> For the complete documentation index, see [llms.txt](https://thisispiggy.gitbook.io/my-wiki/llms.txt). Markdown versions of documentation pages are available by appending `.md` to page URLs; this page is available as [Markdown](https://thisispiggy.gitbook.io/my-wiki/01-step-1/antimicrobials/04-antimicrobials.md). # 04 Antimicrobials ## Metronidazole ![](https://f001.backblazeb2.com/file/wikiFiles/t7sVAdF.jpg) * 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) ![](https://f001.backblazeb2.com/file/wikiFiles/t7sVAdF.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/t7sVAdF.jpg) * No drinking: Concurrent ingestion of alcohol results in a disulfiram-like reaction (flushing, tachycardia, palpitations, nausea, vomiting ## Antifungals * amphotericin, flucytosine * azoles * griseofulvin, terbinafine, echinocandins ### Amphotericin ![](https://f001.backblazeb2.com/file/wikiFiles/kany643.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/kany643.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/kany643.jpg) * infusion related immediate reactions and slow accumulated toxicities ![](https://f001.backblazeb2.com/file/wikiFiles/kany643.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/kany643.jpg) * 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) ### Nyastatin ![](https://f001.backblazeb2.com/file/wikiFiles/kany643.jpg) * 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 ### Flucytosine ![](https://f001.backblazeb2.com/file/wikiFiles/kany643.jpg) * 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) ![](https://f001.backblazeb2.com/file/wikiFiles/kany643.jpg) * 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 ### Azoles ![](https://f001.backblazeb2.com/file/wikiFiles/5pPeRbU.jpg) * Pine cones: cone-azole antifungals (e.g. voriconazole, fluconazole, itraconazole, clotrimazole, miconazole, ketoconazole) ![](https://f001.backblazeb2.com/file/wikiFiles/5pPeRbU.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/5pPeRbU.jpg) * 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) ![](https://f001.backblazeb2.com/file/wikiFiles/5pPeRbU.jpg) * 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) ![](https://f001.backblazeb2.com/file/wikiFiles/5pPeRbU.jpg) * 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) ![](https://f001.backblazeb2.com/file/wikiFiles/5pPeRbU.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/5pPeRbU.jpg) * 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) ### Griseofulvin, Terbinafine, Echinocandins ![](https://f001.backblazeb2.com/file/wikiFiles/CdlC4nD.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/CdlC4nD.jpg) * SE: GI distress, headache, rash; heptatotoxicity, granulocytopenia * Greased up chrome bumper: griseofulvin activates cytochrome P-450 ![](https://f001.backblazeb2.com/file/wikiFiles/CdlC4nD.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/CdlC4nD.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/CdlC4nD.jpg) * Mud puddles: terbinfine can cause GI side effects * Liver spot: terbinafine can cause hepatotoxicity ![](https://f001.backblazeb2.com/file/wikiFiles/CdlC4nD.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/CdlC4nD.jpg) * 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) ## HIV Antivirals ### NRTI ![](https://f001.backblazeb2.com/file/wikiFiles/AHZjKyR.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/KNh17DW.jpg) ![](https://f001.backblazeb2.com/file/wikiFiles/AHZjKyR.jpg) * 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) ![](https://f001.backblazeb2.com/file/wikiFiles/AHZjKyR.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/AHZjKyR.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/AHZjKyR.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/AHZjKyR.jpg) * 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) ![](https://f001.backblazeb2.com/file/wikiFiles/AHZjKyR.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/AHZjKyR.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/AHZjKyR.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/AHZjKyR.jpg) * Excalibur: emtricitabine (nucleoSIDE RTI) * Dark gloves: emtricitabine can cause hyperpigmentation of palms and soles ### NNRTI ![](https://f001.backblazeb2.com/file/wikiFiles/cCZjiEz.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/cCZjiEz.jpg) * Elven pine forest: eevirapine * Queen Elfavirenz: efavirenz * Princess Delavir: delavirdine ![](https://f001.backblazeb2.com/file/wikiFiles/cCZjiEz.jpg) * 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 ### Protease Inhibitors ![](https://f001.backblazeb2.com/file/wikiFiles/8ftTVbk.jpg) * 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** ![](https://f001.backblazeb2.com/file/wikiFiles/8ftTVbk.jpg) * Paul's Smithy: POL gene codes for production of HIV enzymes (e.g. protease) ![](https://f001.backblazeb2.com/file/wikiFiles/8ftTVbk.jpg) * Indigo princess: indinavir * Right on!: ritonovir has greatest cytochrome P-450 inhibitory effect and boosts concentration of other protease inhibitors ![](https://f001.backblazeb2.com/file/wikiFiles/8ftTVbk.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/8ftTVbk.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/8ftTVbk.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/8ftTVbk.jpg) * Speeding rifle: rifampin activates cytochrome P-450 and decreases the concentration of protease inhibitors (rifabutin is better) ### Misc Inhibitors ![](https://f001.backblazeb2.com/file/wikiFiles/YUo3ZSK.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/YUo3ZSK.jpg) * 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) ![](https://f001.backblazeb2.com/file/wikiFiles/YUo3ZSK.jpg) * 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. ![](https://f001.backblazeb2.com/file/wikiFiles/YUo3ZSK.jpg) * **Mare** with CCR5 banner: the entry inhibitor **mara**viroc **allosterically** binds CCR5, not CXCR4 * **Fusion** hook deflector: fusion inhibitor en**fu**virtide binds gp41 ![](https://f001.backblazeb2.com/file/wikiFiles/YUo3ZSK.jpg) * Endoplasmic reef: env encoded surface proteins are first sent to the host cell endoplasmic reticulum ![](https://f001.backblazeb2.com/file/wikiFiles/YUo3ZSK.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/YUo3ZSK.jpg) * Paul the blacksmith producing swords, spell books, and keys: pol gene encodes for protease, reverse transcriptase, and **integrase** ![](https://f001.backblazeb2.com/file/wikiFiles/YUo3ZSK.jpg) * Double helix staircase behind keyhole: integrase allows viral DNA to integrate with host cell DNA * Key deflector blocking route: the inte**gra**se inhibitor ralte**gra**vir/dolute**gra**vir binds viral integrase * Crispy chicken with bite: integrase inhibitors may cause rhabdomyolysis ## Anti Heptatitis ### Interferons ![](https://f001.backblazeb2.com/file/wikiFiles/7QLVrAk.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/7QLVrAk.jpg) * P**a**c 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 ![](https://f001.backblazeb2.com/file/wikiFiles/7QLVrAk.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/7QLVrAk.jpg) * beta invaders: Interferon beta * Combat Lesions through Time and space: Interferon beta treats multiple sclerosis (MS). MS lesions in different time and space ![](https://f001.backblazeb2.com/file/wikiFiles/7QLVrAk.jpg) * gamma ga: Interferon gamma * Destroyed granulomatous asteroids: interferon gamma treats chronic granulomatous disease (CGD). Activate macrophages ### Hep C Treatment ![](https://f001.backblazeb2.com/file/wikiFiles/NiLkunj.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/NiLkunj.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/NiLkunj.jpg) * Purine **G** shaped stakes: ribavirin is a **g**uanosine **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 ![](https://f001.backblazeb2.com/file/wikiFiles/NiLkunj.jpg) * Bursting fruits: ribavirin causes dose dependant hemolytic anemia * Tarantula: ribavirin is teratogenic ![](https://f001.backblazeb2.com/file/wikiFiles/NiLkunj.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/NiLkunj.jpg) * 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 ## Others ### HSV Treatment ![](https://f001.backblazeb2.com/file/wikiFiles/9k1f0Xc.jpg) * Hermes airline: herpes simplex virus (HSV) ![](https://f001.backblazeb2.com/file/wikiFiles/9k1f0Xc.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/9k1f0Xc.jpg) * Branching double helix conveyor belts: viral DNA dependent DNA polymerase * Baggage jam: acyclovir triphosphate incorporates into replicating viral DNA, halting synthesis ![](https://f001.backblazeb2.com/file/wikiFiles/9k1f0Xc.jpg) * Closed baggage check: absence of thymidine-kinase confers resistance (CMV/EBV don't have) ![](https://f001.backblazeb2.com/file/wikiFiles/9k1f0Xc.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/9k1f0Xc.jpg) * Luggage car net: foscarnet is active against acyclovir or ganciclovir resistant HSV, CMV, VZV (no activation at all) ![](https://f001.backblazeb2.com/file/wikiFiles/9k1f0Xc.jpg) * Conveyor belt stop switch: cidofovir and foscarnet directly inhibit viral DNA polymerase ![](https://f001.backblazeb2.com/file/wikiFiles/9k1f0Xc.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/9k1f0Xc.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/9k1f0Xc.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/9k1f0Xc.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/9k1f0Xc.jpg) * 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 ### CMV ![](https://f001.backblazeb2.com/file/wikiFiles/tMr7SFP.jpg) * Mega-Lo Market: cytomegalovirus (CMV) * 50 items or less: CMV infections are more common with a CD4+ count < 50 * Can recycling: ganciclovir ![](https://f001.backblazeb2.com/file/wikiFiles/tMr7SFP.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/tMr7SFP.jpg) * Value: valganciclovir * Open mouth: valganciclovir has better oral bioavailability ![](https://f001.backblazeb2.com/file/wikiFiles/tMr7SFP.jpg) * Organs on ice: valganciclovir or ganciclovir is indicated in high-risk solid organ and bone marrow transplant recipients ![](https://f001.backblazeb2.com/file/wikiFiles/tMr7SFP.jpg) * Princess Izolde: myelosuppression may be additive in patients receiving zidovudine ![](https://f001.backblazeb2.com/file/wikiFiles/tMr7SFP.jpg) * 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 ![](https://f001.backblazeb2.com/file/wikiFiles/tMr7SFP.jpg) * 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)