05/05/2021

OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF PHARMACY Virus
• A small collection of genetic code, either DNA
or RNA, surrounded by a protein coat
VIRAL INFECTION – They reproduce at a fantastic rate, but only in
living host cells
– They can mutate
CLINICAL PHARMACY AND
– They are acellular, contain no cytoplasm nor
PHARMACOTHERAPEUTICS II cellular organelles
PHCP312 – They carry out no metabolism on their own and
must replicate using the host cell’s metabolic
machinery

Human Immunodeficiency Virus Risk Factors

• Blood-borne disease that is typically • Unprotected sexual intercourse
transmitted via – Anal intercourse: 8-fold higher risk
– Sexual route • Prior STD:
– Mother to child transmission – Gonorrhoea and chlamydia: 3 fold increase
– Shared intravenous paraphernalia – Syphilis: 7-fold increase
• Co-infection with other viruses that share the – Herpes genitalias: 25-fold increase
similar route is common • Sharing of intravenous drug paraphernalia
– Hepatitis B and C • Receipt of blood products
– Kaposi Sarcoma herpes virus – Mucosal contact with infected blood or needle stick
injuries
• Maternal HIV infection

HIV is not transmitted by: HIV

• Air or water • Immune deficiency is due to the depletion of
helper T lymphocytes (CD4+)
• Saliva, sweat, tears
• Loss of CD4+ cells results in the development of
• Insects or pets opportunistic infection and neoplastic processes
• Sharing of food or drinks • Reverse transcription
• Characteristic of the virus:
– Enveloped
– Retrovirus in the Retroviridae family, lentivirus genus
• Single-stranded, positive sense RNA virus with DNA
intermediate

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AIDS
• When CD4+ is below 200 cells/mm3
– Characterized by:
• Presence of severe opportunistic infections
– Severe candidiasis, cervical cancer, coccidiomycosis,
cryptococcosis, cyrptosporidiasis, cytomegalovirus,
encepalopathy, herpes simplex, histoplasmosis,
isosporiasis, Kaposi sarcoma, lymphoma,
mycobacterium avium, TB, pneumocystis
pneumonia, salmonella septicaemia, toxoplasmosis
of the brain, wasting syndrome

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HIV Retroviral Genes

• HIV-1 HIV contains 3 species-defining retroviral genes
– May have originated from cross species transfer • GAG
from chimpanzees in central Africa
• POL
– More common
• ENV
• HIV-2
– Slightly lower risk of transmission
• Glycoprotein 120
– Progress more slowly to AIDS • GIV-1 contains 6 accessory genes:
– Less aggressive infection – Tat, rev, nef, vif, vpu, and vpr
– Lower viral load – HIV-2 does not have vpu, but has vpx

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Diagnosis Diagnosis
• Clinical screening for HIV in all adolescent, • ELISA
adult and pregnant women; – Can be used to detect HIV-1 type M, N and O and HIV-
2
• All females ages 13-64 must be tested at least • Confirmatory test
once in their lifetime – False negative confirmatory test may be seen in early
• Restesting annually or more often for those course of infection
who are at risk • Test results can be positive, negative or
indeterminate
• CDC recommends testing for all patients in – Detection of p24 antigen or viral RNA may detect
healthcare settings after the patient is notified greater number

Viral Load and CD4+ HIV Staging

• Viral Load • WHO Clinical Staging of HIV/AIDS for Adults
– Peripheral blood used as a surrogate marker of viral
replication route
and Adolescents with Confirmed HIV Infection
– Quantitative amplification of the viral RNA using NASBA
and RT-PCR
– Patients with greater than 30,000/uL are 18.5 times more • Clinical Stage 1
likely to die of AIDS than those with undetected viral loads – Asymptomatic
• CD4+ – Persistent generalized lymphadenopathy-
– Helper T cells
– Normal value of 500-2000cells/uL
– <200 is indicative of AIDS

HIV Staging HIV Staging

• Clinical Stage 2 • Clinical Stage 3
– Moderate unexplained weight loss – Unexplained severe weight loss
– Recurrent respiratory tract infections – Unexplained chronic diarrhea
– Herpes zoester – Unexplained persistent fever
– Angular cheilitis – Oral hairy leukoplakia pulmonary tuberculosis
– Severe bacterial infections
– Recurrent oral ulceration
– Acute necrotizing ulcerative stomatitis, gingivitis or
– Papularpruritic eruptions periodontitis
– Seborrheic dematitis – Unexplained anemia, neutropenia, or chronic
– Fungal nail infections thrombocytopenia

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HIV Staging Pharmacologic Interventions

• Clinical Stage 4 • HAART
– HIV wasting syndrome – Highly active antiretroviral therapy
– Pneumocystis jirovecii
– Recurrent sever bacterial pneumonia – Principal method for preventing immune system
– Chronic herpes simplex infection deterioration and prophylaxis for specific
– Esophageal candidiasis opportunistic infections indicated for a particular
– Extrapulmonary tuberculosis disease
– Kaposi Sarcoma – Combination of at least 3 drugs to arrest virus
– Cytomegalovirus infection replication and disease progression
– CNS toxoplasmosis • HAART should be given to patient with CD4+ below 35-/uL
– HIV encepalopathy • Should be given to pregnant patients with HIV associated
nephropathy, Hep B, regardless of CD4+ count

Nucleoside and Nucleotide Reverse

Goals of Treatment
Transcriptase Inhibitors
• Dependent on stage of the disease and the • Competitive inhibition of HIV-1 reverse
concominant opportunistic infection transcriptase
• All NRTIs may be associated with mitochondrial
• Prevent deterioration of the immune system toxicity, which may manifest as peripheral
• Achieve an undetectable viral load neuropathy, pancreatitis, lipoatrophy and hepatic
– <50/mL steatosis
– Lipoatrophy and insulin resistance may occur most
– Virally suppressed
frequentlty with the use of the thymidine analogs and
least frequently with Tenofovir, Lamivudine,
Emtricitabine and Abacavir

Nucleoside and Nucleotide Reverse Nucleoside and Nucleotide Reverse

Transcriptase Inhibitors Transcriptase Inhibitors
• Abacavir • Didanosine • Emtricitabine • Lamivudine
– Guanosine analog that is – Synthetic analog of – Fluorinated analog of – Cytosine analog with in-
well absorbed and is deoxyadenosine lamivudine with a long vitro activity against HIV-
unaffected by food – Buffered or enteric- intracellular half-life 1 and HBV
– Dosage reduction is cooated formulations
recommended in mild are necessary to prevent – Recommended for use in – Recommended for use in
hepatic impairment inactivation of acids pregnancy pregnant women
– Recommended for use in – ADR: peripheral distal – Combined with Tenofovir – Levels of lamivudine may
pregnancy sensory neuropathy and for prophylaxis increase when
dose-dependent – ADR: headache, administered with
pancreatits, diarrhea, nausea, rash, trimethoprim-
hypertriglyceridemia, hyperpigmentation sulfamethoxazole
diarrhea, CNS toxicity,
optic neuritis

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Nucleoside and Nucleotide Reverse Nucleoside and Nucleotide Reverse

Transcriptase Inhibitors Transcriptase Inhibitors
• Stavudine • Zidovudine • Tenofovir Disoproxil • Tenofovir Alafenamide
– Thymidine analog – Deoxythymidine analog Fumarate – Phosphonamide prodrug
– Not food-dependent – First approved – Acycli nucleoside – Combination therapy
phosphonate analog of
– Caution is advised in antiretroviral agent • Emtricitabine
adenosine
patients with liver – Can be used in • Elvitegravir + Cobistat
– Competitively inhibits HIV
dysfunction pregnancy and post- reverse transcriptase and + Emtricitabine
exposure prophylaxis causes chain termination • Ripirivine +
– ADR: macrocytic anemia, – Water soluble prodrug Emtricitabine
neutropenia, GI – Ba increases in fasting – Active against HBV
intolerance, headaches, state and in high-fat meal
insomnia – May be used for pregnancy

Non-Nucleoside Reverse Non-Nucleoside Reverse

Transcriptase Inhibitors Transcriptase Inhibitors
• Bind directly to HIV-reverse transcriptase • Delavirdine • Efavirenz
resulting in allostering inhibition of RNA and – 85% oral BA but reduced – Once daily due to long half-
DNA-dependent DNA polymerase activity by antacids or H2- life
blockers – Toxicity may increase owing
• Does not compete with nucleoside
– ADR: skin rash on the to increased BA after a high-
triphosphates nor require phosphorylation to first 3 weeks fat meal
be active – Teratogenic in rats – Taken at night to decrease
– CYP3A4 inducer (Nevirapine) – Extensively metabolized CNS effects
– CYP3A4 inhibitor (Delavirdine) by CYP3A4 and CYP2D6 • Dizziness, frowsiness,
insomnia, nightmares,
– Mixed effect on CYP3A4 (Efavirenz, Etravirine) headache
– May be used in pregnancy

Non-Nucleoside Reverse Non-Nucleoside Reverse

Transcriptase Inhibitors Transcriptase Inhibitors
• Etravirine • Nevirapine • Rilpivirine
– Diarylpyrimidine – Highly lipophilic and – Diarylpyrimidine
– Effective against strains achieves cerebrospinal – Administered with meal
of HIV that had fluid levels that are 45% – May be used in
developed resistance to of those in plasma pregnancy
first generation NNRTIs – Renally excreted – May cause QT
– Taken with meal to – Severe and life- prolongation at high
increase systemic threatening skin rashes dose
exposure including SJS and toxic
epidermal necrolysis

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Protease Inhibitors Protease Inhibitors

• During the later stages of HIV growth cycle, the • All are extensively metabolized by CYP3A4,
gag and gag-pol gene products are translated into with Ritonavir having the most pronounced
polyproteins and these become immature
budding particles inhibitory effect and Saquinavir the least
• By preventing post-translational cleavage of the
gag-pol gene polyprotein, protease inhibitors
prevent the processing of viral proteins into
functional conformations
– Resulting in the production of immature,
noninfectious viral particles

Protease Inhibitors Protease Inhibitors

• Atazanavir • Darunavir • Fosamprenavir • Indinavir
– Azapeptide – Must be co-administered – Amprenavir prodrug – Taken with an empty
– Once-daily dosing with Ritonavir or – Administered with low- stomach, low fat, low
– Required acidic medium, Cobicistat dose Ritonavir proteins and acidic
should be taken with – Should be taken with – High-fat meals decrease medium
meals meals absorption – May cause insulin
– 12hr window period if – ADR: diarrhea, nausea, – This contains a sulfa resistance, unconjugate
used with antacids headache and increases moiety and may cause hyperbilirubinemia and
in amylase and hepatic rashes nephrolithiasis
aminotransferase levels

Protease Inhibitors Protease Inhibitors

• Ritonavir • Saquinavir • Tipranavir
– Pharmacologic “booster” – Original formulation as – For treatment-experienced
hard gel capsule patients who harbor
– For use in pregnant strains resistant to other
women – Reformulated for once- Pis
– Highly protein bound daily dosing in
– Contains sulfonamide
with half life increased combination with low- moeity
by food dose Ritonavir has both
– ADR: liver toxicity,
improved antiviral including life-threatening
effiicacy and decreased hepatic decompensation
GI adverse effects
– Avoided in patients with
– Subject to extensive head trauma or bleeding
first-pass metabolism diathesis

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Fusion Inhibitors Entry Inhibitors

• Enfuvirtide • Maraviroc
– Block HIV entry into cells – CCR5 co-receptor antagonist
– Used in combination with other antiretroviral agents in
– Binds to gp subunit of the viral envelope adult patients infected only with CCR5-tropic HIV-1
glycoprotein preventing the conformation changes
required for the fusion of viral and cellular
membranes
– Lacks cross-resistance with other antiriretroviral
– SQ administration

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Integrase Strand Transfer Inhibitors

• This inhibits strand transfer, the third and final
step of provirus integration, thus interfering
with the integration of reverse-transcribed HIV
DNA into the chromosomes of host cells

Integrase Strand Transfer Inhibitors Antiretroviral used in pregnancy

Recommended Agents Alternate Agents
• Dolutegravir • Elvitegravir
– Taken 2hrs before or – Taken 2hrs before or NRTIs
6hrs after antacids, 6hrs after antacids, Abacavir, Emtricitabine,
laxatives, sulcralfate, oral laxatives, sulcralfate, oral Lamivudine, Tenofovir disoproxil
iron and calcium iron and calcium fumarate, Zidovudine
supplements supplements NNRTIs
– Highly protein bound – Taken with food Efavirenz Rilpivirine
– May increase elimination – Requires boosting with PIs
of metformin Cobicistat
Atazanavir/Ritonavir, Liponavir/Ritonavir
Darunavir/Ritonavir
Integrase Inhibitors
Raltegravir

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Prophylaxis for opportunistic infections Non-Pharmacologic Interventions

• Ganciclovir • Sexual transmission • Vertical transmission
– CMV
– Abstinence – Maternal testing
– Reserved for patients with CD4+ below 50/uL
– Reduction in number of – Cesarean delivery
• Fluconazole
sexual partners – Avoidance of breast
– CD4+ below 100/uL
– Histoplasmosis, coccidiodomycosis, candida – Contraception feeding
• Azithromycin/Clarithromycin – Treatment for other • Bloodborne
– CD4+ below 50/uL STDs transmission
– Mycobacterium avium – Testing for HIV and other – Blood product and donor
• Cotrimoxazole infections screening
– PCP
– Toxoplasmosis and if CD4+ count is below 100/uL
– Dapsone for patients with G6PD

Treatment Hubs in the Philippines

• San Lazaro Hospital
• PGH
• Research Institute for Tropical Medicine
• Makati Medical Center
• The Medical Center, Taguig
• Jose B. Lingad Memorial Medical Center, Pampanga
• Ilocos Training and Regional Medical Center
• Baguio General Hospital
• Love yourself treatment hub – Anglo Clinic,
Mandaluyong
• Cagayan Valley Medical Center
• Bicol Regional Training and Teaching Hospital

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 OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF PHARMACY

RESPIRATORY TRACT INFECTIONS

CLINICAL PHARMACY AND
PHARMACOTHERAPEUTICS II
PHCP312
 Tuberculosis
• A chronic pulmonary and systemic disease
caused most often by M. tuberculosis, and the
leading infectious cause of death worldwide.
• The source of transmission is humans with
active tuberculosis who release mycobacteria
into the sputum.
 Tuberculosis
• In most healthy people primary tuberculosis is
asymptomatic, although it may cause fever and
pleural effusion.
• Generally, the only evidence of infection, if any
remains, is a tiny, fibrocalcific pulmonary nodule
at the site of the infection.
– Viable organisms may remain dormant in such lesions
for decades.
– If immune defenses are lowered, the infection may be
reactivated, producing communicable and potentially
life-threatening disease.
 Clinical Manifestations
• Cough of at least 2 weeks duration
• Unexplained cough of any duration in a close
contact of a known active TB case
• Significant and unintentional weight loss,
fever, bloody sputum, chest pains, easy
fatigability or malaise, night sweats, SOB
 Diagnosis
• Direct Sputum Smear Microscopy
– 2 sputum specimens should be collected through
spontaneous expectoration
– Collected 1 hour apart for Ziehl-Neelsen
microscopy
 Diagnosis
• PCR Test
• Interferon-Gamma Release Assays (IGRAs) – Blood Tests for TB
Infection
• Tuberculin Skin Test: Positive when
– ≥5mm: HIV positive, recent contact with infected person, with
organ transplants, people with chest x:ray findings suggestive of
previous TB and immunosuppressed patients
– ≥10mm: people born where TB disease is common,
Mycobacteriology laboratory workers, people who live or work
in high-risk congregates, with low body weight, children below 5
years old
– ≥15mm: people with no known risk factor
 Pharmacologic Interventions
Drug Target Mechanism of Action
Isoniazid Cell Wall Inhibits mycolic acid synthesis
Rifampicin Nucleic Acid Inhibits transcription by
interfering with DNA-dependent
RNA polymerase
Pyrazinamide Intracellular Targets essential membrane
transport, in fatty acid synthesis
Ethambutol Cell Wall Affects lipid and cell wall
metabolism, inhibits RNA
synthesis
Streptomycin Ribosome Inhibits translation during
protein synthesis
 Classification of Drug Treatment
• Drug-sensitive TB (DSTB)
– For new cases, sensitive tot all first-line drugs
based on culture and sensitivity
• Drug-resistant TB (DRTB)
– Resistant to one or more first-line drugs
 Classification based on
Drug Susceptibility
Mono Resistant TB Resistance to one 1st line anti-TB drug
only (except Rifampicin)
Polydrug Resistant TB Resistance to more than one first line
anti-TB drug (other than both Isoniazid
and Rifampicin)
Multidrug-Resistant TB (MDRTB) Resistance to both isoniazid and
rifampicin
Extensive Drug-Resistant TB (XDRTB) Resistance to any fluoroquinolone and
to atleast 1-3 second line injectable
drugs in addition to multidrug-
resistance
Rifampicin Resistant TB (RR-TB) Resistance to Rifampicin with or
without resistance to other anti-TB
drugs
OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF PHARMACY

VIRAL INFECTION
CLINICAL PHARMACY AND
PHARMACOTHERAPEUTICS II
PHCP312
 Influenza Virus
• Highly contagious airborne infection
• One of the most common infectious disease
– Enveloped, negative-sense, single-stranded RNA
viruses of the family Orthomyxoviridae
 Influenza Types
• A and B
– Causes seasonal diseases (flu)
– A is known to cause pandemics
• Hemagglutinin (H) 18 types
• Neuraminidase (N) 11 types
– B generally change more slowly in terms of their genetic
and antigenic properties than influenza A viruses
• Characterized linegae
– Victoria
– Yamagata
• C: generally causes mild illness and are not thought to
cause human flu epidemics
• D: primarily affect cattle are not known to infect or
cause illness in people
 Naming Influenza Virus

A / Sydney / 05 / 97 / ( H3N2 )

• For influenza A viruses, the hemagglutinin and neuraminidase antigen description

are provided in parentheses
• The 2009 pandemic virus was assigned a distinct name: A(H1N1)pdm09 to
distinguish it from the seasonal influenza A(H1N1) viruses that circulated prior to
the pandemic
 Antigenic Shift and Drift
• Influenza A can mutate 300 times faster than
other microbes
– Antigenic Drift
• Point mutations in certain error-prone regions in the
genes. These mutations are ongoing and are
responsible for the ability of the virus to evade annually
acquired immunity in humans
– Antigenic Shift
• This happens when two kinds of influenza virus infect
the same cell and share their genes to make a new
version of influenza
 Symptoms
• Cough and other respiratory symptoms
• Fever
• Sore throat
• Myalgia
• Headache
• Nasal discharge
• Weakness and severe fatigue
• Tachycardia
• Red, watery eyes
 Complications
• Bronchitis
• Asthma flare-ups
• Heart problems
• Ear infections
• Acute respiratory distress syndrome
• Pneumonia
– One of the most serious complications, and can be
deadly
 Historically important Influenza
Pandemic
• Annual influenza epidemics result in about 3-5 million
cases of severe illness and about 250,000 to 500,000
deaths
– 1918 H1N1 (Spanish Flu) influenza pandemic
• Estimated 40 million deaths worldwide
– 1957 H2N2 influenza pandemic (Asian Flu)
• Estimated 1-2-million deaths worldwide
– 1968 H3N2 influenza pandemic (Hong Kong Flu)
• Estimated 700,000 – 1million deaths worldwide
– 2009 H1N1 (Swine Flu) influenza pandemic
• Estimated 285,000 deaths worldwide
– 2014 H5N1 (Bird Flu) influenza pandemic
 Laboratory Tests
• RT-PCR
• Rapid Test
• Laboratory tests are non-specific but may help
in the workup of influenza
– CBC
• Presence of thrombocytopenia
• Hypoxemia
– Xray
 Pharmacologic Interventions
• Oseltamivir and Zanamivir
– Analogs of sialic acid, interfere with release of
progeny influenza A and B virus from infected host
cells, thus halting the spread of infection within
the respiratory tract
– Neuraminidase inhibitors
– Oseltamivir is converted to oseltamivir carboxylate
– Zanamivir is administered directly to the
respiratory tract via inhalation
 Pharmacologic Interventions
• Peramivir
– Neuraminidase inhibitors
– Cyclopentane analog
• Active against both influenza A and B viruses, and is
approved as a single 600-mg IV dose for acute
uncomplicated influenza in adults
• ADR: increase risk of hallucination, delirium and
abnormal behavior
 Pharmacologic Interventions
• Investigational Drugs
• Ianinamivir Octanoate
– Long acting neuraminidase inhibitor
• IV formulation of Zanamivir
– This is being evaluated in clinical trials and is available
for compassionate use from the manufacturer
• DAS181
– Host-directed antiviral agent with activity against
influenza and parainfluenza that acts by removing the
virus receptor, sialic acid, from adjacent glycan
structures
 Vaccines
• Quadrivalent Vaccine
– Protects people from two type of A influenza A and
two types of type B influenza
• Fluarix Tetra (GSK)
• Jet injector
– Given to people ages 18-64
• Afluria (Pharmajet)
• High-dose vaccine
– Available in the Philippines, given to people over 65
years old, and its dose is four time more potent than
regular vaccine
• Fluzone High Dose Quadrivalent (Sanofi)
• Adjuvant Vaccine
– Provides great protection from the flu for people 65 yrs old
and up
• Fluad (Novartis)
• Cell-Based Vaccine
– This vaccine is made using dead viruses grown in the cells
of mammals
• Flucelvax (Sequris)
• Recombinant Vaccine
– This virus needed for the vaccine is grown through a
technical process
• Flublok Quadrivalent (Protein Science)
• Intranasal
– Live, attenuated vaccine administered intranasally
indicated for active immunization to prevent influenza A
and B
• FluMist (Medimmune)
 Uricosuric Agent
• Probenecid
– Inhibits tubular secretion of active metabolite of
Oseltamivir, reducing its clearance by approx. 50%
and approximately doubling the systemic
exposure to Oseltamivir
• Dosing combination therapy dose has not been
established
 Controlling the spread of infection
• Proper handwashing
• Avoid face touching
• Cover mouth when coughing or sneezing
• Clean surfaces
• Avoid crowds
 11/05/2021

OUR LADY OF FATIMA UNIVERSITY

COLLEGE OF PHARMACY Objectives:
• At the end of this unit, the students are
expected:
Central Nervous System Infection – To explain the pathophysiology of meningitis
– To identify the factors that may induce and
CLINICAL PHARMACY AND potentiate the disease
PHARMACOTHERAPEUTICS II – To discuss the clinical presentation as well as the
PHCP312 diagnosis and laboratory evaluation
– To create a therapeutic outcome

Meninges Meningitis
• Inflammation of the fluid and membranes
surrounding the brain and spinal cord
– Swelling of the meninges may trigger
• Headache
• Fever
• Stiff neck
• Generally feeling unwell

Meningitis Risk Factors

• Symptoms in new born • Age:
– Irritability – Babies are at increased risk for bacterial
– Slowness or irritability meningitis compared to people in other age
– Vomiting groups. However, people of any age can develop
– Poor feeding bacterial meningitis.
– Fontanel bulging • Group setting:
– Infectious diseases tend to spread where large
groups of people gather. College campuses have
reported outbreaks of meningococcal disease,
caused by N. meningitidis

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• Meningitis causes CSF fluid changes, and these

Risk Factors changes can be used as diagnostic markers of
infection
• Certain medical conditions
• Working with meningitis-causing pathogens:
– Microbiologists routinely exposed are at increased
risk for meningitis
• Travel:
– Travelers may be at increased risk for
meningococcal disease if they travel to certain
places

Streptococcus pneumoniae Staphylococcus aureus

• Most common cause of CAP • G(+), cocci, clustered
– Gram (+) • Associated with neurosurgical interventions (CSF
– Non-spore forming and non-motile
shunts), trauma or
– Malignancy
– Diplococci – Decubitus ulcers
– Optochin sensitive vs S. viridans – Cellulitis
• Leading cause of meningitis in patients 2 – Infected intravascular grafts
months of age or older in the US – Chronic alcoholism
– Diabetes mellitus
• May result from vascular invasion and – Osteomyelitis
hematogenous spread – Perirectal abscess

Listeria monocytogenes Neisseria meningitidis

• G(+), facultative anaerobe, catalase (+) and • Meningococcal meningitis
oxidase (-) with tumbling motility due to – Meningococcemia
peritrichous flagella • G(-), diplococci
• Important pathogen in pregnant patients, • High mortality and persistent neurologic
neonates, elderly, patients with cancer and defect
patients who are immunocompromised
• Very contagious and may be acquired through
respiratory or throat secretions

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Haemophilus influenzae Gram-Negative Bacillary Meningitis

• Most common cause of meningitis in children • Elderly debilitated patients are at an increased
6months-3years of age, but this has declined risk of gram (-) meningitis but typically lack
dramatically since immunization the classic signs and symptoms of the disease
• Approximately 20% are ampicillin-resistant • Commonly caused by Pseudomonas aeruginosa
• Vaccination with Hib conjugate vaccines – Common nosocomial infection
begins in children at 2 months
– Considered in patients older than 5 years with
sickle cell disease, asplenia or
immunocompromising diseases

Empiric Therapy
should last at least 48 to 72 hours or until the diagnosis of
bacterial meningitis can be ruled out

Prevention Meningococcal Vaccine

• Pneumococcal vaccines • Meningococcal conjugate or MenACWY
– Pneumococcal conjugate vaccine 13 (PCV13) vaccines (Menactra® and Menveo®)
• 4 doses in infants (2,4,6 and 12-15 months) – All 11-12year olds should get a meningococcal
• If none were given during childhood conjugate vaccine with a booster dose at 16 years
– PCV13 (year 1-age 19-64), PPSV23 (year 2), PPSV23 (after 5 old
years of last PPSV23)
– Pneumococcal polysaccharide vaccine 23 • Serogroup B meningococcal or MenB vaccines
(PPSV23) (Bexsero® and Trumenba®)
• Not effective in children less than 24 months – Teens and young adults (16 through 23 year olds)
• Given to adults also may get a serogroup B meningococcal vaccine

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Non-pharmacologic Prevention
• Hib (Haemophilus influenzae tybe b) • Wash your hands. Careful hand-washing helps
vaccination prevent the spread of germs
– CDC recommends Hib vaccination for all children • Practice good hygiene
younger than 5 years old
• Stay healthy
– CDC does not recommend this for most people 5
years or older unless they: • Cover your mouth
• Have certain medical conditions and are unvaccinated • If you’re pregnant, take care with food.
• Receive a bone marrow transplant