4:6
MANOR REVIEW CENTER
MODULE 6 SUPPLEMENT HANDOUT Updated APRIL 2018
Nico C. Fabian, RPh, MD
Given the following %P
reaction: NaCl + MW
N*V excess- N*V back *( )
AgNO3 ⇒ AgCl = f ∗ 1000 x 100
+NaNO3 amount of sample
Fifty mL of 0.1 N 58
0.1 ∗ 50 - 0.1 ∗ 12.00 *( )
Silver nitrate VS %P = 1 ∗ 1000
was delivered in the 0.1234
Answer: 178.61%
assay of NaCl
(MW:58). The back
titration involved
12.00 mL of 0.1 N
NH4SCN VS. If the
sample weighs
0.1234 g, % purity is
Ms. M.L., Mr. J.M., Rf = distance solute/ distance solvent
Mr. H.U. and their Rf = 9 cm/12 cm
class in the 2D TLC Answer: 0.75
analysis of Banaba
leaves obtained
from Bohol.
If only two spots
were obtained and
spot A travelled 2
cm ahead of Spot B
whose distance
from the starting line
is 7 cm, what is the
Rf of spot A? The
solvent front is 12
cm.
A 10 gram sample N*V ∗ 56.11
of TMT Oil required Acid Value =
amount of sample
30.0 mL of 0.1 N 0.1 ∗ 30.0 ∗ 56.11
KOH VS. What is Acid Value =
10
the acidity index of Answer: 16.83
the unknown oil?

For questions, suggestions, and clarification, please send an email to nicocfabian@gmail.com.

Do not be anxious about anything, but in every situation, by prayer and petition, with thanksgiving, present your requests to God. PHILIPPIANS 4:6