Antibiotics

    . Source: "Infectious Diseases:  A Clinical Short Course" by Frederick Southwick (2008)

     

                     mic.gif

     

    Penicillins (PCN)

    Natural Penicillins

     

    Penicillin
    Names

    Penicillin G (IV SC)   [2-4 x10^6 U IV q4h]

    Penicillin V (PO)   [250-500mg PO q6-8h]

    Mechanism:

    Bind various Penicillin Binding Progeins (PBP), which are family of enzymes for cell wall synthesis.                    

    Hyperosmolar intracellular contents swell and cell membrane lyses.

    • Bacteriolytic
    Clearance
    • RENAL (Adjust for renal dysfunction).  Clearance can be delayed with Probenecid.
    Coverage

    NARROW SPECTRUM

     

     

    G+

    G-

    Screen shot 2013-09-29 at 2.23.54 PM.png

    Ae

    Streptococci

       -Pyogenes  (30% resi)

       -Viridans (+mouth flora)

    (?Enterococci)

    - NOT S.aureus

    Neisseria meningitidis

    NOT G- aerobic bacilli

    Ane

    Most Anerobes

    C. perfringens

    Pasteurella

    Not Bacteroides fragillis!!!!!

    Other

    Spirochetes


     

    Clinical Use
    • S. pygenes, S. viridans, Pasteurella, Leptospira
    • Mouth flora infections (dentists offices)
    • C. perfringens and spirochetes
    Crosses BB barrier only if inflammation.
    Toxicity
    • Allergic reactions (0.7-10%)
    • If Develop IgE mediated anaphylactic reactions --> should never be given B-lactam
      (incl. cephalosporin/carbapenem)

     

     

    Aminopenicillins (Amox/Amp, Amox-Clav)

     

    Aminopenicillins
    Names

    Ampicillin G (IV SC)   q4-6h

    Amoxicillin V (PO) 

    Amoxicillin-Clavulanate q12h

    Mechanism:

    Same as penicillin.  Increases resistance to stomach acid, allowing them to be given orally.

    Amoxicillin 75% abosrbed, 40% for amp.

    • Bacteriolytic
    Clearance
    • RENAL unmodified (Adjust for renal dysfunction).
    Coverage

    MODERATE SPECTRUM

    Covers same organisms as Penicillins +..

     

    G+

    G-

    Ae

    Listeria

    Enterococcus

        (better w/ amp-gent synergy)

    H. influenzae

    (Expanded G- coverage)

    Shingella flexneri

    Salmonella (nontyphoidal)

    Proteus

    SOME E.coli

     

    Combine with Clavulanate (Amox-clav) for better coverage of :

    Staph, H.influ, Moraxella, Amox-resistant H.influ.

    However: high incidence of diarrhea, expensive, not shown better than amox in otitis media.

    Clinical Use
    • Listeria
    • Proteus mirabilis
    • non-B-lactamase-roducing H. influenzae
    • Otitis Media
    Crosses BB barrier only if inflammation.
    Toxicity
    • Same as Penicillins

    Penicillinase-Resistant PCN (Cloxacillin)


    Penicillinase-Resistant Penicillins
    Names

    Cloxacillin (0.25-1g q6h)   or Dicloxacillin

    Oxacillin

    Nafcillin

    Mechanism:

    Same as penicillin.  Short half-life.

    Synthetic modification of penicillin to make it resistant to B-lactamases produced by S. aureus.

    • Bacteriolytic
    Clearance
    • HEPATIC (Adjust for hepatic dysfunction)
    Coverage

    VERY NARROW SPECTRUM

    Covers same organisms as Penicillins +..

     

    G+

    G-

    Ae

    Strep pyogenes (GAS)

    S. aureus (MSSA)

    NOT mouth flora

    NOT Neisseria

    An REDUCED COVERAGE

     

    Clinical Use
    • Primarily indicated for MSSA (S.aureus)
    • Cellulitis (if mild or resolving)
    Toxicity
    • Same as Penicillins
    • Interstitial nephritis risk

    Carboxy/ureido-PCN (pip-tazo)


    Carboxypenicillins and Ureidopenicillins
    Names

    Ticarcillin-clavulanate (Timenthin in USA)

    Piperacillin-tazobactam (3.375 g q6h or 4.5g for pseudomonal coverage)

    (Ticarcillin and Piperacillin monotherapy is discontinued) - clav or tazo added to kill MSSA

    Mechanism:
    • Bacteriolytic
    Clearance
    • Same half-life as penicillin (dosed q6h to prevent tazobactam from bulding up)
    • RENAL (Adjust for renal dysfunction) 
    Coverage

    BROAD SPECTRUM

    Compared to penicillin...

     

    G+

    G-

    Ae

    BROAD, including:

    Strep pyogenes (GAS)

    S. aureus (MSSA)

    BROAD, including:

    Pseudomonas

    Enterobacter

    Proteus

    An

    BROAD, including:

    Bacteroides fragilis (intra-abdominal)

     

    Pseudomonas -> pip-tazo synergy with aminoglycosides (separate doses by 30-60min)

           (need 4.5g for pseudomonas)

    Clinical Use
    • Hospital aspiration pneumonia (covers mouth flora and G- rods)
    • Intra-abdominal infections
    • Gynecologic
    • etc.etc..etc... 
    Toxicity
    • Same as Penicillins

     

    Cephalosporins

    Screen shot 2013-09-29 at 2.24.01 PM.png

    1st Gen

    1st Generation Cephalosporins
    Names

    PO: Cephalexin (Keflex)

    IV: Cefazolin (Ancef)  

    Mechanism/

    Pharm

    - Longer halflife!

    - Well absorbed  (absorption not affected by food)

    Fail to cross BBB

    - Inexpensive

    Clearance
    • RENAL
    Coverage

    NARROW SPECTRUM

     

    G+

    G-

    Ae

    +++

    Strep pyogenes (GAS)

    S. aureus (MSSA)

    NOT Listeria

    NOT Enterococcus

    NOT MRSA

    +

    NOT H.influenzae

    An

    ++

    Oral Cavity Anaerobes

    NOT B. fragilis

     

    Clinical Use
    • Soft tissue infections
    • Surgical prophylaxis
    DO NOT CROSS BB barrier.
    Toxicity
    • 1-3% Allergic rxn.
    • 1-7% of pen allergic pts are allergic to cephalosporins

     

     

    2nd Gen

    2nd Generation Cephalosporins
    Names

    PO: Cefuroxime (Ceftin)

           Cefprozil (Cefzil)

    IV: Cefuroxime, Cefoxitin, Cefotetan  (anerobic activity)

    Clearance
    • RENAL (Adjust for renal dysfunction) 
    Coverage

    MODERATELY BROAD SPECTRUM

     

    G+

    G-

    Ae

    ++

    Strep pyogenes (GAS)

    S. aureus (MSSA)

    NOT Enterococcus

    NOT MRSA

    ++

    (Improved)

    H.influenzae
    Neisseria

    Moraxella

    An

    ++

    Only cefoxitin and cefotetan

     

    Clinical Use
    • PID (cefoxitin and cefotetan)
    • RARELY USED
    Penetrate all body cavities (even BB barrier)
    Toxicity
    • 1-3% Allergic rxn.
    • 10% cross-reactivity for allergic reactions with penicillin
    • Cefotetan and cefamandole have methylthiotetrazole ring
      (decreases prothrombin production - need VitK prophylaxis if malnourished)

     

     

    3rd Gen

    3rd Generation Cephalosporins
    Names

    PO: Cefixime (Suprax)

    IV: Cefotaxime

          Ceftriaxone    (Only one excreted by liver, but biliary sludging, not used in kids)

          Ceftazidime  (Covers pseudomonas, but NOT S.aureus)

          Cefoperazone  (Covers pseudomonas, but NOT S.aureus)

    Pharm/Mech Ceftriaxone - long half-life (once daily dosing) (avoid in kids - acalculous cholecystitis)
    Clearance
    • RENAL (Adjust for renal dysfunction)   (Except ceftriaxone)
    • HEPATIC (Only ceftriaxone)
    Coverage

    BROAD SPECTRUM

    Compared to 1st and 2nd Gen: 

     

    G+

    G-

    Ae

    +

    Strep pneumo 

      (including mod-pen-resistant)

    Strep pygenes (GAS)

    S. aureus (MSSA)

    NOT Enterococcus

    NOT MRSA

    NOT Resistant Pneumococcus

    +++

    (Improved, covers many G-'s!)

    N. meningitidis + gonorrhoeae

    H. influenzae

    Moraxella

    Pseudomonas (only ceftazidime and cefoperazone)

    NOT Serratia

    NOT Acinetobacter

    NOT Enterobacter cloacae

    An

     

     

    Clinical Use
    • Community Acquired Pneumonia (CAP)   (Ceftriaxone, cefotaxime)
    • Community Acquired Bacterial Meningitis (Ceftriaxone, cefotaxime)
    • N. gonorrhoeae
    Penetrate all body cavities (even BB barrier)
    Toxicity
    • 1-3% Allergic rxn.
    • 10% cross-reactivity for allergic reactions with penicillin

     

    4th Gen

    4th Generation Cephalosporins
    Names

    PO: None

    IV: Cefepime (In USA)

          Cefpirome (in Europe: less Pseudomonas)

    Pharm/Mech

    Zwitter-ionic, means have both positive and negative charges on molecule

    - Can penetrate G- outer membrane (increases coverage)

    - Can penetrate all body cavities (including BB barrier)

    Clearance
    • RENAL (Adjust for renal dysfunction) 
    Coverage

    VERY BROAD SPECTRUM

    Compared to 3rd Gen: 

     

    G+

    G-

    Ae

    +++

    S. pneumoniae

      (including moderate pen-res strains)

    S. pyogenes

    Staph aureus (MSSA)

    NOT Enterococcus

    NOT MRSA

    NOT Listeria

    +++

    (Improved, covers many G-'s!)

    Pseudomonas (q8h dosing to help)

    An

    NOT B. fagillis

     

    Clinical Use
    • Excellent broad-spectrum activity 
    • Nosocomial infections
    • G- meningitis
    • Febrile neutropenia
    Penetrate all body cavities (even BB barrier)
    Toxicity
    •  

    Monobactams

    • Mostly Gram negative coverage
    • No cross-reactivity with penicillin

     

    Carbapenems

    Carbapenems
    Names

    PO: None

    IV: Imipenem  (Better G+'s, Enterococcal, seizures, not used in meningitis)

         Meropenem  (Better G-)

         Ertapenem   (Better G-, but NOT pseudomonas, once-daily - home use)

    Pharm/Mech
    • Modified B-lactam ring... highly resistant to cleavage.
    • Zwitterionic (excellent G- penetration and penetrates all body cavities)
    • Bacteriocidal
    • Resistance: some produce carbapenemases to hydrolyze carbapenems
    Clearance
    • RENAL (Adjust for renal dysfunction) 
    Coverage

    VERY BROAD SPECTRUM

     

     

    G+

    G-

    Ae

    +++

    S. pneumoniae

      (including moderate pen-res strains)

    S. pyogenes

    Staph aureus (MSSA)

    Listeria, Nocardia, MAI

    Enterococci (only pen-sensitive - static) 

    NOT MRSA

    NOT pen-resistant S. pneumo

    +++

    (Covers many G-'s!)

    Pseudomonas (q8h dosing to help)

    Serratia (Imipenem or meropenem)

    NOT Burkholderia

    An

    ++

    NOT C.diff

    Oth Mycobacterium avium intracellulare (MAI)

     

    Clinical Use
    • Empiric sepsis (Imipenem, meropenem) (esp if polymicrobial)
    • Severe intra-abdominal infections
    • Complicated pyelonephritis
    • Serratia
    • Meningitis (meropenem, NOT imipenem b/c of seizure risk)
    Penetrate all body cavities (even BB barrier)
    Toxicity
    • Kill all normal flora ... high risk of MRSA, Pseudomonas, Candida.

    Aminoglycosides

    Aminoglycosides
    Names

    Neomycin

    Gentamicin

    Tobramycin (Anti-Pseudomonal!)

    Amikacin

    Netilmicin

    (Listed in lessening ototoxicity)

    Pharm/Mech
    • Derived from Streptomyces spp.
    • At neutral pH positively charged (better antibacterial activity)
    • Enter bacterium:
      • Precipitate DNA and other negatively charged components
      • Bind 30S subunit of 16S ribosomal RNA and halt translocation
    • NEED MONITORING! (Aminoglycoside and Creatinine levels)
      • If critically ill: Need loading dose and level 30min post-infusion
      • Dosing based on Ideal Body Weight (IBW)
      • IV: Peak: at 30min post-infusion; trough at 30min pre-infusion (30min to distribute)
        • Takes 3 doses to equilibrate (monitoring after 3 doses?)
      • Often given once daily to avoid S/E
    • BACTERIOCIDAL (Concentration-dependent killing + post-abx growth suppression effect)

     

    Clearance

    • RENAL (Adjust for renal dysfunction) 
    Coverage

    NARROW SPECTRUM

     

    G+

    G-

    Ae

    - - -

    some?

    Synergy With Cell wall blockers:

    (Vanco, B-lactams)

    - S. aureus, S. viridans, 

    Coag-neg staph, Listeria,

    JK corynebacteria

     

    +++

    Most aerobic G- bacilli

    Pseudomonas

    An

    - - -

    Oth  

     

    Clinical Use
    • Synergy with cell wall blocking abx (vanco, or B-lactams)
      • Empiric Endocarditis (Penicillin+aminoglycoside)
      • Pseudomonas (Tobramycin+ anti-pseudomonal penicillin or cephalosporin)
      • S. viridans and Enterococcus faecalis (Gentamycin + Penicillin)
    • Streptomycin or gentamicin for:
      • Yersinia pestis
      • Tularemia
      • Brucella
    Toxicity
    • NEPHROTOXICITY (Reversible, renal cells regenerate)
      • Proximal tutuble cells take up aminoglycosides --> necrosis
      • Decrease GFR in 5-25% of pts.
        • Often after >3d of treatment.
        • Increased risk: elderly, hepatic dysfunction, volume depletion
          hypotension
        • Worse with vanco, clinda, lasix
        • If GFR drops or Cr rises: need to increase dosing interval (q8h-->q12h--> daily)
      • Reverses once stop drug.
      • (Actually better than creatinine at detecting renal function)
    • OTOTOXICITY (Irreversible)
      • Damage to outer hair cells --> affect high frequency sound.
      • In 3-14% of pts, often after >9d of tx
      • Highest risk--> lowest: Neomycin, gentamicin, tobramycin, amikacin, netilmicin
      • Better with OD dosing compared to q8h.
    • Avoid in myesthenia gravis (often causes some neuromuscular blockade)

    Glycopeptide (vanco)

    Glycopeptides
    Names

    PO: Vancomycin (for C.diff only, no absorption)

    IV: Vancomycin

          Teicoplanin (rare)

    Pharm/Mech
    • Binds G+ D-ala-D-ala precursor preventing incorporation into peptidoglycan.
    • Incorporation blocks transpeptidase and transglycolase enzymes.
    • Also interfere with RNA synthesis
    • Rapidly kill actively growing organisms.
    • 2-hour post-abx effect.
    • BACTERIOCIDAL (if growing)
    Clearance
    • RENAL (Adjust for renal dysfunction) 
    Coverage

    NARROW SPECTRUM

    Gram + only!

     

    G+

    G-

    Ae

    ++++

    MRSA

    MSSA

    Coag-neg staph

     (S. epidermitis)

    Strep pneumo (+pen-resistant)

    S. viridans

    S. bovis

    Corynebacterium jeikeium

    Enterococcus (but VRE rising)

    NO COVERAGE

    An

    C. difficile

     

    • Vancomycin resistant Enterococcus (VRE) on the rise

    •  

      In japan- isolated S. aureus that was intermediately resistant.

    Clinical Use
    • Coag-neg staphylococcal line sepsis
    • Bacterial endocarditis
    • Pneumococcal meningitis
    • Corynebacterium jeikeium
    • C. diff (Oral) (but try metronidazole first b/c can cause VRE)

    Penetrates BB barrier ONLY in inflammation.

    Little data on bone/tissue penetration.

    Toxicity
    • "Red man syndrome" with rapid infusion (histamine release) Infuse over 1hour.
    • Phlebitis is common
    • Ototoxicity --> tinnitus leading to deafness (uncommon)
    • Potentiates nephrotoxicity of aminoglycosides.

     

    Macrolides

    Macrolides
    Names

    OLD: Erythromycin (Oldest, QID dosing, poor PO abosrp. GI upset, Cyp450, deafness)

    Newer: (better PO absorption)

    Clarithromycin

    Azithromycin

    Talithromycin

    Pharm/Mech
    • Inhibit protein biosynthesis.
    • Bind 50S domain of ribosome
    • Block passage of nascent proteins through ribosome exit tunnel.
    • Ketolides - newer macrolides.  Broader spectrum.
      • Talithromycin binds 50S with higher affinity (binds two regions of 23S rRNA)
    • Generally BACTERIOSTATIC, but CIDAL in larger doses.
    • Also have anti-inflammatory effects.
    Clearance
    • HEPATIC  (Azithromycin secreted in bile unchanged)
    Coverage

    Reasonably wide  SPECTRUM

     

    G+

    G-

     

    Ae

    +++


    S. pneumo (10-20% resistance)

    S. aureus (but don't use)

      (resistance is EASY point mutation)

    Mouth aerobes

    +

    H. pylori

     

    erythromycin.gif

      (Erythromycin)

    An

    Mouth anaerobes

    NOT B. fragillis

    Atyp

    Atypical Pneumonia: Chalmydia, mycoplasma

    MAI complex (especially Clarithromycin)

    Chlamydia (one dose)

    Chancroid, Ureaplasma

     

    • S. pneumo resistance rising (10-15%). Resistance more likely if pen-resistant (40-60%)

    • Talithromycin can still be used for S. pneumo (binds differently)

    Clinical Use
    • CAP (S. pneumo resistance - 10-15%)
    • Alternative to penicillin in pen-allergic pts.
    • H. pylori (azithro, clarithro)
    • Mycobacterium avium intracellulaire (MAI complex) - clarithromycin
      (or azithro if prophylaxing HIV+ pts)
    Toxicity
    • Generally safe.
    • Talithromycin: can have blurry vision, diplopia, cases of sudden severe hepatitis.
    • May exacerbate myesthenia gravis
    • Prolong QT interval (erythromysin -- Vtach)
    • Metabolized by P450 3A4
      • Increases serum levels: statins, short acting benzos (midaz),cispride, ritonavir, tacrolimus

     

    Clindamycin

    Clindamycin
    Names

    Clindamycin (IV and PO)

    Pharm/Mech
    • Like macrolides, binds 50S ribosomal subunit.
    • DOES NOT cross BB
    • Generally BACTERIOSTATIC, but CIDAL in larger doses.
    Clearance
    • Hepatic.. secreted in bile.
    Coverage

    REASONABLY WIDE SPECTRUM

    Similar to macrolides

     

     

    G+

    G-

    Clindamycin.png

    Ae

    +++

    Excellent G+ coverage

    S. pneumoniae (even mod-pen-resistant)

    Strep pyogenes (GAS)

    MSSA

     

     

     

    VERY LITTLE

    NOT H. influenzae

     

    An

    +++ Excellent!

    Atyp

    Toxoplasma

     

    • Does not cross BB barrier.

    Clinical Use
    • S. pyogenes pharyngitis (in penicillin allergy)
    • NOT for Otitis Media (no H.influ coverage)
    • Toxoplasma (2nd line, if sulfa-allergic)
    Toxicity
    • Diarrhea (20%)
      • Half of those with diarrhea have C. difficile diarrhea (Pseudomembranous colitis)
      • Worst drug for C.diff diarrhea.  
      • Abx concentrations persist for 5 days in stool, and reduction in clinda-sensitive flora
        for up to 14 days!!!

     

    Tetracyclines

    Tetracyclines
    Names

    Tetracycline

    Doxycycline (best aborbed 100%)

    MInocycline (can cause vertigo, rarely used)

    Tigecycline (Newest, broader spectrum, IV only)

    Pharm/Mech
    • Well absorbed (70-80%)  (Doxycycline is best)
      • Ca+ and Mg+ containing products impair absorption.
    • Enter G- bacteria by diffusing through the porins.
    • Bind 30S ribosomal subunit, and block tRNA binding to the mRNA-ribosome complex.
      • Inhibit protein synthesis in bacteria.
      • Also block mammalian mitochondrial protein synthesis.
    • BACTERIOSTATIC!
    • ALSO Metalloproteinase inhibitors (tissue breakdown), so assist this way independent of
      their antimicrobial activity)
    Clearance
    • Tetracycline: RENAL
    • Others: LIVER
    Coverage

    BROAD SPECTRUM

     

    G+

    G-

    Tetra-, Doxy-, Mino- Tigecycline (IV)

    Ae

    +++

    Many G+'s

    (even if resistant)

     

    ++

    MANY G-'s

    NOT Pseudomonas

    NOT Proteus

     

    - Vibrio spp.

    - Mycobacterium marinum

    - Borreila burgdorferi

    - Leptospira

    - Chlamydia spp.

    - Rickettsia spp.

    - Brucella

    - S. aureus

      (including MSSA, MRSA)

      Vancomycin int. resistant

       S. aureus (VISA)

    - Enterococci (+ VRE)

    - Strep pneumo 

       (even pen-resistant)

    - Acinetobacter baumannii

    - Stenotrophomonas maltophilia

    - Enterobacteriaceae (+ESBL)

      B. fragilis

      C. perfringens

      C. difficile

    An

    ?

    Atyp

    Many! (see to the right)

     

    Clinical Use
    • UTI (uncomplicated, conc. in urine)
    • Doxy-Gent: brucellosis
    • Lyme disease (Borrelia burgdorferi)
    • PID + Chlamydia
    • Rickettsial inf. (Rocky Mountain spotted fever, ehrlichiosis, Q fever, typhus fever)
    • Does NOT reliably cover strep (do not use as empiric treatment for skin infections)
    Toxicity
    • Photosensitivity (red rash at sun exposed areas)
    • Hypersensitivity (less common than penicillin, but do occur)
    • Interfere with enamel formation (do not use in kids <8yo or pregnant).
    • In Renal Failure: increase azotemia (inhibit protein synthesis)
    • Rare
      • Minocycline: vertigo (rarely used)
      • Benign intracranial hypertension (pseudotumor cerebri)

     

     

    Quinolones

    Quinolones
    Names

         1st Gen:   

    Ciprofloxacin  (Antipseudomonal,  G- coverage only)

         2nd Gen aka "Respiratory Quinolones"

    Levofloxacin   (Antipseudomonal)  

    Moxifloxacin  (Hepatic clearance, most QT prolongation, covers anaerobes in vitro)

    Gatifloxacin  (Covers anaerobes)

    Gemifloxacin  (Hepatic clearance)

    Pharm/Mech
    • Inhibit two enzymes critical to DNA synthesis:
      • DNA gyrase: regulates superhelical twists of bacterial DNA
      • Topoisomerase IV: segregates newly formed DNA into daughter cells.
    • Blocking DNA synthesis: destroys baceria
    • Excellent bioavailability (IV = PO typically)
    • BACTERIOCIDAL (Concentration-dependent killing)
    Clearance
    • Moxifloxacin + Gemifloxacin: LIVER
    • Others: RENAL
    Coverage

    BROAD SPECTRUM

     

    G+

    G-

    Ae

    +++  NOT ciproflox

    Levoflox

    Gatiflox

    Gemiflox

    MSSA, S. pneumo, Enterococcus

    S. pyogenes, 

     

    +++

    All quinolones

    Cipro better

       (pseudomonas coverage)

     

     

    An

    Gatiflox, Moxiflox (in vitro only)

    Atyp

    Pneumonia atypicals covered, Bartonella, Chlamydia

     

    Clinical Use
    • Cipro
      • UTI, Prostatitis, Gonococcal urethritis (alt. to cerfriaxone)
      • Traveller's Diarrehea (ETEC E. coli and Shingella)
      • Salmonella typhi (typhoid fever), Salmonella gastroenteritis (if tx needed)
      • Cat scratch disease (Bartonella henselae)
    • Levo, Moxi,Gati - improved G+ coverage
      • CAP for non-hospitalized adult.
      • Soft-tissue infection (if G+'s and G-'s involved)
    Toxicity
    • Common: Mild anorexia, Nausea/vomiting/abdo discomfort.
    • MSK (Arthropathy)  (RARE)
      • Cartilage Damage + Tendinopathy, DO NOT use in kids routinely (Cartilage damage)
    • Gatifloxacin - dysregulation of glucose (hyper/hypoglycemia)
    • QT prolongation (Concentration-dependent conduction delay) - Moxifloxacin is the worst.

    Others

    Rifampin

    • Generally weak, easy resistance.
    • DO NOT USE BY ITSELF.
    • Always use as an adjunct to therapy.
    • Useful for entering biofilms  --> (infected joints, lines, clots such as endocarditis).

     

     

    Summary

     

     

    Forms

    Spectrum

    Does not get

    Penicillin

    Penicillin G (IV SC)

    Penicillin V (PO)

     

    G+

    G--

    Ae

    Streptococci

    (Enterococci)

    Neisseria mening.

    Ane

    Most, not Bacteroides frag.

    Used for GBS in pregnancy

    - Not S. aureus

    - Not G- aerobic bacilli

     

    Cloxacillin

     

    - Extended G+ coverage (Staph Aureus)

    -  Sucks for streptococci

     

     

    Methicillin

    Not used in pts

    For lab testing only

    - Allergic interstitial nephritis

     

    Aminopenicillin

    - Ampicillin

         (IV, qid)

    - Amoxicillin

         (PO tid)

    - Same as penicillin

    - Better vs enterococcus

    - Most H.influenzae

    - Some G- bacilli (Ecoli)

     

    Amoxicillin Clavulinate (Clavulin®)

     

    - Many G-  aerobic bacilli

    - Most S.aureus

     

    Piperacillin

     

    - Same as Ampicillin

    - Extend Gram- spectrum

    - Covers pseudomonas

     

     

    Piperacillin

    Tazobactam

     

    - Most G- G+ and anaerobes!

     

    Carbapenems

    Imipenem

    Meropnem

    Ertapenem

    - Extremely broad spectrum

    - G+ G- anaerobes

    - (Sickest pt, resistnt org, ICU)

     

    Cephalosporins

    PO

    IV

     

     

     

    1st

    Cephalexin

    (Keflex)

    Cefazolin

    (Ancef)

    G+ : All

    G- : E.coli, Klebsiella, Proteus

    G+: Enterococcus

    G-:

     

    2nd

    Cefuroxime

    Cefuroxime

     Cefoxitin

     Cefotetan

    G+: Weaker than 1

    Bold – cover anaerobes

     

     

    3rd

    Cefixime

     (Suprax)

    Cefotaxime

    Ceftriaxone

    Ceftazidime

    - Cover S. aureus, S. pneumoniae + gonorrhea + e.coli

    - Some Strep

    Bold – covers pseudomonas, but bad for GP

     

     

    4th

     

    Cefepime

    Cefpirome

    +++

    +++

    Macrolides

    (bacteriostatic)

    - Erythromycin (oldest,

     4x/day, gi upset, Cyp450, deafness)

     

    - G+ aerobes (not Enterococcus)

    - G- aerobes

    H. influ,

    B. pertussis,

    Campylobacter

    Legionella

    - some G+ anaerobes

    - Atypicals: Chlamydia, Mycoplasma, Legionella

     

    Enterococcus

     

     

    - Clarithromycin (Biaxin) (2x/day, drug int, less gi upset)

    - Azithromycin

     (od, less drug int, less gi)

    - Better H.influenzae coverage

     

    Tetracyclines

    (bacteriostatic)

    - Avoid in kids + pregnancy

    - G+

    - Atypicals: (Chlamydia, mycoplasma, Rickettsia, Syphilis)

    Enterococcus

    Vancomycin

    Only give IV, except if C.diff then give PO)

    - Last resort G+ aerobes

    - Also C.diff (give po)

     

     

    Linezolid

    New

    - For resistant G+ aerobes

     

    Clindamycin

    (bacteriostatic)

    Give PO or IV, causes c.diff diarrhea

    Above diaphragm

    - G+ aerobes (+ S.aureus)

    - Not Entercocci

    - G- anaerobes (+ B.fragillis)

     

    Metronidazole

    (dna – cidal)

    Po or iv, no ETOH, reaction (flushing, n/v)

    Below diaphragm

    - Anaerobes (B. fragilis, C.dif, trichomonas, Entameba)

     

    Aminoglycosides

    (cidal)

    Iv or im, od dosing

    Ototoxicity, Nephrotoxicity

    - Gentamycin

    -Tobramycin

    Amikacin

    - G- aerobes

    -

    Bold covers pseudomonas

     

     

    TMP-TMX

    - po mostly (iv rare)

    - Allergies (rash, AIN, hepatitis, hyperkalemia)

    Bactrim ® Septra ®

    - G- aerobic bacilli

    - PCP

    - UTI use

     

    Fluoroquinolone

    Po + IV

    -Ciprofloxacin

    -Ofloxacin

    Avoid in kids+pregnancy

     

    G – aerobic bacilli (pseudomonas 25% resistance)

    G+ aerobes (not streptococci)

    Streptococci

     

     

    -Levofloxacin

    -Moxifloxacin

    -  Also H. influenza

    -  Strep pneumo

    -  Mycoplasma

    -  Chlamydia pneumonia

    -  Legionella

     

    Nitrofurantoin

    (cidal)

    Damages DNA

    -Avoid in renal failure

    - safe in preg (avoid near term)

    - Cause neuropathy, pulm. fibrosis

    -  Most G- aerobes

    -  Staph sapro + enterococci

    -  Use in uncomplicated lower UTI, sucks doesn’t work for pyelonephritis

     

                   
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