Pharm 1 Antibiotics Lectures 11 and 12

This is the meds themselves, not the conceptual stuff (lectures 9 and 10)

What classes are Beta Lactams?

1. Penicillins

2. Cephalosporins

3. Carbapenems: Imipenem/cilastatin, Meropenem, Ertapenem

4. Monobactam: Aztreonam (back up option for Penicillin anaphylaxis allergy. Gram negative only.)

beta lactam MOA

block action of penicillin binding proteins (PBPs)

all bactericidal

includes: penicillins, cephalosporins, carbapenems, and monobactams

bacterial sinusitis first line Tx

Amoxicillin–clavulanate (Augmentin) (PO) (875 mg/125 mg twice daily for 5–7 days in adults)

Beta lactamase inhibitors

amox-clav (Augmentin) (PO): OM, bacterial sinusitis, CAP, COPD exacerbation, diabetic foot infection, cat/dog/human bites, diverticulitis. Does not cover MRSA or Pseudonomas.

ampicillin-sublactam (Unasyn) (IM/IV): same as Augmentin + intraabdominal infections

pipericillin-tazobactam (Zosyn) (IM/IV): CAP, HAP, nosocomial infections, moderate-to-severe diabetic foot infection, intraabdominal infections, UTIs. Covers pseudonomas unlike the other two.

cover G+ and G-. Not MRSA.

AE: diarrhea, especially w/ Augmentin

pipericillin-tazobactam (Zosyn) (IM/IV):

CAP, HAP, nosocomial infections, moderate-to-severe diabetic foot infection, intraabdominal infections, UTIs.

Covers pseudonomas unlike Amox-Clav and Ampicillin-Sublactam

antistaphylococcal penicillins

1. Dicloxacillin (PO)

2. Nafcillin (IV)

3. Oxacillin (IV, IM)

cover MSSA and strep

uses: lactational mastitis, nonpurulent cellulitis, erysipelas, impetigo

AE: N/V/D, nephritis, elevated LFTs

pregnancy safe

What 2 antibiotics are semisynethetic/aminopenicillins?

1. Amoxicillin (PO)

2. Ampicillin (IV)

G+ and G-

OM, bacterial sinusitis, strep pharyngitis, H. pylori

OM: 80-90 mg/kg/d; strep: 50 mg/kg/d

AE: N/V/D, rash

Penicillin V (oral only) is used to treat WHAT?

Group A strep pharyngitis

skin caused by strep pyogenes

gingivitis

asplenia prophy

not use for cellulitis from staph aureus

covers strep pyogenes/GAS, S. pneumoniae, anerobes

What antibiotics do you not use for cellulitis due to s. aureus?

Peniciilin V and G (b/c poor coverage)

Penicillin G (IV/IM)

G+ and G-

IM benzathine penicillin G: one time injection for GAS, tonsillitis, syphyllis

IV penicillin G: intrapartum antibiotic prophylaxis for pregnant women with GBS

AE: hypersensitivity, C. diff colitis

IM Benzathine Penicillin G (Bicillin L-A)

one-time IM injection

strep throat, tonsillitis, and syphyllis (caused by Treponema pallidum)

prophylaxis: hypersensitivity, RF and glomerulonephritis

What 2 gram-negative pathogens are covered by Penicillin G (IV/IM)

1. Trepomena Pallidum (syphilis)

2. N. meningitidis

Penicillin G AEs

hyperkalemia, C. diff colitis, hypersensitivity

What can IV penicillin G be used to treat?

prophylaxis in pregnant women with GBS

neurosyphilis

teeth / odontogenic soft tissue infections

toxic shock syndrome, streptococacal

Endocarditis

meningitis

Do antistaphylococcal penicillins (Dicloxacillin, Nafcillin, Oxacillin) treat MRSA?

no, penicillins don’t cover MRSA

Dicloxacillin (PO)

class: antistaphylococcal penicillin, covers MSSA and streptococci

mastitis (lactational)

Which antistaphylococcal Penicillin is administered PO?

Dicloxacillin: covers MSSA, strep. Mostly for lactational mastitis.

Aminopenicillins

1.Amoxicillin (PO)

2.Ampicillin (IV)

indications:

• Otitis media
• Bacterial sinusitis
• Strep pharyngitis

Pediatric dosing concentrations:
• Otitis Media: 80-90mg/kg/day (max 4000mg/day)
• Strep Pharyngitis: 50mg/kg/day (max 1000mg/day)

What adverse effect is more common when taking aminopenicillins (Amoxicillin and Ampicillin)?

rash!!!!

Doxycycline

• class: tetracycyline

• covers MRSA, Rickettsia, Borrelia, atypicals, G+, G-

• First line for:

1. RMSF

2. Lyme

3. Chlamydia (7 days)

4. Skin infections from S. aureus

• N/V/D, photosensitivity, teeth discoloration in kids

• CI with pregnancy, lactation, Isotretinoin, kids <8

• do not administer w/ chelating agents

Doxy is first line for what major infections?

1. RMSF

2. Lyme

3. Chlamydia (7 days)

4. Skin infections from S. aureus

Amoxicillin (oral) and Ampicillin (IV) dosing for otitis media and strep?

Otitis Media: 80-90mg/kg/day (max total daily dose suggested 4000mg/day)
Strep Pharyngitis: 50mg/kg/day (max total daily dose 1000mg/day)

Amoxicillin-Clavulante (Augmentin) indications

otitis media (2nd line to Amoxicillin)

sinusitis and preseptal cellulitis

diabetic foot infection

bite from dog, cat, human

diverticulitis

What adverse effect is the most common when taking Amox-Clav (Augmentin) and Ampicillin-Sulbactam (Unasyn)? especially Augmentin

diarrhea

How does Pipericillin-Tazobactam (Zosyn) differ from other ABX+beta lactamase inhibitors (Amox-Clav and Ampicillin-Sublactam)?

covers pseudomonas

Which are the only 2 B-lactams that cover MRSA

Ceftaroline (IV)
Ceftobiprole (IV)

Both 5th generation cephalosporins

first generation cephalosporins

Cephalexin (Keflex) (oral)

Cefadroxil (Duricef) (oral)

Cefazolin (Ancef) (IV): surgical prophylaxis

• skin and soft tissue infections: nonpurulent erysipeleas/cellulitis, impetigo (numerous lesions), lactational mastitis, mild diabetic foot infection

• acute uncomplicated UTI

• safe in pregnancy

• mostly G+ coverage, some G-

What infections may be treated with first generation cephalosporins (Cephalexin, Cefdroxil, Cefazolin)?

skin and soft tissue infections: nonpurulent eryspelas/cellulitis, impetigo, lactational mastitis, mild diabetic foot infection

otitis media (if Penicillin allergy)

group A strep (Penicillin V is first line though)

acute uncomplicated UTIs

Cefazolin: surgical prophylaxis

What first generation cephalosporin is used for surgical prophylaxis?

Cefazolin (Ancef) (only one in its class that is IV)

What adverse effects may be caused by first generation cephalosporins?

genital candidiasis

elevated LFTs

hypersensitivity

interstitial nephritis

What are the 5 second generation cephalosporins?

1. cefuroxime (Ceftin) (oral)

2. cefaclor (Ceclor) (oral): cannot use if anaphylaxis w/ Penicillin

3. cefprozil (Cefzil) (oral): cannot use if anaphylaxis w/ Penicillin

4. Cefoxitin (IV): anaerobe coverage

5. Cefotetan (IV): anaerobe coverage

2 PROfessional FURry FOXes drinking TEA on the FLOR (clor)

cover G+ G-, anaerobes

Second generation cephalosporins treat what types of organisms?

1. cefuroxime (Ceftin) (oral)

2. cefaclor (Ceclor) (oral): cannot use if anaphylaxis w/ Penicillin

3. cefprozil (Cefzil) (oral): cannot use if anaphylaxis w/ Penicillin

4. Cefoxitin (IV): anerobe

5. Cefotetan (IV): anaerobe

gram pos, gram neg, AND anaerobes

(more gram neg than 1st gen)

What 2 second gen cephalosporins have anaerobe coverage?

Cefoxitin and Cefotetan (only 2 in class that are IV)

treating WHAT CONDITION with a second gen cephalosporin may cause a Jarisch-Herxheimer reaction?

Lyme disease treated with ___ can cause a reaction

What are the 4 third gen cephalosporins?

Cefdinir (Omnicef) (PO)

Cefixime (Suprax) (PO)

Ceftriaxone (Rocephin) (IV or IM): first line for gonorrhea; AE: ceftriaxone-calcium precipitation

Ceftazidime (Fortaz) (IV or IM): Pseudonomas coverage

you can TRI to tax ME but you won't get a DIME (you just have to remember Cefdinir on ur own lol)

Which 3rd gen cephalosporin is the first line treatment for Gonorrhea?

Ceftriaxone

Remember TRI not to get Gonorrhea

Ceftriaxone should be avoided in what population?

neonates!!!

remember TRI not to kill neonates w Ceftriaxone

Pseudonomas coverage

Ceftazidime (3rd generation)

Cefepime (4th generation)

Ceftobiprole (5th generation)

Imipenem and Meropenem (class: carbapenem)

Aztreonam (class: monobactam)

Pipericillin-tazobactam (Zosyn)

Gentamycin and Tobramycin (aminoglycosides)

Ciprofloxacin and Levofloxacin (Cipro better)

What is the only 4th gen cephalosporin?

Cefepime

Cefepime covers what type of pathogens?

MOSTLY gram neg and a lil gram pos

Pseudomonas

for skin and soft tissue infections, CAP, HAP, complicated UTIs (pyelonephritis)

Which 3 cephalosporins cover Pseudonomas?

Ceftazidime (3rd generation)

Cefepime (4th generation)

Ceftobiprole (5th generation)

two 5th gen cephalosporins

Ceftaroline (IV): covers MRSA

Ceftobiprole (IV): covers Pseudonomas and MRSA

What type of organisms does Ceftaroline cover?

gram pos and gram neg

AND MRSA

(not pseudonomas)

Ceftaroline and Ceftobiprole AE (both IV)

drug induced hemolysis

Tx for a bite from a dog, cat or human?

amox-clav (Augmentin) (oral) = first line

or ampicillin-sublactam (Unasyn) (IV/IM)

Pasturella: cat, dog bite

Capnocytoophaga: dog bite

Eikenella corrodens: human bite

What cephalosporins have MRSA coverage?

Ceftaroline (5th gen) covers ___

What antibiotics are Carbapenems? (all IV)

Ertapenem: no Pseudonomas coverage.

Meropenem: Treats meningitis. Pseudonomas coverage. Some seizure risk.

Imipenem: Pseudonomas coverage. Seizure risk. Always with Cilastatin.

G+ and G-. No MRSA coverage.

all cover Pseudonomas except Ertapenem

AE: increased seizure risk (especially w/ Impipenem)

Which carbapenem can be used to treat meningitis?

Meropenem (IV)

What is the most common adverse effects associated with Carbapenems (Imipenem/cilastatin, Meropenem, Ertapenem) (all IV)?

seizure risk (esp. with Imipenem), infusion site reactions, GI upset, renal disease caution

no MRSA coverage

usually ok if allergic to Penicillin

Imipenem is ALWAYS formulated with what?

Cilastatin

Aztreonam (IV)

class: monobactam

G- only including Pseudomonas

mostly for pts w/ Penicillin allergy, renal insufficiency, or can’t tolerate aminoglycosides

Pneumonia, meningitis, sepsis

Which cephalosporins can you prescribe if allergic to Penicillins? (anaphylaxis vs not)

if rash only: can prescribe any cephalosporin

if anaphylaxis: can prescribe any cephalosporin EXCEPT aminocephalosporins:

1.Cephalexin (Keflex): 1st gen

2.Cefadroxil (Duricef): 1st gen

3.Cefaclor (Ceclor): 2nd gen

4.Cefprozil (Cefzil): 2nd gen

What antibiotic is a Monobactam?

Aztreonam (IV):

G- only including pseudonomas and enterobacter

back up option for penicillin anaphylaxis

Pneumonia, meningitis, sepsis

Monobactams (Aztreonam, IV) cover what kind of organisms?

gram neg ONLY

In what situations would u use Monobactams? (Aztreonam)

ONLY if the patient has a Hx of anaphylaxis to penicillins

What infections can Monobactams (Aztreonam) treat?

pneumonia

meningitis

sepsis

What antibiotic is a glycopeptide?

Vancomycin (IV, PO)

Vancomycin (IV, PO)

class: glycopeptide

gram positive ONLY: MSSA, MRSA, Streptococci

IV: skin, bone, joint infections; MSSA bactermeia and endocarditis if Penicillin allergy

Oral only for C. dificile-associated diarrhea

AEs: nephrotoxic, ototoxic, red man syndrome

In what situation would IV vanc be used to treat a MSSA infection (bacteremia or endocarditis)?

if the patient has a serious allergy to Penicillin

What is the ONLY thing oral Vanc is used to treat?

C. difff diarrhea

What adverse effects are associated with Vanc?

nephrotoxicity

ototoxicity

Red man syndrome

Daptomycin

class: Lipopeptie

Treats VRE

does not treat pneumonia b/c inactivated but pulmonary surfactant

monitor CPK

Vancomycin (IV, oral)

• MSSA
• MRSA
• Streptococc

oral Vanc: for C. dificile diarrhea only

IV vancomycin for:

• Skin and soft tissue infections
• Bone and joint infections
• MRSA pneumonia
• MRSA bacteremia
• MRSA endocarditi

AEs:

• Nephrotoxic
• Ototoxic
• “Red man syndrome”

What pathogen does Daptomycin cover that Vanc DOESN'T?

Vancomycin-resistant Enterococcus (VRE)

both cover G+

What antibiotic classes are protein synthesis inhibitors?

Macrolides: Azithromycin (Zithromax; Z-pak), Clarithromycin (Biaxin), Erythromycin

Tetracyclines

Lincosamide

Aminoglycosides

Oxazolidinones

Pleuromutilins

What 3 antibiotics are Macrolides?

Axithromycin

Clarithromycin

Erthromycin

Macrolides (Azithromycin, Clarithromycin, Erythromycin) cover what types of organisms? What does Azithromycin treat?

gram neg, gram pos, AND atypical

Azithromycin: CAP, bronchitis, sinusitis (S. pneumoniae, H. influenzae), pertussis, 2nd line for strep and chlamydia

Fosfomycin (Contepo) (oral)

single-dose to treat uncomplicated UTI

generally absent from default Urine C&S panel

Which antibiotic is generally absent from default Urine C&S panel?

Fosfomycin (Contepo) (oral only)

treats uncomplicated UTIs

Tx for chlamydia

1st line: Doxycycline

2nd line: Azithromycin (single dose, often for non-compliant pts, pregnancy safe)

macrolides (Azithromycin, Clarithromycin, Erythromycin) AEs

QT prolongation / risk of torsades de pointes if combined w/ SSRIs, TCAs, antipsychotics

hepatoxicity (avoid with cholestatic jaundice pts)

Macrolides (Azithromycin, Clarithromycin, Erythromycin) are the second line treatment for WHAT?

strep!!!!

Which macrolide can be used to treat H. pylori along with a PPI and Amoxicillin?

clarithromycin

torsades de pointes

QT prolongation risk

1. Macrolide if combined with an SSRI, TCA, or antipsychotic

2. Fluoroquonolones

What antibiotics are tetracyclines?

tetracycline

Doxycycline

Minocycline

Omadacycline

What types of organisms are covered by tetracyclines?

gram pos, including MRSA

gram neg

atypical: Mycoplasma pneumoniae, Legionella pneumophilia, Chlamydophila pneumoniae

weirdos: Rickettsia rickettsii (RMSF), Borrelia burgdorferi (Lyme), Plasmodium (malaria)

Doxy is the first line antibiotic for what infections?

1. Lyme

2. RMSF

3. Chlamydia

oftentimes used for S. aureus skin infections

adverse effect of Tetracyclines

N/V/D (MC)

teeth discoloration

hepatotoxicity

photosensitivity (mostly Doxy)

cation chelation (do not give w/ dairy products)

ototoxicity: vestibular ARs like hearing loss and tinnitus (Mino and Doxy)

CI in pregnancy

Doxycycline ADRs

Teeth discoloration in children

Esophageal irritation/ulceration, GI irritation

May deposit in the bone

Impaired absorption with certain vitamins or dairy products

Photosensitivity

Why should children under 8 not take Doxy?

may cause permanent discoloration of teeth

Doxycycline contraindications

Children < 8yo (risk of permanent discoloration of teeth)
Pregnancy
Lactation
Isotretinoin use

milk, antacids, ferrous sulfate

lincosamide class

Clindamycin (PO, IM, IV):

gram pos, MRSA, and some anaerobes

a first line for cellulitis or abscess and diabetic foot infection, used for TSS

AE: C. difficile diarrhea

How is Clindamycin administered?

PO, IM, or IV

Clindamycin (PO, IM, IV)

class: Lincosamide

gram pos, MRSA, and some anaerobes

a first line for cellulitis or abscess and diabetic foot infection, used for TSS

AE: C. difficile diarrhea

What adverse effects can be caused by Clindamycin?

C. diff!!!!!!!

or

GI upset

pseudomembranous colitis (?)

aminoglycosides class

Gentamicin (IV, ophthalmic)
Tobramycin (IV, inhale, ophthalmic)
Neomycin (topical, PO)
Streptomycin (IM)
Amikacin (IV)

cover Pseudonomas, no anaerobe coverage (b/c rely on oxygen), little G+ coverage

indications: serious G- infections

in combination with other agents

AE: nephrotoxicity, ototoxicity

What adverse effects are associated with aminoglycosides?

nephrotoxicity (this class loves to hang out in the urinary tract!)

ototoxicity (irreversible)

Lefamulin (Xenleta) (PO, IV)

class: pleuromutilin

alternative agent for CAP

Strep. pneumo

H. flu

M. Cat.

MRSA

AE: diarrhea, QT prolongation

CI: pregnancy

Linezolid (PO, IV)

class: Oxazolidinones

covers MSSA, MRSA, VRE

AE:

diarrhea

serotonin syndrome

peripheral neuropathy

optic neuropathy

bone marrow suppression

What adverse effects are caused by Nitrofurantoin?

nausea

headache

elevated LFTs

avoid with low eGFR

Chloramphenicol (IV)

ONLY used for life-threatening infections when you have no other option: RMSF, bacterial meningitis

can cause aplastic anemia, thrombocytopenia, gray baby syndrome

Inhaled / Nebulized Tobramycin

Class: aminoglycoside

Treats P. Aurg LRTIs in pneumonia & CF

TMP-SMX (Bactrim) (oral, IV)

• antifolates: inhibit dihydrofolic acid and dihydrofolate reductase respectively. Synergistic. Bactericidal.

• cover G+ including MRSA and G-

• first line for pneumocystitis jirovecii pneumonia (PJP), uncomplicated UTI, purulent cellulitis and abscess, and chronic prostatitis

• 160 mg - 800 mg

• renal dosing

• avoid G6PD or folate deficiency

• no strep coverage

AE:

skin rash

bone marrow suppression

↑ serum creatinine

hyperkalemia

folate deficiency

first line for prostatitis?

acute over 35 y/o or chronic: TMP-SMX or Ciprofloxacin or Levofloxacin

acute <35 y/o or STI: Ceftriaxone + Doxycycline

chronic: alpha-blocker Tamsulosin

cause: usually E. coli from UTI or Chlamydia and Gonorrhea

pneumocystitis jirovecii pneumonia (PCP or PJP)

• atypical fungus that synthesizes its own folic acid to survive. “Fungal pneumonia”

• opportunistic infection in patients with HIV or AIDs (immunocomp)

• Tx and prophylaxis: TMP-SMX (oral, IV) (21 days)

TMP-SMX does not cover what?

strep

What are the most common adverse effects of Trimethoprim-Sulfamethoxazole? (oral, IV)

skin rash

bone marrow suppression

↑ serum creatinine

hyperkalemia

Trimethoprim-Sulfamethoxazole (oral, IV) indications

uncomplicated UTI: 1st line

skin: PURULENT cellulitis (MRSA), abscess

acute over 35 y/o or chronic prostatitis: 1st line (fluoroquinolones is other option)

pneumocystitis jirovecii pneumonia (PJP)

In which patients should you AVOID using trimethoprim-sulfamethoxazole? (oral, IV)

CI: folic acid deficiency, G6PD deficiency

relative CI: pregnancy

Which antibiotics inhibit nucleic acid / DNA function or synthesis? (bactericidal)

Fluoroquinolones

Rifampin