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Drug-Bug Sheet DRUG-BUG SHEET Drug Bug(s) Clinical Pearls about Drug IV to PO Natural Penicillins Streptococci, enterococci (moderate), Short half-life, dosed frequently Usual dose: 125-500 mg PO Q6-8hr Penicillin V (PO) Treponema pallidum Usual dose: Penicillin G (IV) *drug of choice for syphilis Due to rising resistance, penicillin is a 12 to 24 million units/day Q4-6hr poor empiric choice for most infections Renally dosed Aminopenicillins Good activity against streptococci and Susceptible to beta-lactamases; enterococci; moderate activity against resistance common; High incidence of enteric GNRs (E.coli, Proteus, diarrhea when given orally (amoxicillin); Klebsiella, H. influenzae) combine with aminoglycoside to achieve *no staph coverage bactericidal activity against enterococci Amoxicillin Can be formulated with clavulanate (to Usual dose: (PO) combat beta-lactamases) 500 mg PO Q8hr Renally dosed Ampicillin Can be used at high doses or in Usual dose: (IV or PO) combination with sulbactam for VRE 1-2 g IV Q4-6hr, 250-500 mg PO Q6hr Renally dosed Amoxicillin/clavulanate Both: MSSA, streptococci, Both have identical spectrum of activity Usual Dose: 500 mg (amoxicillin) (PO) enterococci, many anaerobes, enteric Q12hr GNRs Renally dosed Ampicillin/sulbactam Sulbactam is drug of choice for Usual Dose: 1.5-3 g IV Q6 (IV) Acinetobacter baumannii (combo used Renally dosed at a higher dose) Antistaphylococcal All: Interchangeable therapeutically: No renal adjustments! Penicillins MSSA, streptococci Methicillin (no longer used) = oxacillin = Usual dose: Nafcillin nafcillin → susceptibilities are the same 2 g IV Q4hr (IV) Can be used as continuous infusion to optimize PK Usual dose: Oxacillin Kill more quickly than vancomycin → 2 g IV Q4hr (IM, IV) should use these agents for MSSA Usual dose: Dicloxacillin (PO) Dicloxacillin: oral dosage form 125-500 mg PO Q8hr Antipseudomonal All: Great choice for empiric nosocomial Usual dose: Penicillins P. aeruginosa, streptococci, MSSA, infections 4.5 g Q6hr Piperacillin/ enterococci, enteric GNRs, Same spectrum as Unasyn + tazobactam (IV) Haemophilus, many anaerobes antipseudomonal coverage Renally dosed Carbapenems All: All: good for nosocomial infections in MSSA, streptococci, anaerobes, patients who have already received enteric GNRs, drug of choice for various other classes of antibiotics; may ESBL-producing GNRs have cross-reactivity with penicillins; Meropenem (IV) Pseudomonas, Acinetobacter, Can be administered as an inhalation Usual dose: moderate for enterococci 0.5-2 g IV Q8hr Renally dosed Imipenem-Cilastatin Pseudomonas, Acinetobacter, High risk of seizures, do not use in Usual dose: (IM or IV) moderate for enterococci meningitis; cilastatin given to reduce 1 g IV Q8hr nephrotoxic product formation Renally dosed Ertapenem Does NOT cover enterococci or Once daily dosing; cannot use for Usual dose: (IV) Pseudomonas Pseudomonas or Acinetobacter 1 g IV Q24hr Renally dosed Anti-CRE agents CRE, MSSA, streptococci, anaerobes, Recently improved in 2017 for use in Usual dose: Meropenem/ enteric GNRs, drug of choice for complicated UTIs 4 g IV Q8hr Vaborbactam (IV) ESBL-producing GNR CRE = carbapenem resistant Renally dosed enterobacteriaceae Monobactam Pseudomonas, GNRs, Acinetobacter Can be administered as an inhalation, Usual dose: no allergy cross-sensitivity with beta- 500 mg - 1 g IV Q8-12hr Aztreonam (IV, IM) Poor activity against gram positive lactams, similar spectrum coverage to Renally dosed organisms and anaerobes ceftazidime 1st generation *Think: mostly gram positive* Main uses: All renally dosed cephalosporins All: Commonly used for 24 hours as surgical MSSA, streptococci, some enteric prophylaxis Cefazolin (IV) GNRs 1st gen cephs and antistaph PCNs used Usual dose: for narrowing MSSA coverage (cefazolin 1-2 g IV Q8hr has better anti-strep activity) Cephalexin (PO) Usual dose: 250 mg - 1000 mg Q4-6hr Cefadroxil (PO) 2nd generation All: Main use: URIs, CAP, gonorrhea, All renally dosed cephalosporins Some enteric GNRs, Haemophilus surgical prophylaxis Neisseria, moderate activity against Streptococci, Staph Cefuroxime (PO,IV) No anaerobic coverage Drug interactions: Inhibits Vitamin K Usual dose: production- increased bleeding risk; 500 mg PO Q12hr disulfiram-like reaction with alcohol 1.5 g IV Q8hr Cefoxitin (IV, IM) Anaerobic coverage Cefoxitin and cefotetan are Usual dose: cephamycins: anaerobic coverage for 1-2 g IV Q6-8hr many anaerobes in GIT → often used Cefotetan (IV, IM) Anaerobic coverage for prophylaxis in abdominal surgeries Usual dose: 1-2g IV Q12hr 3rd generation Streptococci, enteric GNRs, MSSA One class of antibiotics with strongest cephalosporins Do NOT cover enterococci, association with C. diff, all three agents anaerobes, MRSA, or Pseudomonas listed here cross BBB and can be used in CNS infections Ceftriaxone (IV) One-time dose of 125 mg IM used for Usual dose: gonorrhea treatment - patients receive Ceftriaxone - No renal adjustments! 1-2 g Q12-24hr azithromycin for chlamydia coverage as well Usual dose: Cefotaxime 1-2 g IV Q6-12hr Renally dosed Ceftazidime Does NOT cover MSSA or Cefepime has replaced ceftazidime for Usual dose: streptococci (no gram pos), but has empiric coverage of PSAR and 500 mg - 1 g IV Q8-12hr antipseudomonal coverage nosocomial GNRs (due to resistance) Renally dosed 4th generation The most broad of the cephalosporins: IV formulation only Usual Dose: cephalosporins 2g IV Q8hr MSSA, streptococci, enteric GNRs, Replaced ceftazidime in use of empiric Cefepime (IV) Pseudomonas, Acinetobacter coverage of PSAR and nosocomial Renally dosed GNRs 5th generation MRSA activity! (“Anti-MRSA Approved for skin and soft tissue Usual Dose: cephalosporins Cephalosporin”) infections and CAP 600 mg IV over 5-60 min Q12hr Often utilized in combination with Ceftaroline (IV) MSSA, MRSA, streptococci daptomycin for persistent MRSA Renally dosed bloodstream infections Ceftazidime/avibactam **Broadest ESBL profile, 3rd gen ceph, approved for complicated Usual Dose: 2.5 g IV over 2 hrs Q8hr (IV) antipseudomonal activity, no intra-abdominal infections in Renally dosed streptococci or anaerobic coverage combination with metronidazole Ceftolozane/ ESBL and antipseudomonal coverage, 5th gen ceph, approved for complicated Usual Dose: 1.5 g IV over 1 hr Q8hr Tazobactam (IV) covers gram positive strep but NOT intra-abdominal infections in Renally dosed staph (no MSSA coverage) combination with metronidazole Fluoroquinolones *Consider Resistance* All: Do not take with cations (aluminum, Ciprofloxacin (PO, IV, Enteric GNRs (E.coli, Proteus, calcium, magnesium); separate by at Usual Dose: 500 mg Q12hr Otic, Ophthalmic) Klebsiella, H. influenzae) least 2 hours, BBW: tendon rupture, risk Renally dosed Pseudomonas, Atypicals of QTc prolongation, diarrhea a large *no S. pneumoniae coverage side effect (can lead to C. difficile) Usual Dose: 500-750 mg Q24hr Levofloxacin (PO, IV, Enteric GNRs (E.coli, Proteus, Higher MICs/doses needed for Renally dosed ophthalmic) Klebsiella, H. influenzae), S. Pseudomonas coverage pneumoniae, atypicals, 1:1 IV to PO conversion Pseudomonas, MSSA “Respiratory quinolone” - useful in treatment of CAP Usual Dose: 400 mg Q24hr No renal adjustments Moxifloxacin (PO, IV, Enteric GNRs (E.coli, Proteus, No use in UTIs ophthalmic, intraocular) Klebsiella, H. influenzae), S. 1:1 IV to PO conversion pneumoniae, atypicals, MSSA, anaerobes “Respiratory quinolone” Macrolides *Think: upper and lower respiratory Prolonged half-life → short course may No renal adjustments! tract infections* be adequate for most infections Atypicals, H. flu, M. catarrhalis, H. Azithromycin (PO, IV, pylori, Mycobacterium avium, S. 1:1 IV to PO conversion Usual Dose: varies; 250-500 mg PO ophthalmic) pneumoniae, S. pyogenes 1 g x 1 dose for gonorrhea QD Clarithromycin (PO) Increasing S. pneumo resistance, not Drug interactions! Macrolides inhibit Usual Dose: 250-500 mg PO BID as good coverage as ceftriaxone CYP450 enzymes (azithromycin does not have as many interactions) Lincomycin Gram positive and gram negative Diarrhea large side effect (can lead to C. Usual Dose: 150-300 mg Q6, Clindamycin anaerobes, S. pyogenes, difficile), as well as rash 300 mg BID (vaginosis), 300-450 mg (PO, IM, IV) Plasmodium species (malaria), MSSA, Use D-test for susceptibilities → positive Q6-8 (HIV) CA-MRSA, Chlamydia trachomatis, result means clindamycin resistant PCP, Toxoplasma organism is present and this is NOT the No renal adjustments drug of choice Does not cover gram negative 100% bioavailable with oral doses, but aerobes lower PO doses to improve GI effects Aminoglycosides All: All: Renally dosed! Good activity against gram: E.coli, ADEs: nephrotoxicity (see an increase in Gentamicin Klebsiella, pseudomonas, SCr), irreversible ototoxicity with high Gentamicin Usual Dose: 3 (IV,ophthalmic, topical) Acinetobacter doses- perform baseline and periodic mg/kg/day divided Q8 audiology, potential for neuromuscular Moderate activity against MSSA and blockade when given in high doses Tobramycin Usual Dose: 3 Tobramycin (IV, MRSA, viridans streptococci, mg/kg/day IV in 3 equal doses Q8, ophthalmic) enterococci (when combined with a Used with beta-lactams to provide up to 5 mg/kg/day (life threatening) beta-lactam) synergistic effects Amikacin Usual Dose: 15 mg/kg/day Amikacin (IV, IM) Poor activity against atypicals, Poor lung and CNS penetration → IV/IM Q8-12 anaerobes, gram + (monotherapy) adjust dose for IBW or ABW to avoid overdosing in obese patients Streptomycin Usual Dose: 1-2 g/day Streptomycin (IM) IM
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