Antimicrobialagents-rev1.pdf

ANTIMICROBIAL AGENTS
Lo is E B ren ne m an , M SN , ANP , FN P, C
Table 1 - PENICILLINS
Natural penicillins - not resistant to beta-lactamase
pen icillin G Po tass ium (Pfizer pen , Pen tids) - P O, IM , IVpen icillin G So dium : IM, IVben zathine G p enic illin (B icillin) - IM benzathine penicillin G benzathine and penicillin G procaine (Bicillin CR) IMpenicillin G procaine (W ycillin, Pfizerpen AS) IM, IVpenicillin V Potassium (Pen Vee K, V-Cillin, Veetids, Pen-V) - PO Beta-lactamase stable penicillins - resistant to beta-lactamase
clox acillin (C loxa pen ) - PO ; dicloxacillin (Dynapen) - POnafcillin (Un ipen, Na fcil) - IV, ox acillin (Prosta phlin) - IV Beta-lactamase stable combination penicillins - additive inactivates beta-lactamase
amoxicillin-clavulanate (Augmentin), ampicillin-sulbactam (Unasyn),ticarcillin-clavulanate (Timentin), piperacillin-tazobactam (Zosyn) Aminopenicillins (effective against gram positive and gram negative)
am oxicillin (Am oxil, Polymox ) - PO , am ox icillin/cla vulan ate (Aug m en tin) - POam picillin (Om nipen, Prin cipe n) - P O, IV , am picillin/sulbactam (Unasyn) - PO , IVbacampicillin (Spectrobid) - PO Antipseudom onal penicillins
ticarc illin diso dium (Tic ar) - IV , ticarcillin/clav ulanate (T im entin) - IVm ezloc illin (M ezlin) - IV, p ipera cillin (Pipra cil) - IVpiperacillin tazo bac tam (Zo syn) - IV , azlocillin (Azlin) - IV most commonly used agents within a given class are underlined Co m m ents : Beta -lacta m ase sus cep tibility limits m ost a gen ts for use in sk in-sk in structure s. Afew agents are stable and accordingly indicated. Anaerobic coverage is highly variable.
Am inopenicillins and antipseudomonal agents have reasonably good coverage. Penicillin-allergyis fairly comm on sometimes causing anaphylaxis. Agents are otherwise non-toxic and can beused in pregnancy 2002 Lois E. Brenneman, MSN, CS, ANP, FNP Table 2 - CARBAPENEMS - beta-lactam ase stab le
im ipenem plus c ilastatin (P rim axin ) - IVmeropenem (Merrem) Table 3 - MACROLIDES - effective against typical and atypical organisms
1st generation - unre liable co vera ge a gainst H influenzae
erythromycin (E-Mycin, Eryc, E.E.S., Ery-Tab, EryPed)dirithromycin (Dynabac) 2nd generation - reliable c ove rage aga inst H. influenzae
clarithrom ycin (Biaxin)azithromycin (Zithroma x) Good coverage S. au reus (MSS A) a nd s trepto coc cal sp., M c ata rrh alis , chlamydia sp,m ycop lasm a sp , legionella sp .
Som e coverage: ana erob es (in con sistent) No coverage ente rococc i or S epiderm idis, gm - rods.
CLINICAL INDICATION AND COMMENTS: Drug of c hoice for bronchitis. Use 2nd gen (H. influenzae) forbronchitis in smok er or any sinusitis, otitis, AECB. Azithrom ycin used to cover ST D ch lam ydiaand non -specific u rethritis. Goo d choice for dental prophylaxis and treatm ent of streptococcalpharyngitis in penicillin-allergic. Good skin and skin structure coverage. Not subject to beta-lac tam as e. L ow incide nc e of alle rgic re ac tion . Overall safe and non -toxic . Can be us ed inpregnancy (except estolate formulation). These agents are widely used in primary care although2nd generation has tended to replace erythromycin in many settings due to improved coverageaga inst H. influenzae and much improved tolerance. Erythromycin tends to be poorly toleratedresulted in signific ant GI distress. Ce rtain fo rm ulation s (PCE , E-m ycin, Eryc , Ped iazole) te nd tobe better tolerated. Causes significant phlebitis with IV administration and very poorly toleratedvia tha t route .
2002 Lois E. Brenneman, MSN, CS, ANP, FNP Table 4 - CEPHALOSPORINS
1st generation cephalosporins:
PO: cefadroxil (Duricef), Cephalexin (Keflex), cephradine (Velosef) cefazolinParenteral: cefazolin (Ancef, Kefzol), cephapirin (Cefadyl) 2nd generation cephalosporins:
PO: cefuroxime axetil (Ceftin), cefaclor (Ceclor), cefprozil (Cefzil), loracarbef (Lorabid)Parenteral: cefamandole (Mandol), cefotetan (Cefotan), cefuroxime (Zinacef) 3rd generation cephalosporins
PO: cefixime (Suprax), cefpodoxime proxetil (Vantin), ceftibuten (Cedax), cefdinir(Omnicef), cefditoren (Spectrocef) Parenteral: cefoperazone (Cefobid), cefotaxime (Claforan), ceftazidime (Fortaz) Tazicef, Tazidime), Ceftizoxime (Cefizox), ceftriaxone (Rocephin), moxalactam 4th generation cephalosporins: Cefepime (Maxipime), cefpirome (HR810)
1ST gen best for gram positives (except enterococci) with some gram negative coverage (M.
Catarrhalis, E. coli, P. mirabilis, K. pneumoniae) - Good beta-lactamase resistance - Used
extensively with skin and skin structure infections
2ND gen increases coverage of gm negatives but some gm positive is lost; no enterococci -
overall broad spectrum - widely used in variety of infections 3RD gen: excellent gm negative coverage; limited gram positive esp against S aureus but
streptococcal sp. Is still good. Widely used for surgical prophylaxis; used empirically with
aminoglycoside for gm negative meningitis and for fever unknown origin.
4th gen: good gram positive and broad array of gm negative incl P aeruginosa
Much less beta-lactamase resistance as compared to penicillins. First and second generationha ve bro ad er sp ec trum . Can be us ed in re sp iratory tract in fectio ns , sin us itis, o titis, sk in and sk instructures (1st gen is best choice). An alternative in UTI where other agents are not an option Cross reactivity (8%) with penicillin allergy. Overall non-toxic; can be used in pregnancy. Cansubstitute for penicillin in allergic patient e.g. strep pharyngitis . Inconsistent to poor foranaerobes. Some 4 th generation have pseudomonal coverage; 1st-3rd generation have nocov erag e.
2002 Lois E. Brenneman, MSN, CS, ANP, FNP Table 5 - TETRACYCLINES - effective against typical and atypical organisms
tetracycline (Sumycin, Achromycin)do xyc yclin e (D oryx, V ibram ycin )m ino cyc line (M ino cin )demecolcine (Declomycin)meclocycline (Meclan)oxytetracycline (Terramycin) un de rline d indic ate s th e m os t co m m on ly used agen ts; oth ers a ge nts rar elyused Min ocyc line is ex trem ely active aga inst M RS A an d M RS E an d us ed s ucc ess fully withstaphylococcal infections. Doxycycline active against some strains VRE; regulartetrac ycline is poorly ac tive ag ains t S. pneumoniae howeve r doxycycline is activeaga inst S. pneumoniae including penicillin-resistant strains M. pneumoniae, Psittac osis , Q fe ver, C. trach om atis , G. ing uin ale , Bruc ella, T. pallidum,rickettsia, Bo rre lia re cu rre ntis , Tu larem ia, Anthrax , Leptosp irosis, Yersinia pestis,Ac tino myc es isra elii, Noc ardia P. multocida, H. pylori, Mycobacterium marinum, VRE, plasmodium falciparum m alaria,c. p ne um on ia, Ba cillary angio mato sis , Vibrio vulnificus, Aeromonas, Plesiomonas,Eh rlichio sis , Le gio ne lla, L ym e dise as e. A lso denta l plaqu e proph ylax is NEW USES FOR MINOCYCLINE - Methicillin-R esis tant-Staphylococcus aureus (MRSA) 2002 Lois E. Brenneman, MSN, CS, ANP, FNP Table 6 - SULFONAMIDES
Bro ad spe ctru m - sys tem ic
Trimethoprim-Sulfamethoxazole - (Bactrim) -SMP-TMX Topical skin esp burns
Silver sulfadiazine (Silvadene cream) -Mafenide acetate (Sulfamylon cream) - rarely used (metabolic acidosis) Urinary tract age nts
Sulfisoxazole (Gantrisin, Azo-Gantrisin)Su lfam eth ox azo le (G an tan ol, A zo-Gan tan ol) Op hthalm ic agents
Sulfacetamide sodium (Bleph-10, Cetamide, Blephamide, Sulamyd) V ag in al c re am s
Sulfathiazole (Sultrin vaginal cream an d tablets, Triple Sulfa) - vaginal therapySulfanilamide (AVC, Vaginal Sulfa, Vagitrol) - vaginal cream Inflamm atory bow el disease ag ents
Sulfasalazine (Azulfidine) * - sulfonamide plus salicylate * mesalamine (Pentasa, Canasa) a salicylate with no sulfa moiety is more commonlyused since benefit for IBD derives from antiinflammatory effect of salicylate; sulfa moiety is irrelevant. Underline are most commonly used agents; others rarely used - Tradition al use : UT I, pros tatitis, epidid ym itis, OM , shige llosis, P. C arinii pneumonia- Good activity against variety of comm unity-acquired organisms H influenzae, M catarrhalis, E coli, P mirabilis, K. Pneumoniae, enterotoxigenic E.
Co li, Shigella species and Y enterocolitica. Listeria and PCP Little or no activity: P. aeruginosa - Anaerobic bacteria including Ba cte roide s frag ilis - Good activity against many strains of S aureus and some strains of MRSA - Newer nosocomial pathogens: Stenotrophomonas m altophilia and Burkholderia cepacia.
- Penetrates CSF: alternative therapy for Listeria meningitis in pcn-allergic patient- Im m uno com prom ised patien t: - PCP p roph ylax is - C NS to xo pla sm os is- Diarrhe a from Isos pora belli and Cyclo spo ra.
- W egner’s granulomatosis - TMP -SMX results in fewer relapses 2002 Lois E. Brenneman, MSN, CS, ANP, FNP Table 8 - AMINOGLYCOSIDES - high toxicity - systemically only for serious infections - IV
amikacin (Amikin)tobramycin (Tobrex, Tobrex ophthalmic)gentamycin (Garamycin, Garamycin ophthalmic ) netilmicin (Netromycin)neomycin (Mycifradin, Neosporin) - now used only topically due to toxicity Gram negative rods (enterobacteriaceae), S. aureus (MSSA), S. faecalis,L. monocytogenes No coverage: streptococcus sp, neisseria sp, atypicals, anaerobes Table 9 - URINARY TRACT ANTIBIOTICS - used exc lusively for UT I - no systemic absorption
nitrofurantoin (Macrobid, Mac rodantin) - UTI - E. coli, S. saprophyticus on lyfosfom ycin (Monurol) - UTI - E. c oli, S sa prophy ticu s, E . fac ialis , not for pseudomethenam ine (Mandelamine, Hiprex, Urised) - liberates formalin in bladder Trimethoprim-sulfamethoxazole (Bactrim) and fluoroquinolones are more commonly used forUTI 2002 Lois E. Brenneman, MSN, CS, ANP, FNP Table 10 - CLINDAMYCIN and VANCOMYCIN
van com ycin (Vanc ocin) - IV (PO on ly for C diffic ile) - tox ic
Indication: S. aureus (MRS A), C. difficile (pseudomem branous colitis)Covers : gram pos itive (strep sp , stap h sp incl M RS A, en teroc occ i sp, Lmonocytogenes), some anaerobes: clostridia sp (incl C. difficile) and actinomycesNo coverage: gm negatives, non-clostridia anaerobes clindamycin (Cleocin) - toxic - indicated for only serious gm + infe ctions - PO and IV
Indication: respiratory, skin, soft-tissue, septicemia, intraabdominal, female pelvic orgen ital, bone /joint.
Coverage: streptococcus sp and S. aureus (MSSA), some gram positiveanaerobes (not clostridium).
No coverage: enterococci, S epididymis, gram negatives rods (enterobacteriaceae ) TRADITIONAL USES CLINDAMYCIN (since 1960s) - Intra-abdom inal infections (covers B . fragilis and other anaero bes) *- Anaerobic pulmonary infections- Pelvic infections *- Bacterial vaginosis (used topically) - D oe s n ot p en etrate CN S th us not us ed for m en ing itis- Anaerobic lung infections- Diabetic foot, polymicrobial osteomyelitis, infected decubitus * * Requires combo with agent for gram negative coverage usually quinolone Diabetic foot infections *, S aureus, infected sacral decubitus ulcers *, PCP, cerebraltoxoplasmosis, Babesiosis, Staphylococcal intravenous or prosthetic deviceinfections) * Requires combo with agent active against aerobic gm-negative bacilli Babesiosis: clindamycin in combo with quinine is drug of choicePCP; clindamycin in combo with pyrimetham ine is alternative for cerebraltox op las m os isS. aureus osteomyelitis: highest bone-to-serum ratio Fo llow ed by va nc om ycin , na fcillin, to bram ycin , ce fazolin , ce ph alo thin 2002 Lois E. Brenneman, MSN, CS, ANP, FNP Table 11 - NEW ANTIBIOTIC AGENTS
linezolid (Zyvo x) - first of new class - PO and IV
Indication: vancomycin resistant E. faecalis (VREF), skin /sk in structu res, p ne um on ia(nosoco m ial, com m unity acquired)Coverage: Stap h sp (incl M RS A), S trep s p, En teroc occ i sp, L m ono cytogene s,No coverage: gm negatives, inconsistent for anaerobes quinu pristin-dalfopristin (Syn ercid) - tox ic with po tential fo r adv erse intera ctions - IV
Indications: serious life-threatening infections with VREF bacteremia, Complicated skin-skin structure infections with S aureus (MSSA), S pyogenesCoverage: Strep sp., S taph sp, (MRSA), E. Faecium, L monocytogenes, some an ae robe s, s om e atypic alsNo coverage: most gm negatives Table 12 - MISCELLANEOUS ANTIBIOTICS
M etronidaz ole (Flagyl, M etroG el) - anaerobes, parasites
- Anaerobic and some protozoa; similar to second generation of tetracyclines- Attains therapeutic levels in all tissues including brain and csf- Effective for serious anaerobic infections including brain abscesses Ba cte rial vagin os is, trich om on as , gia rdias is, a m eb ias isEffective for polymicrobial infections when agent to cover gm neg bacillus and gmpositive cocci eg levofloxacin (also good for oral polymicrobial infections) Drug of cho ice for ps eu do m em bran ou s c olitis Vancomycin often used in seriously ill patient Useful vs H pylori in combo regimen with bismuth, omeprazole and tetracyclineUseful in Crohn’s disease -> healing of perianal diseaseTop ica lly helpful fo r ro sa ce a and also bac terial va gin os is Rifam pin (Rifad in) - N. meningitis prop hylaxis or ca rrier, M. tuberculin
2002 Lois E. Brenneman, MSN, CS, ANP, FNP

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