2017

Antibiotics Made Easy by Nezar Bahbri

WRITTEN BY:
ALAA SAAD AREHAILI
ALHUSSEN FAHAD KHAWAJI
HADEEL FAHAD ALSULAIMANI
HADI HASSAN DAGHREERI
SEHAM YAHYA ALZAHRANI
JNADI MOHAMMED MADKHALI
KHALIL IBRAHIM KARIRI
REVIEWED BY: DR. NEZAR BAHABRI
 Systematic Approach to pick your Antibiotic:
• Stability: is the patient stable or unstable (tachycardic- tachypnic-hypotensive-desaturated)
• Know your enemy: You must know the most common organisms in each disease
-If the patient is stable: you have to cover the most common causative organisms.
-If the patient is unstable: you have to cover all causative organisms.
• Do you have the right gun: Make sure that your Antibiotic covers your organism.
• Special war land: Make sure that the Antibiotic can reach to the affected organ.
N.B: 3 places we should check it twice (bone, brain, pregnancy) because the Antibiotic may not reach to although it covers the
organism.
Ex: cefuroxime, ceftriaxone, Tazocin all cover the Staph but in osteomyelitis the only one which can reach to the bone is ceftriaxone.

Ex: in UTI usually we use Bactrim or doxycycline but in pregnant women we don’t because it may lead to embryo/fetal developmental
toxicity, inhibits folate metabolism.

CLASSIFICATION OF BACTERIA:
The bacteria can be classified according to:
❖ Gram stain (positive vs negative)
• G (+): they are the heroes of this life.
• G (-): contain fat so it causes diseases in the abdomen.
• Anaerobes: live without air (mouth, abdomen, abscess).

❖ Morphology (Cocci vs rod / bacilli vs coccobacilli)

70% Of the organisms are (G+ cocci &G-bacilli) other than these we should open the book.
 I

GRAM POSITVE COCCI:

1. Staph: is everywhere in your body but
it doesn’t harm except if there is a wound
(surgery, central line ...etc.), And it can be
covered 99.9% by vancomycin.

2. Strept (married staph; in form of

couple): causes diseases in the diaphragm and
above, legs and below.

3. Enterococcus: in chains or pairs, cause disease in the Abdomen (Gallbladder, urine, abdominal abscesses) and if you found it in the
blood OR sputum think about abdominal perforation.

If you find nitrate test negative in urine analysis your organism most probably is Enterococcus.

If you find nitrate test positive in urine analysis your organism most probably is
gram -ve bacilli (most probably E. COLI)
 GRAM NEGATIVE BACILLI:
1. E.coli (same sites of Enterococcus)
2. klebsiella (same sites of Strept)
3. Proteus
4. Pseudomonas (special situation), it can affect any organ in immunocompromised patients [diabetic patients, chemotherapy,
AIDS].

When we say, this Antibiotic covers Gram +ve that mean it covers staph and Strept only NOT ENTEROCOCCUS (if it covers enterococcus we
say gram +ve including enterococcus).

When we say this Antibiotic covers Gram -ve that mean it covers (E.coli, klebsiella, proteus) NOT PSEUDOMONUS

• Growth requirement (aerobic vs anaerobic)

• Biochemical reaction (lactose fermenting vs non-fermenting)

Some t
 Group CEPHALOSPORINS
Examples 1st
generation 2ndgeneration 3rd generation 4th generation
Cefazolin & Cephalexin cefuroxime ceftriaxone ceftazidime cefepime
Route of Iv oral Iv & oral Iv Iv Iv
administration
Gram + Yes very well Yes Yes No Yes
Gram - Yes, but less effective than cephazolin Yes, better Yes Yes, pure gram -ve Yes
than
cephazolin
Anaerobes No, so not used in abscess Yes No No Yes
Atypical No No No No No
MRSA No No No No No
ESBL No No No No No
Pseudomonas No No No Yes Yes
Enterococcus All the cephalosporins DOES NOT cover Enterococcus or spice organisms
As we move through generations, gram +ve efficacy is decreasing while gram -ve one is increasing.
*****
Notes ❖ Very will distributed to almost It is used in ❖ It is the most common I.v ❖ Its dose given as ❖ It has an
GIT/GU and antibiotic used in the 3 times per day. amazing
every area in the body.
lung infections world. ❖ It has an distribution
although, we depend on it in and abscess. ❖ It has the least side effects amazing including its
among all cephalosporins distribution ability to reach
MSSA bacteremia, in skin, MSSA
It is not generations. the brain.
including its
in bone, MSSA in joints but not working in ❖ It has an amazing ❖ It is the widest
heart + brain. distribution everywhere ability to reach spectrum
used in Lung, GI/GU infections the brain.
in the body, so treat all the among all
and abscess. body from brain to toe. ❖ Once you find cephalosporins
sensitive gram - generations.
❖ It is the best among ❖ Its dose is given once per ve infection, so
cephalosporins in killing gram day. ceftazidime is
❖ Doesn't affect the kidney the drug of
+ve especially staph, doctors so it doesn't need renal choice, cuz it is
called it the guy for staph. adjustment. the best to kill
gram -ve.
❖ It is the second commonest to be ❖ Example: if
given for staph in blood (MSSA there is
sensetive gram -
bacteremia) after Oxacillin, but ve in brain
they don't use oxacillin, why? following
surgery, so your
Because oxacillin dose is every 4 Ab of choice will
hours WHILE cephazolin dose is be ceftazidime.

every 8 hours So it's the

preferred.
❖ Doesn't go with bad infections
like complicated GI/GU,
 (septic), lung infection,
osteomyelitis except if the
patient has STAPH.
❖ Cephazolin is the drug of choice
pre-operative cuz it covers the
most common gram +ve (in
lung) and gram -ve (in GIT/GU).
 Group Penicillin
Examples Augmentin Tazocin
Route of administration Oral & IV IV
Gram + Yes very well Yes
Gram - Yes very well Yes
Anaerobes Yes, so used in abscess Yes, so used in abscess
Atypical No No
MRSA No No
ESBL No No
Pseudomonas No Yes
Enterococcus Yes, doctors called penicillin group as the players of Yes, doctors called penicillin group as the
enterococcus players of enterococcus
Notes ❖ The best oral AB because it has huge coverage and less ❖ It is a Piperacillin/tazobactam.
side effects. ❖ It is better than ceftriaxone because it
❖ It has very well distribution to most of the body parts. covers pseudomonas so it has a wider
❖ Can't reach to the brain and bone. broad spectrum, so they said " when
❖ Important side effects:
someone is sick, give him tazocin ".
• If given to patient with EBV will develop rash due to
❖ It has very well distribution to most of
cross reactivity, so to avoid rash give cefuroxime.
• Some times may cause Mild hepatotoxicity. the body parts.
❖ Doctors consider it the king of GIT + GU
infections cuz it covers both gram +ve
including enterococcus and gram -ve
including pseudomonas.
❖ Can't reach to the brain.
❖ Better to be used by an infectious
disease specialist.
 Group GLYCOPEPTIDES
Example Vancomycin
Route of administration Oral or IV
Gram + YES
Gram - NO
anaerobes No
atypical No
MRSA YES
ESBL NO
pseudomonas No
enterococcus Yes
Notes ❖ Purely gram +ve including MRSA.
❖ Bactericidal.
❖ Recommended for any septic patient.
❖ Reach every part in the body.
❖ Loading dose: 15-20 mg/kg
❖ Maintenance dose: 10 mg/kg Q8-12 hours.
❖ Not nephrotoxic unless there is co-morbidity.
 Group Carbapenem
EXAMPLES Imipenem / Meropenem Ertapenem
Route of IV IV - IM
administration
Gram + Yes Yes
Gram - Yes, they cover broad gram -ve organisms including ESBL and pseudomonas Yes
Anaerobes Yes, they cover broad anaerobic organisms Yes
Atypical No No
MRSA No No
ESBL Yes (the best) Yes (step down grade)
Pseudomonas Yes No
Enterococcus Yes, but less than Tazocin No
Notes ✓ They are B lactam, and in general: all B lactams are considered to have the least ✓ Not available in Saudi Arabia
side effects among all antibiotics. except if there is a special
✓ In cholecystitis, the first choice is Tazocin. request.
✓ UTI can be caused by many organisms and all can be detected using Nitrate test ✓ Not a first choice in ESBL but it's
If it’s nitrate negative that mean the organism is enterococcus, and the first just a step down, so if there is a
choice for enterococcus is tazocin. patient with ESBL: start with Emi
✓ It has super amazing distribution to all the body, so it reaches the Brain, heart, or Mera then when the patient
ear …. etc. improves and you want to
Difference between Imipenem / meropenem: discharge him, then give
Imipenem: Ertapenem.
1. 4 times/day ✓ One /day
2. Oldest and the doctors have the habit of using the newest ✓ It is very well distributed to most
3. contraindicated in people who have seizure activity. of the body parts including Brain.
Meropenem: ✓ But doesn't reach Bone, so Not
1. 3 times/day used in osteomyelitis.
2. Newest
3. No contraindication
 Group
Quinolones (kings of atypical) Colistin sulphate
Examples Moxifloxacin Levofloxacin Ciprofloxacin
Route of Iv-oral oral &IV Oral & IV Oral & IV
administration The Oral is as good as the IV
Gram + Yes, broad coverage, it is the best killer of Yes, but less No No
gram +be among quinolones effective than
moxifloxacin
Gram - Yes, broad coverage Yes Yes, pure gram -ve Yes, pure gram -ve
Anaerobes Yes Some No No
Atypical Yes Some No No
MRSA No No No No
ESBL No Yes Yes ?
Pseudomonas No Yes Yes Yes?
Enterococcus Yes No No No
Notes - This drug is used to treat TB ❖ Cipro and levo are safe for ❖ This drug can be used if Imipenem
❖ Advantage: Advantage: children and pregnant women. is Not working.
- Can be taken as Oral dose. It goes to ❖ Has excellent distribution ❖ it removes the fat layer of gram –ve
- The Oral is as good as the IV everywhere everywhere. ❖ It takes 5 days to work
- It’s called (banana juice) it is yellow including the ❖ Side effect: ❖ It causes nephrotoxicity and
in color so it does Not go to the yellow urine. • It may cause confusion in elderly. hepatotoxicity and pancytopenia.
things for example: if you have UTI It is better than • Has bad interaction with
and it’s caused by enterococcus does moxifloxacin in warfarin, so it makes warfarin
Not give moxifloxacin because it does urine, but more active leading to bleeding ❖ IT IS NOT A CHOIES UNLESS IT IS
Not go to the urine. moxifloxacin is from everywhere in body. THE ONLY CHOIES.
- It goes everywhere except urine. better in
abdomen. • SO, if the patient is taking
warfarin do Not give him/her
ciprofloxacin because it will
increase the INR and increase the
bleeding tendency.
 Group Macrolides
Examples Azithromycin Clarithromycin
Route of administration Oral, IV Oral, IV
Gram+ Yes Yes
Gram - Yes (some) Yes (some)
Anaerobes No No
Atypical Yes Yes
ESBL No No
Pseudomonas No No
Enterococcus No No
Notes ❖ Very good drug for above diaphragm ❖ Dose: twice daily (BID)
infections ❖ Cause bad abdominal pain
❖ Dose: once for 3 days
❖ Well tolerated and well distributed
❖ Has an anti-inflammatory effect

Group
Flagyl (metronidazole)
Route of administration Oral, IV, topical, vaginal, rectal.
Gram+ No
Gram - No
Anaerobes Yes
Atypical No
ESBL No
Pseudomonas No
Enterococcus No
Notes ❖ Pure anaerobes.
❖ Can be used in case of Entamoeba histolytica and trichomonas vaginalis
❖ Side effects: metallic taste, nausea, vomiting epigastric pain, extrapyramidal
effect, nervousness.