Drug List (Sulfonamides) • • • • • Protype/Important sulfisoxazole sulfamethoxazole sulfadiazine trimethoprimsulfamethoxazole • • • • • Others Sulfasalazine silver sulfadiazine sulfacetamide sulfadoxinepyrimethamine • triple-sulfonamides Drug List (Penicillins) • • • • • • Prototype/Important Pen G (natural pen) • • • • Nafcillin (Penase resis.) • Ampicillin (aminopen.) • Piperacillin (antipseud.) • • Related Drugs Others Pen G procaine Pen G benzathine Pen V Methacillin, oxacillin Amoxacillin Ticarcillin Clavulanic acid, sulbactam (beta lactamase inhibitors) Drug List (Cephalosporins) • • • • • Prototype/Important • Cefazolin (1st gen.) • Cefuroxime (2nd gen.) • Cefotaxime (3rd gen.) • Cefepine (4th gen.) • Others Cephalexin (oral, 1st gen.) Cefaclor (oral, 2nd gen.) Cefixime (oral, 3rd gen.) Ceftriaxone (long duration, 3rd gen.) Cephalosporins (half-life) • • • • Cefazolin (1.5-2hr) Cefuroxime (1.3 hr) Cefotaxime (1 hr) Cefepine (1 hr) • • • • Cephalexin (1 hr) Cefaclor (0.75 hr) Cefixime (3-4 hr) Ceftriaxone (6-8 hr) Drug List (other beta lactams) • Prototype • Imipenem • Others • Imipenem-cilistatin Drug List (aminoglycosides) • Prototype • Gentamicin • • • • Others Amikacin Streptomycin Neomycin Drug List (antitubercular) • Important • Isoniazid • Rifampin • • • • Others Streptomycin Ethambutol Pyrazinamide Drug List tetracyclines/chloramphen. • Prototype • Tetracycline • Chloramphenicol • Others • Doxycycline • Minocycline Drug List (agents for UTI) • • • Prototype/Important Methenamine Ciprofloxacin • Related agents • Phenazopyridine • • • • • Others Nitrofurantoin Norfloxacin (only UTI) Ofloxacin, Levofloxacin Moxifloxacin, Sparfloxacin, Trovofloxacin (newer expanded spectrum) Drug List (miscellaneous) • • • • • Prototype Erythromycin Clindamycin Vancomycin Metronidazole • Others • Azithromycin Penicillin Subclasses Pen G Nafcillin Ampicillin Amoxacillin Ticarcillin Piperacillin Resistant to No beta lactamases Clinical status Yes(gram pos.) No Spectrum Strep. N.men. Staph. (penicillinaseproducing) same as Pseud.aerug., some pen G plus enteric gram neg. H.flu., bacilli E.coli Combined with beta lactamase inhibitors No No Yes No Yes Clinical Status of Penicillins • Pen G & V: Group A Strep., most Strep. pneumoniae, N. meningitidis, T. pallidum (syphilis) • Nafcillin: penicillinase-producing Staph. • Ampicillin/Amoxacillin: H.flu. (otitis media, URTI), E.coli (UTI), Shigella, Salmonella • Piperacillin: Pseud. aerug. (UTI), some gram neg. bacilli Cephalosporin Subclasses First Gen. Second Gen. Third Gen. (Cefazolin) (Cefuroxime) (Cefotaxime) Spectrum Resistance to beta lactamases Clinical status CNS penetranc e same as Pen G plus Staph. more gram neg. Klebsiella Relatively resistant to gram pos. inadequate Expanded gram neg. and H. flu. Good gram neg. bacilli (hospitalacquired) Increased vs. gram neg. More resistant to gram neg. inadequate for most adequate Clinical Status of Cephalosporins • Cefazolin: serious Klebsiella pneumoniae, alternate to penicillins for strep. & staph.; prophylaxis in surgery vs. staph & enteric gram neg. • Cefuroxime: gram neg. hosp. infections resistant to 1st gen. ceph., including beta lactamase-producing strains, H.flu. (Cefaclor used orally for some H. flu.) • Cefotaxime: serious gram neg. bacilli esp. if meningitis, beta lactamase-producing gonococci (ceftriaxone preferred); may be combined with AG; some other 3rd gen. ceph. useful vs. Pseud.aerug. (ceftazidime) What are the major differences between imipenem, penicillins and cephalosporins ? • Spectrum • Distribution – Why is it combined with cilistatin? • Toxicity • Clinical Status Major Differences in Imipenem, Penicillins, Ceph. • Spectrum – Imipenem broadest covers most gram neg. bacilli (very resistant to beta lactamases) Staph., plus anaerobes (B. fragilis) • Pharmacokinetics – Imipenem metabolized by renal dehydropeptidases (need cilistatin) • Toxicity (Imipenem) – allergic responses, superinfections, thrombophlebitis, seizures (rare) Major features of Penicillins • Spectrum – Pen G best for strep. but not cover staph. – Ampicillin for strep., H. flu., salmonella/shigella, E. coli • Pharmacokinetics – eliminated by renal secretion • Toxicity – allergic rxs, seizures in high doses – Ampicillin: rash, diarrhea (superinfections) – Piperacillin: platelet dysfunction, thromophlebitis Major Features of Cephalosporins • Spectrum – 1st gen.: strep., staph., more gram neg.bacilli – 2nd gen.: more gram neg. in hospital, H. flu. – 3rd gen.: best vs. gram neg. bacilli (very resistant to beta lactamases) • Pharmacokinetics – eliminated by renal secretion (some metabolized) • Toxicity – allergic rxs, superinfections, low potential renal toxicity What are the unique features of aztreonam? • Compared with penicillins and cephalosporins – Spectrum – Pharmacokinetics – Adverse effects » Is there cross-sensitivity with penicillins? Unique Features of Aztreonam • Monobactam with only gram neg. spectrum • no cross allergenicity with pen or ceph • used alone only for UTI • potential gram pos. superinfections • must be given parenterally What are the important characteristics that all aminoglycosides have in common? • Spectrum • Pharmacokinetics • Adverse effects Features of Aminoglycosides • excellent vs. aerobic gram neg. bacilli • limited distribution to extracellular fluids • eliminated almost entirely by glomerular filtration (monitor renal function) • serious toxicities – irreversible ototoxicity – vestibular toxicity – nephrotoxicity – neuromuscular blockade Summarize the status of aminoglycosides and third generation cephalosporins • Clinical status of aminoglycosides • Clinical status of third generation cephalosporins • Clinical status of imipenem Aminoglycosides vs 3rd Gen. Cephalosporins/Imipenem • 3rd gen ceph.: preferred vs. gram neg. sepsis to avoid serious toxicities of AG • some 3rd gen. ceph. better vs. Pseud. while other better vs. other gram neg. bacilli • initial therapy of life-threatening sepsis involves combination of AG plus either 3rd gen. ceph. / antipseudomonal pen/ imipenem • imipenem reserved for mixed infections that my involve anerobes (B. fragilis) Erythromycin • Clinical use • Adverse reactions Erythromycin • Clinical Uses • Respiratory infections (Chlamydia, Mycoplasma, Legionella, Bordetella) • Alternate to pen in mild-moderate infect.(strep., H. flu.) • Adverse effects – frequent GI disturbances – cholestatic hepatitis with estolate ester in adults – inhibition of hepatic CYP3A (drug interactions) Tetracyclines • Clinical use • Adverse reactions Tetracyclines • Clinical use – some gram neg. infections – Rickettsia, Chlamydia, Mycoplasma – spirochetes, Lyme disease, acne, travelers diarrhea • Adverse reactions (numerous) – discolor teeth in children, phototoxicity, GI disturbances, superinfections – vestibular toxicity (minocycline) – renal toxicity (if renal insufficiency, outdated tetracyclines – hepatic toxicity (high doses in malnourished, pregnancy, liver disease) Ciprofloxacin • Clinical use • Adverse reactions Ciprofloxacin • Clinical use – oral or IV for variety of gram neg. enteric bacilli – good for UTI; some used for genital infections due to chlamydia or gonococci – some used for respiratory tract infections due to Mycoplasma, Legionella, Brucella, Mycobacteria – newer analogs better vs. Strep. Pneumoniae Ciprofloxacin • Adverse reactions – some GI – rash – cartilage damage in children, tendon ruptures – photosensitivity – CNS toxicity (dizziness, ataxia, insomnia) – seizures (rare) – Hepatotoxicity only with Trovafloxacin – Photosensitivity most frequent with sparfloxacin Chloramphenicol • Clinical use • Adverse reactions Chloramphenicol • Clinical use – alternate for meningitis due to H.flu., N. meningitidis, Strep. pneumoniae – severe anaerobic infections of CNS – alternate to tetracyclines for rickettsia, chlamydia, brucellosis • Adverse reactions – aplastic anemia (rare), bone marrow suppression (reversible), superinfections, Gray Baby syndrome Sulfamethoxazole-Trimethoprim • Clinical use • Adverse reactions Trimethoprim-Sulfamethoxazole • Clinical use – UTI due to susceptible gram neg. bacilli – otitis media or chronic bronchitis due to H. flu., Strep. pneumoniae – Pneumocystis carinii – Salmonella, Shigella, toxigenic E. coli Trimethoprim-Sulfamethoxazole • Adverse reactions – Hematopoietic disorders: anemias (give folinic acid) – Hypersensitivity Reactions: frequent allergic reactions to sulfonamides (rash photosensitivity), – CNS toxicity (headache, depression, hallucinations) – higher incidence side effects in AIDS (fever, rash, leukopenia, diarrhea) What drugs are useful in treating anaerobic infections caused by B. fragilis? • List five examples Drugs are useful in treating anaerobic infections caused by B. fragilis • Clindamycin • Chloramphenicol • Metronidazole • Imipenem • Some 2nd gen. cephalosporins – cefoxitin, cefotetan – some 3rd gen. cephalosporins and antipseudomonal penicillins have moderate activity What advantages do these drugs have compared to others within the same class? • Azithromycin (Zithromax) • Ceftriaxone (Rocephin) • Doxycycline (Vibramycin) • Levofloxacin (Levequin) Advantages of Azithromycin • Improved spectrum vs. erythromycin – especially vs. Mycobacterium avium complex, H. influenzae, Chlamydiae, some gram neg. • Long half-life due to accumulation in macrophages and fibroblasts (5 day regimen for respiratory tract infections) • Not inhibit liver CYP metabolism of other drugs Advantages of Ceftriaxone • Increased activity vs. gram-neg. bacilli, esp. in treating meningitis • Highly resistant to beta lactamases esp. Neisseria gonorrheaea and H. influenzae • Long half-life, used as single dose regimen for gonorrhea Advantages of Doxycycline • Complete oral absorption, not affected by food or antacids • Not require dose reduction for patients with reduced renal function • Often used for traveler’s diarrhea since better oral absorption and less GI disturbances Advantages of Levofloxacin (Moxifloxacin) • expanded spectrum vs. some gram pos. esp. Strep. pneumoniae • also reliable vs. other resp. tract pathogens such as chlamydia, mycoplasma , Legionella, H. influenzae • good vs. gram neg. causes of UTIs and gastroenteritis Case #1 • Trauma accident with severe burn patient • Pseud. aerug. pneumonia • start with cefotaxime (3rd gen. ceph.) • infection worsened • patient finally dies of intracerebral hemorrhage Case #1 Questions • 1. Why may a third generation cephalosporin be a poor choice? • 2. What complications of some third generation cephalosporins make them a particularly bad choice on the basis of the patient’s risk factors? • What classes of antimicrobial drugs are reasonable choices for treating infections caused by Pseudomonas aeruginosa? List the notable limitations of each drug class. Case # 1(Answers) • 1. cefotaxime not highly effective vs. Pseudomonas esp. in burn unit as resistance with single drug therapy • (use antipsuedomonal pen plus AG) • 2. some third gen. ceph. cause bleeding (hypoprothrombinemia) and impair phagocytosis (pneumonia can worsen, resist.) • 3. alternatives: piperacillin (platelet dysfunction, hypersensitivity) plus amikacin (nephrotoxicity, ototoxicity), or 3rd gen. ceph.(ceftazidime), or imipenem or fluoroquinolone) Case #2 • Otitis media initially that developes into meningitis due to Strep. pneum. • Given Cefaclor (oral 2nd gen. ceph.) as out patient • patient worsens to comatose state and given massive doses of penicillin and has status epilepticus • regains consciousness upon decreasing dose of penicillin Case #2 Questions • 1. Was an oral, “second generation cephalosporin the best antimicrobial considering the most likely organism(s) to be causing his otitis media? • 2. What feature of penicillin makes it dangerous in very high doses in patients with a more permeable blood-brain barrier? • 3. What alternative antimicrobials may be recommended in the treatment of meningitis caused by Streptococcus pneumoniae? Case #2 (answers) • 1. 2nd gen. ceph. orally may be inadequate dose to prevent meningitis; parenteral dose preferred or high doses of amoxacillin or penicillin but pt compliance a concern; could use amoxacillin-clavulanic acid to cover beta lactamase producing strains • 2. pen G in high doses causes convulsions esp. if inflammed meninges • 3. alternatives: IV pen G or ampicillin, cefotaxime, or chloramphenicol Case #3 • Cefuroxime (2nd gen. ceph.) induces antibiotic associated colitis with severe diarrhea leading to death Case #3 Questions • 1. What disease entities are associated with the administration of broad-spectrum antimicrobials? • 2. Are these complications of broad-spectrum antimicrobials ever lethal? If so, by what means? • 3. What antimicrobial, if any, is recommended to treat the probable cause of diarrhea in this patient? Case #3 (answers) • 1. overgrowth or superinfection from exotoxin-producing Clostridium difficile, staph. or candida • 2. exotoxin-producing C. difficile may produce fatalities • 3. oral vancomycin or metronidazole Case #4 • UTI in 22 year old woman with gram neg. bacteria and PMNs in urine Case #4 Questions • 1. What is the most likely organism to be causing her UTI? • 2. What organism must be excluded as a possible cause of her pyuria to avoid infection of the upper genital tract that might leave her infertile or with an ectopic pregnancy? • 3. Assume that the gram-neg. bacteria are bacilli. On the basis of the most likely organism, what antimicrobials are candidates for being the best to treat her UTI? Case #4 Questions (cont.) • 4. If she were a patient in the Burn Unit who had developed a UTI, on the basis of the most likely organism, what antimicrobials would be likely to be effective in her management? • 5. How would your management of a UTI differ if you knew she was just recovering from profound renal failure associated with recent trauma? • 6. If she were pregnant, how would treat the UTI? Explain your selections/nonselections. Case #4 (answers) • 1. E.coli, other gram neg. bacilli • 2. exclude gonococcal urethritis • 3. sulfisoxazole, ampicillin/amoxacillin, TMP/SMX, tetracycline, norfloxacin • 4. in burn unit cover resistant strains of gram neg. bacilli; use TMP/SMX or norfloxacin/other fluoroq. • 5. avoid sulfonamide & AG if poor renal function; use amoxacillin, doxycycline, or fluoroquinolone • 6. if pregnant avoid sulfonamides, tetracycline, fluoroquinolone; consider amoxacillin alone or with clavulanic acid Case #5 • Pneumonia due to Pseudomonas aeruginosa after surgery for crush injury to chest and arm • Therapy with aminoglycoside plus piperacillin • serum creatinine becomes elevated Case #5 Questions • 1. Outline the options available to the surgical management team and evaluate them. • 2. What types of patients tend to be predisposed to aminoglycoside toxicities? Case # 5 ( answers) • 1. order serum levels of AG; delay next dose by 4-8 hours; change from AG to antipseudomonal 3rd gen. ceph. (ceftazidime) or fluoroquinolone or aztreonam • 2. pts predisposed to AG toxicity: low GFR, elderly, dehydration or volume depleted, prior AG rx, or other nephrotoxic drugs
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