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Home , Antibiotic, Lincosamides, Metronidazole, Pseudomonas

03/15 Revised BCPS PharmD, Traugott, Kristi PharmD; Li, Julius

Peptostreptococci

spp. Propionibacterium Staphylococci

Micrococci Enterococci

Diphtheroids Streptococci

Streptococci spp.

Staphylococci spp.

flora Skin spp.

spp.

Enterobacteriaceae

flora Gut

Yeasts

, Ex: lactam - beta Ex:   spp. Moraxella

spp. Haemophilus ratio Cmax:MIC maximizing by T>MIC extending by efficacy increases infusion

spp. Neisseria Less frequent but higher doses increases efficacy efficacy increases doses higher but frequent Less - extended or administration frequent More  

Diphtheroids

concentrations peak maximizing by killing Optimize MIC above time maximizing by killing Optimize  

Staphylococci

Streptococci

dependent - Concentration dependent - Time

flora Respiratory

spp. Actinomyces

etronidazole M luoroquinolones F hloramphenicol C ulfonamides S

spp.

arbapenems C enicillins P etracyclines T () lindamycin C

spp. Porphyromonas

ephalosporins C ancomycin V rimethoprim T () rythromycin E

Diphtheroids

spp. Lactobacillus ” Murder Cell Complete For Proficient Very “ ” bacteriostatic for ECSTaTiC “

Staphylococci

Streptococci Bactericidal versus Bacteriostatic

flora Oral

live” normally “Where

Pharmacodynamics &

Man Microbiome

Pharmacotherapy Antibiotic for Guide Pocket

Clarithryomycin

Aminoglycosies

Metronidazole

Azithromycin

Ciprofloxacin

Moxifloxacin

Levofloxacin

Meropenem

Vancomycin Daptomycin

Clindamycin

Quinu/Dalfo

Doxycycline

Ceftazidime

Cefuroxime

Polymyxins

Aztreonam

Ceftaroline

Tigecycline

Penicillin G

Amox

Imipenem

Ampicillin TMP

Amp

Cefepime

Cefazolin

Cefoxitin

Linezolid

Pip

Drug

-

-

-

- Tazo

SMX

Sulb Bug Clav

Beta-hemolytic streptococci * + + + + + + + + + + + + + + + + + ± + + + + + + + ± + + Viridans group streptococci + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + (MSSA) ± * + + + * + + + + + + + + + + + + + + + + + + + + + + Staphylococcus aureus (MRSA) + + + + + + * + + + + + + ± ± Enterococcus faecalis + * + + + + + + + + + + + + + + Enterococcus faecium ± + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + Klebsiella spp. + + + + + + + + + + + + + + + + + + + + + + + + Enterobacter spp. + + + * + + + + + + + + + + + + + + + Citrobacter spp. + + + * + + + + + + + + + + + + + + + Serratia spp. + + + * + + + + + + + + + + + + + Proteus spp. + + + + + + + + + + + + + + + + + + + + spp. + + + + + + + + + + + + + + + + aeruginosa + + + + + + + + + + + maltophilia ± + + + * Bacteroides spp. + + + + + + + + ± ± + + + + + + + spp. + + + + + + + + + + + + + + + + +

Clostridium spp. + + + + + ± ± + ± ± ± ± + + + + ± ± + + + + + + + Refer to hospital to Refer antibiogram susceptibilityfor of specific rates organisms

Peptostreptococcus spp. + + + + + + + + + + + + + + + + + + + + + + + + ± of Activity of Spectrum Against Common Bacteria Atypicals + + + + + + + +

* = of choice Julius Li, PharmD; Kristi Traugott, PharmD, BCPS Revised 03/15 Antibiotic Pharmacotherapy by Class Refer to Guidelines for Dosing in Renal Failure for both dosing in normal renal function and renal dose adjustments Antibiotic Adverse Reactions Drug Interactions Clinical Pearls

Penicillins Generally of choice for bacteria once susceptibility known Penicillin G, oxacillin, None (e.g. MSSA, penicillin-susceptible S. pneumoniae, - ampicillin, susceptible enterococci) Beta-lactam inhibitor Excellent anaerobic activity combinations has unique activity against Acinetobacter spp. (doses amoxicillin-clavulanate, None based on sulbactam, >6 g/day) ampicillin-sulbactam, Consider amox-clav 500-125 mg q8h dosing for gram-negative, an- - GI upset (, ) aerobic, or mixed (more clavulanate needed) reactions Leukopenia, thrombocytopenia (rare) Cross-reactivity with penicillin <5% Cefazolin, ceftriaxone, Neurologic (altered mental status, ) None Caution with third generation cephalosporins (e.g. ceftriaxone) and , , Interstitial nephritis SPACE bugs+ (ampC producers) ceftaroline Hepatotoxicity (oxacillin) Generally reserved for multidrug resistant gram-negatives (MDR-GN) Ertapenem, , Drug of choice for ESBL producers None , Excellent anaerobic activity Cross-reactivity with penicillin allergy <5% Monobactams Generally reserved for severe penicillin allergy (e.g. ), but None may cross-react with ceftazidime allergy Fluoroquinolones GI upset (nausea, , diarrhea) Neurologic (dizziness, AMS, seizures) Increasing resistance may limit use, particularly with E. coli Phototoxicity Caution with cations (reduced Higher dose for P. aeruginosa (e.g. cipro 750 mg q12h, levo 750 q24h) Tendonitis, cartilage erosion ) Highly bioavailable, PO = IV QT prolongation Inhibits 1A2 (cipro) Moxifloxacin = poor urine penetration (not used for UTIs) Dysglycemia QT prolongation risk = moxi > levo >> cipro Peripheral neuropathies GI upset (nausea, vomiting, epigastric distress) Highly bioavailable, PO = IV (doxy, mino) Photosensitivity Caution with cations (reduced Tige = severe nausea, may need scheduled pre-dose Minocycline Teeth discoloration bioavailability) Mino, tige = has activity against multidrug resistant organisms (even Vertigo (minocycline) if tetra or doxy resistant)

Macrolides GI upset (nausea, vomiting, diarrhea) , azithromy- Inhibits 3A (ery > clari >> azi) QT prolongation risk = ery >> clari > azi QT prolongation cin, Glycopeptides Red man syndrome Red man syndrome can be prevented by slowing infusion rates or Nephrotoxicity None premedicate with diphenhydramine (rare) IV vanc for systemic infections, PO vanc for C. difficile Cyclic Generally reserved for severe, resistant gram-positive infections (e.g. Skeletal muscle toxicity Daptomycin None MRSA, VRE) if vancomycin failure or resistant Eosinophilic Not for pulmonary infections (deactivated by lung ) Oxazolidinone Generally reserved for severe, resistant gram-positive infections (e.g. MRSA, VRE) if vancomycin failure or resistant Thrombocytopenia Inhibits MAO (weak) Highly bioavailable, PO = IV Peripheral neuropathies p-glycoprotein substrate Higher toxicity risk with long-term (>2 weeks) Higher risk for with due to MAO inhibition with serotonergic agents (e.g. SSRIs, TCAs) and (e.g. red wine) Lincosamide GI upset (diarrhea > nausea, vomiting) Increasing resistance in S. aureus and streptococci may limit use None Elevated LFTs (minor) Increasing resistance in anaerobes, particularly Bacteroides spp. Hypersensitivity reactions Highly bioavailable, PO = IV - Leukopenia, anemia None Dose for severe infections = 15 mg/kg/day based on TMP component Hyperkalemia, renal failure (e.g. PCP, spp.) Highly bioavailable, PO = IV GI upset (nausea) Excellent anaerobic activity None Avoid due to reaction Taste disturbances (metallic) Higher risk for peripheral neuropathies with long-term therapy Peripheral neuropathy Only used for UTIs, but without Nitrofurantoin Pulmonary toxicity None Do not use with poor renal function (low urinary penetration) Hepatotoxicity (rare) Low resistance = good option for multidrug resistant organisms Aminoglycosides Nephrotoxicity preferred for P. aeruginosa infections , tobramycin, None May be used synergistically for severe gram-positive infections Vestibular toxicity Ami = may have activity even if gent or tobra resistant Nephrotoxicity Last line for MDR-GNs due to high toxicity risk and limited efficacy None , B Neurotoxicity (oral/peripheral ) Consider for systemic infections and colistin for UTIs Julius Li, PharmD; Kristi Traugott, PharmD, BCPS Revised 3/15 + SPACE bugs = , , , Citrobacter freundii, Enterobacter spp. Approfed by P&T Committee 6/2015