04 Antimicrobials
Last updated
Last updated
Metro: metronidazole
Mr Fragilis stabbed in the abdomen: coverage of polymicrobial anaerobic infections (e.g. intra-abdominal infections)
Broken helix: free radical metabolites disrupt bacterial DNA (bactericidal)
Do not enter: activity against Entamoeba histolytica
Colonel Giardia with the protozoan shield: activity against Giardia
Mr. Trichomonas with the strawberry: treats vaginitis and cervicitis caused by Trichomonas
Mrs. Trichomonas: treat both patient and partner
Ms. Gardner with the venus fly trap: treats bacterial vaginosis caused by Gardnerella
Helicopter: substitute for amoxicillin in the triple therapy for Helicobacter pylori infection in penecillin-allergic patients
Mlle. Clostridium with the gas mask: activity against anaerobic bacteria (e.g. Bacteroides, Prevotella, Fusobacterium, Clostridium
Chocolate fondu fountain: treats pseudomembraneous colitis caused by Clostridium difficile
No drinking: Concurrent ingestion of alcohol results in a disulfiram-like reaction (flushing, tachycardia, palpitations, nausea, vomiting
amphotericin, flucytosine
azoles
griseofulvin, terbinafine, echinocandins
Amphibian: amphotericin (anti-fungal)
Non sterol: fungal cell membrane composed of ergosterol, not your usual cholesterol
Holes in amphibian tank: amphotericin and nystatin bind ergosterol to form holes in the fungal cell membrane, leading to electrolyte loss and cell death. Down regulation of erosterol leads to resistance
Ivy: IV administration of amphotericin
Fat bubble: liposomal formulations of amphotericin prevent binding to human cholesterol membranes (decreased toxicity)
Organ systems model: amphotericin treats severe systemic fungal infections
infusion related immediate reactions and slow accumulated toxicities
Amphibian binding cholesterol necktie: amphotericin toxicity results from non-selective binding to mammalian cholesterol membranes
Fainting and holding head: hypotension and headache are immediate infusion-related toxicities of amphotericin
Shake and bake: fevers and chills are immediate infusion-related toxicities of amphotericin
Tongue on brain: intrathecal administration of amphotericin to treat fungal CNS infections
Shaking brain: intrathecal administration of amphotericin can cause seizure and other CNS side effects
Blue veiny pattern: thrombophlebitis at injection site is an immediate infusion-related toxicity of amphotericin
1 shaped acid tube: renal tubular acidosis (RTA) type 1 is cumulative toxicity of amphotericin
Depleted potassium banana peel: RTA type 1 is associated with hypokalemia
Magnet falling into sink: amphotericin can cause hypomagnesemia (due to renal magnesium wasting)
Emergency saline wash: volume expansion with IV normal saline before amphotericin administration prevents kidney damage
Cracked and drained kidney: amphotericin induced damage to renal tubular cells can cause anemia (decreased erythropoietin production)
Nyce: nystatin (same mechanism of action as amphotericin)
Canada: nystatin is treats Candida infections (candidiasis)
Snow on crotch: topical nystatin treats mucocutaneous candidiasis (e.g. vaginal candidiasis)
Swish and swallow drinking fountain: oral nystatin rinse treats oropharyngeal candidiasis
Flute: flucytosine (anti-fungal)
Meningitis helmet: flucytosine and amphotericin combo treats cryptococcal meningitis
"Crypt": flucytosine and amphotericin combo treats Cryptococcus infections (e.g. cryptococcal meningitis)
C turned into U: cytosine deaminase in fungal cells converts flucytosine (a fluorinated cytosine) into 5-fluorouracil (5-FU)
Smeared double helix and single strand: flucytosine halts fungal DNA and RNA/protein synthesis
Pine cones: cone-azole antifungals (e.g. voriconazole, fluconazole, itraconazole, clotrimazole, miconazole, ketoconazole)
Emerald perimeter: ergosterol comprises the fungal cell membrane
Crushed emerald builder: azole antifungals inhibit the synthesis of ergosterol
Lane closed: azole antifungals inhibit the conversion of lanosterol to ergosterol
Broken chrome bumper: azole antifungals inhibit fungal cytochrome P-450 responsible for the conversion. Also SE because CYP 450
Car crushing vortex: voriconazole inhibits mammalian cytochrome P-450, dose reduction of other medication needed (cyclosporin, statin, tacrolimus)
Blurry flashes: voriconazole may cause blurry vision of flashes of light
Sepia tone: voriconazole may cause changes in color vision
Aspirating scarecrow with lung hyphae: voriconazole treats invasive aspergillosis (caused by Aspergillus fumigates)
Canada: voriconazole treats Candida infections (e.g. esophageal candidiasis)
Flying monkey: fluconazole
Canada: fluconazole treats Candida infections (e.g. mucocutaneous candidiasis)
Snow on crotch: one-time oral dose of fluconazole treats vaginal candidiasis
Snow in gutter: systemic fluconazole treats esophageal candidiasis
Crypt: fluconazole treats Cryptococcus infections (e.g. cryptococcal meningitis), lifelong therapy
Meningitis mohawk helmets: fluconazole has high levels of CNS penetration (treats cryptococcal meningitis)
Good witch: itraconazole (azole antifungal)
Dimorphic butterfly: itraconazole treats systemic infections with dimorphic fungi (e.g. histoplasmosis, blastomycosis, coccidioidomycosis, sporothrix))
Tarnished ruby slippers: itraconazole treats onychomycosis and dermatophytosis
Tin man: dermatophytes (tinea)
Close trim: topical clotrimazole treats tinea infections (e.g. dermatophytosis)
My cone: topical miconazole treats tinea infections (e.g. dermatophytosis)
Snow on crotch: clotrimazole and miconazole treat vaginal candidiasis
treats onychomycosis and cutaneous dermatophytes
Adrenal lock: ketoconazole inhibits 17,20-desmolase (the first step of steroid hormone synthesis from cholesterol)
Male and female symbols: ketoconazole inhibits production of androgens and estrogens
Moon face: ketoconazole inhibits overproduction of cortisol (treats the symptoms of cushing's disease)
Ketoconazole can cause anti-androgenic side effects (e.g. gynecomastia)
Broken spindle vines: griseofulvin binds fungal cell microtubules, halting mitosis
Rusty tin man: dermatophytes (e.g. tinea corporis, tinea pedis, and tinea cruris)
Grease: griseofulvin antifungal agent, stay in keratin tissues thus best for capitis and skin
Tin man hat: oral griseofulvin and terbinafine are first line therapy for tinea capitis in children
SE: GI distress, headache, rash; heptatotoxicity, granulocytopenia
Greased up chrome bumper: griseofulvin activates cytochrome P-450
Turban: terbinafine (anti-fungal agent)
Non sterol: fungal cell membrane composed of ergosterol (not your usual cholesterol)
Squealing pig pen: terbinafine inhibits fungal squalene epoxidase causing accumulation of squalene
Little tin man: topical terbinafine is used to treat tinea infections (e.g. dermatophytosis)
Biting nails: oral terbinafine treats onychomycosis
Tin man hat: oral griseofulvin and terbinafine are first line therapy for tinea capitis in children
Mud puddles: terbinfine can cause GI side effects
Liver spot: terbinafine can cause hepatotoxicity
Echino-Canadian fur cap: echinocandins (e.g. caspofungin, micafungin, anidulafungin)
Crumbling brick wall: echinocandins act at the fungal cell wall
Polysaccharide shaped wall: echinocandins inhibit the synthesis of beta-1-3-glucan (polysaccharide, not ergosterol) in the fungal cell wall, not cell membrane
Ivy: echinocandins are delivered IV for systemic Candida infections (e.g. candidemia)
Canada: echinocandins have excellent activity against Candida infections (e.g. mucocutaneous candidiasis)
Exhaust pipe with snow: echinocandins treat esophageal candidiasis
Scarecrow with lung hyphae: echinocandins treat invasive aspergillosis (caused by Aspergillus fumigatus)
Knights of the Round Table: NRTIs
Reverso transcriptum: reverse transcriptase
Nucleoside-shaped mace: NRTIs are nucleotides or nucleosides (sugar on base)
Broken double helix bookmark: NRTIs incorporate into growing viral DNA strand. Competitive inhibitor
Broken spike: NRTIs lack a hydroxyl group at the 3' end (no phosphodiester bond formation > chain termination)
Page 3' to 5': NRTIs inhibit 3' to 5' phosphodiester bond formation
Activating "P" scroll: nucleosides need phosphorylation by cellular enzymes in order to be activated
Feast: -dine suffix of NRTIS (e.g. lamivudine, stavudine, zidovudine)
Sir Lancelot: Lamivudine (nucleoSIDE RTI)
Sir Tristan: tenofovir (nucleoTIDE RTI)
Princess Izolde and dove sigil: Zidovudine (nucleoSIDE RTI)
Sir Steve: stavudine (nucleotide RTI)
Sir Dan: didanosine (nucleoSIDE RTI)
Abracadabra: abacavir (nucleoSIDE RTI)
Excalibur: emtricitabine (nucleoSIDE RTI)
Woodgrain cisternae: NRTIs can cause mitochondrial toxicity
Sour milk: NRTIs can cause lactic acidosis
Stockings and gloves: lamivudine, stavudine, and didanosine can cause peripheral neuropathy
Sir Lancelot: Lamivudine (nucleoSIDE RTI)
Hippie Hippo sigil: lamivudine and tenofovir treat hepatitis B infection
Woodgrain cisternae: NRTIs can cause mitochondrial toxicity
Sour milk: NRTIs can cause lactic acidosis
Stockings and gloves: lamivudine, stavudine, and didanosine can cause peripheral neuropathy
Sir Tristan: tenofovir (nucleoTIDE RTI)
Actively sailing the tide: tenofovir is a nucleotide and does not need activation by phosphorylation
Hippie Hippo sigil: lamivudine and tenofovir treat hepatitis B infection
Princess Izolde and dove sigil: Zidovudine (nucleoSIDE RTI)
Pregnant Izolde: Zidovudine is used during pregnancy and breastfeeding to reduce vertical transmission of HIV
Devoured marrow: zidovudine may cause myelosuppression
Pale white dress: zidovudine can cause megaloblastic anemia
Multi-lobed sand timer: zidovudine can cause agranulocytosis
Centrally fat horse: zidovudine and stavudine can cause lipodystrophy (redistribution of fat from extremities to trunk)
Sir Steve: stavudine (nucleotide RTI)
Centrally fat horse: zidovudine and stavudine can cause lipodystrophy (redistribution of fat from extremities to trunk)
Woodgrain cisternae: NRTIs can cause mitochondrial toxicity
Sour milk: NRTIs can cause lactic acidosis
Stockings and gloves: lamivudine, stavudine, and didanosine can cause peripheral neuropathy
Sir Dan: didanosine (nucleoSIDE RTI)
Squeezed sponge: didanosine can cause pancreatitis
Woodgrain cisternae: NRTIs can cause mitochondrial toxicity
Sour milk: NRTIs can cause lactic acidosis
Stockings and gloves: lamivudine, stavudine, and didanosine can cause peripheral neuropathy
Abracadabra: abacavir (nucleoSIDE RTI)
HLA-B spell: Abacavir hypersensitivity is associated with the HLA-B 57:01 allele
Delayed reaction to rash: abacavir may cause a delayed type 4 hypersensitivity reaction
Excalibur: emtricitabine (nucleoSIDE RTI)
Dark gloves: emtricitabine can cause hyperpigmentation of palms and soles
Outside camelot: not Knights of the Round Table - NNRTIs
Fleeing "P"d signal: NNRTIs are not phosphorylated by intracellular enzymes
Arrow in Reverso Transcriptum: direct binding and allosteric inhibition of HIV reverse transcriptase
Broken double helix bookmark: halted DNA polymerase activity
Elven pine forest: eevirapine
Queen Elfavirenz: efavirenz
Princess Delavir: delavirdine
Jaundiced yellow glow and liver spot: liver failure can occur within 6 weeks of starting therapy
Dark moon: side effect of insomnia and nightmares
Mesmerized by hallucinations: side effect of CNS symptoms (e.g. dizziness, drowsiness, headache, psychosis)
Tarantula: teratogenic. Avoid both efavirenz and delavirdine in pregnancy
Chrome bumper: varying effects on the cytochrome P-450 system
Sloughed off mask: side effect of Stevens-Johnson syndrome (SJS-TEN). Association with skin rash
Guinevere: -navir suffix of protease inhibitors
Fleeing "P" signal: protease inhibitors are not phosphorylated by intracellular enzymes
Sword in the stone: protease inhibitor
immature knight: virion remains immature. HIV must cleave long proteins into smaller ones. Inhibit polyprotein cleavage
Paul's Smithy: POL gene codes for production of HIV enzymes (e.g. protease)
Indigo princess: indinavir
Right on!: ritonovir has greatest cytochrome P-450 inhibitory effect and boosts concentration of other protease inhibitors
Elevated candy jar: side effect of hyperglycemia due to insulin resistance
Elevated butter: side effect of dyslipidemia
Central adiposity: side effect of lipodystrophy
Broken chrome bumper: inhibition of cytochrome P-450
Indigo princess: indinavir
Stones in kidney fountain: indinavir may cause nephrolithiasis
Adequate hydration helps to prevent nephrolithiasis
Elevated candy jar: side effect of hyperglycemia due to insulin resistance
Elevated butter: side effect of dyslipidemia
Central adiposity: side effect of lipodystrophy
Broken chrome bumper: inhibition of cytochrome P-450
Right on!: ritonovir has greatest cytochrome P-450 inhibitory effect and boosts concentration of other protease inhibitors
Elevated candy jar: side effect of hyperglycemia due to insulin resistance
Elevated butter: side effect of dyslipidemia
Central adiposity: side effect of lipodystrophy
Broken chrome bumper: inhibition of cytochrome P-450
Speeding rifle: rifampin activates cytochrome P-450 and decreases the concentration of protease inhibitors (rifabutin is better)
Invading ship: budding virion invades next cell
120 battering ram: surface glycoprotein gp120 allows HIV to gain entry
41 grappling hook: surface glycoprotein gp41 facilitates HIV fusion, if made it then:
Reverso transcriptum spell: reverse transcriptase
Double helix staircase behind keyhole: integrase allows viral DNA to integrate with host cell DNA
Gagged prisoners in the core of the ship: gag structural gene codes for virion core proteins (e.g. p24, p7) (24 hours, 7 days)
24 hour sundial: gag structural gene codes for virion core proteins (e.g. p24, p7)
Envoy coming ashore: env structural gene encodes viral envelope proteins for infiltration (e.g. gp41, gp120)
120 battering ram: surface glycoprotein gp120 allows HIV to gain entry
Helper squire and CCR5 banner: gp120 binds to the host cell CD4 molecule and chemokine receptor (CXCR4 or CCR5)
41 grappling hook: surface glycoprotein gp41 facilitates HIV fusion
In the HIV replication cycle, polyprotein precursors are encoded by structural genes (gag, pol, and env). Only the polyprotein product of the env gene is glycosylated to become gp160. The gp160 is then proteolytically cleaved within the endoplasmic reticulum and Golgi apparatus to form gp120 and gp41. gp120 mediates viral attachment by binding to the CD4 receptor of susceptible cells. Transmembrane gp41 anchors gp120 through noncovalent interactions, thereby mediating the fusion process between viruses and target cells. A few antiretroviral medications interact with these glycoproteins.
Mare with CCR5 banner: the entry inhibitor maraviroc allosterically binds CCR5, not CXCR4
Fusion hook deflector: fusion inhibitor enfuvirtide binds gp41
Endoplasmic reef: env encoded surface proteins are first sent to the host cell endoplasmic reticulum
Reverso transcriptum spell: reverse transcriptase
Doubling army: reverse transcriptase transcribes viral RNA into double stranded DNA
King arthur and elf queen elfavir: NRTIs and NNRTIs inhibit reverse transcriptase. Resistance from mutated pol gene
Paul the blacksmith producing swords, spell books, and keys: pol gene encodes for protease, reverse transcriptase, and integrase
Double helix staircase behind keyhole: integrase allows viral DNA to integrate with host cell DNA
Key deflector blocking route: the integrase inhibitor raltegravir/dolutegravir binds viral integrase
Crispy chicken with bite: integrase inhibitors may cause rhabdomyolysis
Infected manager releasing cyto-coins: interferons are immunomodulatory cytokines released from virus infected cells that activate immune response (modulate T cells, activate macrophages, buff up antiviral cell response)
Luke: interleukins upregulate interferon synthesis in infected cells
Pac man: Interferon alpha
yellow Hippo: interferon alpha treats hepatitis B and C infections
Melanotic ghost: interferon alpha treats malignant melanoma
Hairy creature: interferon alpha treats hairy cell leukemia
Posies: interferon alpha treats Kaposi sarcoma caused by HHV8
Accumulated tokens: interferon alpha treats condyloma accuminata caused by HPV
Plush cancer crab in kidney machine: interferon alpha treats renal cell carcinoma
Interferon alpha may cause a flu like syndrome, or more severe symptoms including profound fatigue, tinnitus, retinopathy, confusion; occurs within a few hours.
Devoured marrow: interferon alpha may cause myelosuppression
Plush wolf: interferon alpha may cause drug induced lupus
beta invaders: Interferon beta
Combat Lesions through Time and space: Interferon beta treats multiple sclerosis (MS). MS lesions in different time and space
gamma ga: Interferon gamma
Destroyed granulomatous asteroids: interferon gamma treats chronic granulomatous disease (CGD). Activate macrophages
Sea Hippo: hepatitis C
Identify the HCV genotype to select treatment regimen
Stony liver under microscope: liver fibrosis is assessed before beginning treatment
Photographic evidence: all patients with virologic evidence of chronic HCV infection should be considered for treatment
Sustained search for 6 months: sustained virologic response (SVR) - HCV RNA not detected by PCR for 6 months after stopping treatment
Alpha shaped antenna: once weekly pegylated-interferon alpha is the traditional standard treatment (with daily ribavirin)
Ribs: daily ribavirin is the traditional standard treatment (with once weekly pegylated interferon alpha
Purine G shaped stakes: ribavirin is a guanosine nucleoside analog
3 pepper shakers: ribavirin is phosphorylated three times by intracellular enzymes into its active nucleotide form
Disrupted RNA rope: the activated nucleotide form of ribavirin inhibits RNA production
Bursting fruits: ribavirin causes dose dependant hemolytic anemia
Tarantula: ribavirin is teratogenic
Sofa with nucleoside pattern: sofosbuvir - a nucleoside analog
Disrupted RNA rope: sofosbuvir inhibits NS5B RNA production
Fatigued explorer: side effects of sofosbuvir include fatigue and nausea
Stuck machete: NS3/4A protease inhibitor
Simmering: simeprevir (a protease)
Flash photo: seide effects of simeprevir include photosensitivity and rash
Broken chrome bumper: simeprevir inhibits cytochrome P450
North Sea under investigation: new investigational drugs include second generation NS3/NS4A protease inhibitors and NS5A inhibitors
Hermes airline: herpes simplex virus (HSV)
Recycling bin: acyclovir
Purine shaped luggage: guanisine nucleoside analog
Hermes with "P" luggage tag: converted to acyclovir monophosphate via virus encoded thymidine-kinase (occurs selectively in virus/Hermes cells) (only affect infectd cells)
Herpesvirus-encoded thymidine-kinase is the rate determining activation step
Bag checkers with "P" tags: converted 2x more to acyclovir triphosphate by cellular kinases
Branching double helix conveyor belts: viral DNA dependent DNA polymerase
Baggage jam: acyclovir triphosphate incorporates into replicating viral DNA, halting synthesis
Closed baggage check: absence of thymidine-kinase confers resistance (CMV/EBV don't have)
Security officer Cid: Cidofovir
"P" access badge: cidofovir does not require phosphorylation by the viral kinase "3 active against acyclovir or ganciclovir resistant HSV, CMV, VZV
Luggage car net: foscarnet is active against acyclovir or ganciclovir resistant HSV, CMV, VZV (no activation at all)
Conveyor belt stop switch: cidofovir and foscarnet directly inhibit viral DNA polymerase
Valet parking: valacyclovir
Daily rate for frequent flyers: daily valacyclovir suppressive therapy for multiple yearly episodes of recurrence
Open mouth: valacyclovir has improved oral bioavailability
Recycling bin: acyclovir
Ivy: IV acyclovir treats serious HSV and VZV infections
Red winged helmet: IV acyclovir treats HSV encephalitis
Baby Hermes helmet: IV acyclovir treats neonatal HSV
Zeus: varicella zoster virus
Family value: famcyclovir and valacyclovir are preferred treatments for VZV due to superior activity and less frequent dosing
3 days: during active shingles infection, valacyclovir and famcyclovir are most effective if given within 3 days of onset of symptoms
Prepare: HSV prophylaxis
Cane and organs: HSV prophylaxis important in immunocompromised states and transplant patients
Pregnant: HSV prophylaxis important in pregnant women with active recurrent genital herpes
Kidney sharps: IV acyclovir can cause interstitial nephritis or crystalline nephropathy
Adequate hydration prevents renal side effects
Uncommon CNS side effects: delirium, confusion, vertigo, hallucinations
Mega-Lo Market: cytomegalovirus (CMV)
50 items or less: CMV infections are more common with a CD4+ count < 50
Can recycling: ganciclovir
G toys: Ganciclovir is guanisine analog
Market worker with "P" label gun: converted to ganciclovir monophosphate by a CMV encoded kinase (UL97)
Customers with "P" label guns: converted to ganciclovir triphosphate by cellular kinases
Branching double helix conveyor belts: viral DNA dependent DNA polymerase
Grocery jam: ganciclovir triphosphate incorporates into replicating viral DNA, halting synthesis
Value: valganciclovir
Open mouth: valganciclovir has better oral bioavailability
Organs on ice: valganciclovir or ganciclovir is indicated in high-risk solid organ and bone marrow transplant recipients
Princess Izolde: myelosuppression may be additive in patients receiving zidovudine
Car net: foscarnet
Spilled kidney beans: foscarnet may induce renal insufficiency
Broken milk bottles: foscarnet may cause hypocalcemia
Falling magnets: foscarnet may cause hypomagnesemia
Banana peel: foscarnet may cause hypokalemia
Shaking: foscarnet may induce seizures
Security officer Cid: Cidofovir
Broken kidney: cidofovir nephrotoxic, leading to proteinuria, azotemia, and metabolic acidosis
Probation officer Cid: probenecid blocks the tubular secretion of cidofovir, limiting its toxic effects
No drugs touching kidney: probenecid prevents excretion and increases plasma concentrations of many different drugs (e.g. penicillins, methotrexate, NSAIDs)
