General Antibiotic Considerations

Nafcillin/oxacillin

Vancomycin

Daptomycin

Linezolid

Oritavancin/dalbavancin

drugs that cover only gram positives

Aztreonam

Polymyxin

Aminoglycosides

drugs that cover only gram negatives

Pen G (IM, IV), Pen V (PO)

natural penicillins

Methicillin, nafcillin, oxacillin, dicloxacillin

anti-staphylococcal penicillins

staph (MSSA), strep, gram-positive anaerobic cocci; no gram-negative or enterococcus

anti-staphylococcal penicillins activity

PCN-G coverage + improved activity against enterococci

aminopenicillin activity

ampicillin, amoxicillin

aminopenicillins

piperacillin/tazobactam (Zosyn); amoxicillin/clavulanate (Augmentin); ampicillin/sulbactam (Unasyn)

Penicillin/B-lactamase inhibitors

common broad spectrum therapy for hospitalized patients (Pseudomonas)

piperacillin/tazobactam (Zosyn) use

diabetic food infection, community acquired pneumonia, dental infections

amoxicillin/clavulanate (Augmentin) use

enterococcus

not covered by cephalosporins

cefazolin (IV), cephalexin (PO), cefadroxil (PO)

1st generation cephalosporins

gram-positive, some gram negatives (E. coli, Klebsiella)

1st generation cephalosporins activity

Cefuroxime, Cefaclor, Cefprozil

2nd generation cephalosporins

Cefoxitin, cefotetan

cephamycins

gram-positive, some gram-negative (EPK, HMN)

2nd generation cephalosporin activity

2nd generation + bacteroides

cephamycin activity

IV: cefotaxime, ceftazidime, ceftriaxone, ceftolozane; PO: cefdinir, cefixime, cefpodoxime

3rd generation cephalosporins

strep, some gram-negatives

ceftriaxone and ceftazidime cover pseudomonas

3rd generation cephalosporin spectrum

cefepime

4th generation cephalosporin

coverage of AmpC producing organisms and pseudomonas

4th generation cephalosporin activity

ceftaroline

5th generation cephalosporin

MRSA, limited enterococcal

5th generation cephalosporin activity

imipenem, meropenem, Doripenem, ertapenem

carbapenems

everything but MRSA

ertapenem - does not over APE (Acinetobacter, pseudomonas, enterococci)

carbapenems activity

aztreonam

monobactams

only gram negatives

monobactams activity

vancomycin (IV), Oritavancin (IV), dalbavancin (IV)

glycopeptides

broad gram-positive activity, including MRSA (oritavancin: +VRE)

glycopeptides activity

broad gram-positive including MRSA, VRE (don't use for pneumonia)

daptomycin (cyclic lipopeptide) activity

linezolid (IV/PO), tedizolid (IV/PO)

oxazolidinones

broad-spectrum gram-positive including MRSA and VRE

oxazolidinones activity

erythromycin (IV/PO), azithromycin (IV/PO), clarithromycin (PO)

macrolides

excellent for atypical respiratory pathogens

macrolides activity

MRSA, strep, gram-positive anaerobes

clindamycin activity

minocycline, doxycycline, tetracycline

tetracyclines

MRSA, atypicals, tick-borne pathogens

tetracyclines activity

gentamycin (IV), tobramycin (IV), amikacin (IV)

aminoglycosides

mostly gram-negative, used for synergy with other agents for gram-positive

aminoglycosides activity

ciprofloxacin, moxifloxacin, levofloxacin

fluoroquinolones

moxifloxacin and levofloxacin

respiratory fluoroquinolones

strep, gram-negatives (levo and cipro - pseudomonas), atypicals

fluoroquinolones activity

sulfamethoxazole-trimethoprim (IV/PO)

folic acid antagonists

gram-positives including MRSA, Stenotrophomonas, PJP

folic acid antagonists activity

gold standard for anaerobic coverage

metronidazole activity

· Vancomycin

· Linezolid/tedizolid

· Daptomycin

· Ceftaroline

· Dalbavancin/Oritavancin

· Clindamycin

· Doxycycline

Delafloxacin

drugs that cover MRSA

· Piperacillin/tazobactam

· Cefepime

· Ceftazidime

· Carbapenems (not erta)

· Aztreonam

· Ciprofloxacin, levofloxacin

· Aminoglycosides

· Polymyxin and colistin

Ceftolozane/tazobactam

drugs that cover pseudomonas

· Metronidazole

· Piperacillin/tazobactam

· Ampicillin/sulbactam

· Amoxicillin/clavulanate

· Moxifloxacin

Cefoxitin

drugs that cover gram-negative anaerobes

penicillin, amoxicillin

drugs to treat strep pneumoniae

penicillin

drugs to treat other types of strep infections other than strep pneumoniae

oxacillin, nafcillin, dicloxacillin OR 1st generation cephalosporins

drugs to treat Staph infections (MSSA)

ampicillin, amoxicillin

drugs to treat enterococcus infections

cefepime

drug to treat AmpC producer (enterobacter, klebsiella) infections

meropenem, imipenem-cilastatin, Doripenem

drugs to treat ESBL producing bacterial infections

· Nausea and vomiting

· Diarrhea

· Hypersensitivity reactions (ranging from rash to anaphylaxis)

· C. diff

reactions to all antibiotics

· Diarrhea: particularly with amoxicillin-clavulanate

· Nephrotoxicity: interstitial nephritis most common in PCN derivatives (nafcillin, oxacillin)

· Hypersensitivity reactions: penicillins are the most common reported drug allergies of all classes

· Seizures: reduced seizure threshold, particularly with imipenem, penicillin, cefepime

· Neurotoxicity: associated with higher concentrations of cefepime

reactions to beta-lactams

· Nausea and vomiting - particularly with erythromycin

· QTc prolongation

reactions to macrolides

· Photosensitivity

· Discoloration of teeth (children)

AVOID in pregnancy and children <8

· Esophagitis (take with full glass of water)

· Minocycline: skin discoloration

· GI upset

reactions to tetracyclines

· Nephrotoxicity: associated with higher doses and longer duration

· Vancomycin infusion syndrome

o Erythematous rash on head, neck, trunk

o Associated with rapid infusion rates

o Pre-treat/treat with antihistamines

o Previously known as "red man's syndrome"

· Thrombocytopenia

reactions to vancomycin

· Myopathy (rare rhabdomyolysis)

o Creatinine kinase increases >4xULN

o Onset >7 days

o Increased risk with statins

o Monitor: creatinine kinase (CK) weekly and for muscle pain and weakness

· Eosinophilic pneumonia/pneumonitis

reactions to daptomycin

diarrhea, C. diff

reactions to clindamycin

· >2 weeks, reversible

o Myelosuppression

· >6 weeks, may be irreversible

o Peripheral neuropathy

o Optic neuritis

o Lactic acidosis

reactions to linezolid

· Nephrotoxicity: gentamicin = amikacin > tobramycin

· Ototoxicity: gentamycin > tobramycin > amikacin (Irreversible)

reactions to aminoglycosides

· Rash

· Orange/yellow discoloration of tears, sweat, urine, body fluids

· Liver dysfunction/hepatitis

· Thrombocytopenia

reactions to rifampin

· Dark urine

· Rare/severe: pulmonary fibrosis, hepatitis

reactions to nitrofurantoin

· Tendonitis and tendon rupture

· QTc prolongation

· C. diff

· Peripheral neuropathy

· Photosensitivity

· Blood glucose disturbances

reactions to fluoroquinolones

· Hypersensitivity (rash)

· Photosensitivity

· N/V/D

· Renal toxicity/artificial increase in serum creatinine

· Hyperkalemia

reactions to trimethoprim/sulfamethoxazole

· Metallic taste

· Dark urine

· Peripheral neuropathy with prolonged use

reactions to metronidazole

· Iron w/ cefdinir --> red stool

· Antacids w/ cefaclor, cefdinir, cefpodoxime --> reduced bioavailability

· Probenecid --> inhibits renal secretions of most antibiotics

beta-lactam DDIs

· Valproic acid (VPA) --> reduces concentration of VPA and increases risk of seizures

carbapenems DDIs

· Erythromycin/clarithromycin --> strong CYP3A4 inhibitors and substrates

· Azithromycin --> minor substrate of CYP3A4; few significant DDIs

· Antiarrhythmics --> macrolides increase QT interval, additive prolongation with other QT-prolonging agents

macrolides DDIs

· Reduced absorption when taken with multivalent cations including Al, Mg, and Ca (separate taking antacids by 2 hours)

tetracyclines DDIs

· Weakly inhibit MAO --> increased risk of serotonin syndrome; Careful with SSRIs, venlafaxine, dextromethorphan, methadone

linezolid DDIs

· Nephrotoxicity - increased risk with Amphotericin B, cisplatin, cyclosporin, vancomycin, indomethacin, foscarnet, polymyxins

aminoglycosides DDIs

· CYP3A4 and CYP2C9 and p-glycoprotein inducer

· CYP3A4/2CP9 substrates: warfarin, lamotrigine, phenytoin, valproic acid, caspofungin, dapsone, doxycycline, azole antifungals, HIV medications, amiodarone, digoxin, calcium channel blockers, statins, oral contraceptives, cyclosporin, tacrolimus, antidepressants

rifampin DDIs

· Multivalent cations (Mg, Al, Ca) decrease absorption

· Antiarrhythmics --> increased risk of torsade de pointes

· Ciprofloxacin + tizanidine: increases tizanidine concentrations very significantly, increasing hypotensive and sedative effects

fluoroquinolones DDIs

· Warfarin: enhances anticoagulation effect

· Inhibits renal tubular secretion - increases methotrexate, digoxin, dapsone, amantadine

Trimethoprim/sulfamethoxazole DDIs

Disulfiram: alcohol including OTC cold products

warfarin - increased anticoagulation effect

decreased clearance: lithium, cyclosporin, tacrolimus, carbamazepine, phenytoin

metronidazole DDIs