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Introduction
Many ways to choose antibiotics: Empiric therapy in sick pt, aiming at most likely/most serious organisms Directed therapy if organism known Host factors : pregnancy, renal failure, immune compromise, allergies
Antibiotics aimed at certain site eg. CNS
Environmental factors: travel, exposures, IDU, where pt lives etc Agent factors: type of bacteria suspected at that site, resistance patterns for institution,
Classification
Easiest to classify by means of action in destroying bacteria: I. cell wall synthesis inhibitors
Penicillins, Cephalosporins, Carbapenems, Glycopeptides
III. Anti-metabolites
Sulphonamides
The action against cell wall means very important in fighting gram positive infections Resistance now common due to either altered binding proteins (as in S. pneumoniae) or b lactamase enzymes which cleave the antibiotic .
Aminopenicillins
Ampicillin, amoxicillin Good against gram postives enterococcus, listeria But extended spectrum so action against some gram negative rods (E.coli, H. influenzae, Proteus) If combined with clavulin (blactamase inhibitor) =wider spectrum useful for sinus infections, otitis media,
Subgroup: cefotetan, cefoxitin (called the cephamycins) cover anaerobes Remember: Cefaclor (Ceclor) associated with serum sickness
Used now for MRSA, Coagulase negative Staphylococcus (CNS), Enterococci Oral use for C. difficile Adverse effects: red man syndrome from rapid infusion and histamine release
Also Nephrotoxicity, rare ototoxicity with long term exposure
Bind 30S cause misreading of mRNA Best used against gram negative infections
great for gram negative sepsis as are cidal Cant work against anaerobes Synergy against gram positives enterococcal endocarditis Tobramycin has good activity against Pseudomonas
Macrolides
Bind 50S ribosome, prevent translocation of growing protein chain
Clarithromycin covers CAP,sinusitis, H.pylori, Legionella Azithromycin also used for respiratory infections- atypicals and Moraxella, H.flu, Legionella
ALSO for Chlamydia Rx
Covers gram positives and anaerobes Good for cellulitis, abscess, some use for diabetic foot infections.
IV used for necrotizing fasciitis.
Beware of people with suspected TB these agents also cover TB, dont use if treating CAP but think TB in differential
Rifampin
Binds DNA-dependent RNA polymerase Good gram positive coverage Side effects: Orange tinged tears etc, induces P450 so drug interactions
V. Antimetabolites
Sulfonamides
Block folic acid synthesis in bacteria which is vital for synthesis of DNA, amino acids
Trimethoprim
Blocks folate pathway by inhibiting dihydrofolate reductase
Summary
Gram positive agents:
Penicillins (Pen GAS) (Clox MSSA) Cephalosporins Vancomycin Clindamycin
Summary
Anaerobic agents:
Piptazo Imipenem Clindamycin Metronidazole
Anti-Pseudomonal agents:
Piperacillin, Ceftazidime, Cefepime, Imipenem, Tobramycin, Ciprofloxacin
Summary
Skin 1st gen cephalosporins Cloxacillin (if known MSSA) Clindamycin (usually for Pen allergic) Vancomycin/Daptomycin/Linezolid MRSA Lung Cefuroxime mild cases +/- Macrolide Ceftriaxone and Macrolide (CAP requiring hospital) Moxifloxacin (CAP outpt/inpt)
Summary
Urine TMP-SMX (Septra) Cipro Keflex Nitrofurantoin Ceftriaxone (pyelonephritis/hospitalized) Sepsis Piptazo, Carbapenems, Cefipime, +/- MRSA agent