1 - Antimicrobial Pharmacotherapy Flashcards
Where and in what age groups are the majority of antibiotics used?
- Community
- Very young and very old (likely due to immune status)
When are antimicrobials commonly recommended for those aged 9 years and younger?
- Disease of the ear (otitis media)
- URTI
When are antimicrobials commonly recommended for those aged 10-19 years?
URTI
When are antimicrobials commonly recommended for those aged 60 years and older?
- Lower UTI
- Acute bronchitis
- Skin and soft tissue infection
What are the most common antimicrobials used in the community setting and for which conditions?
- Amoxicillin; diseases of the ear
- Azithromycin / clarithromycin; acute bronchitis
- Cephalexin; SSTI
- Ciprofloxacin and nitrofurantoin; lower UTI
Amoxicillin and ampicillin class and coverage
- Extended spectrum penicillin
- Gram neg - neisseria and treponema pallidum (like penicillin); also E. coli, proteus, and H. influenzae
- Gram pos - streptococcus, enterococcus, listeria
Azithromycin and clarithromycin class, function, and coverage
- Azithromycin = azalide
- Clarithromycin = macrolide
- Function = inhibit s30S ribosome (bacteriostatic)
- Gram pos - variable streptococcus (not PRSP), variable staph aureus (not MRSA)
- Gram neg - H. influenzae
- Atypicals - mycoplasma, legionella, chlamydia
Ciprofloxacin class, function, and coverage
- 2nd gen fluoroquinolone
- Inhibits gyrase, topoisomerase in DNA synthesis (bactericidal)
- Gram neg = E. coli, klebsiella, citrobacter, pseudomonas, enterobacter, serratia
- Atypicals = mycoplasma, legionella, chlamydia
What is important to remember about ciprofloxacin?
If used against gram pos, microorganism will acquire resistance
Cephalexin and cefazolin class, function, and coverage
- 1st gen cephalosporin
- Inhibit cell wall synthesis (bactericidal)
- Gram pos = streptococcus, staph aureus (not MRSA), not enterococcus
- Gram neg = proteus mirabilis, E. coli, Klebsiella
Nitrofurantoin class, function, and coverage
- Nitrofuran
- Inhibits ribosome, DNA through intracellular reduction to active metabolites
- E. coli, E. faecalies, staphylococcus (including S. saprophiticus)
What are the most common antimicrobials in the hospital setting?
- Cefazolin
- Ciprofloxacin
- Piperacillin-tazobactam
- Vancomycin
- Ceftriaxone
- Metronidazole
- Levofloxacin
- Cloxacillin
- TMP/SMX
- Ampicillin
Piperacillin-tazobactam class and coverage
- Extended spectrum penicillin and beta-lactamase inhibitor
- Gram neg - neisseria and treponema pallidum (like penicillin); also E. coli, proteus, and H. influenzae (like amoxicillin); staph aureus (not MRSA)
- Gram pos - streptococcus, enterococcus, listeria (like amoxicillin); also citrobacter, acinetobacter, pseudomonas, enterobacter, serratia, beta-lactamases (not ESBLs)
- Anaerobes / bacteroides
Vancomycin class, function, and coverage
- Glycopeptide
- Inhibits cell wall synthesis (bactericidal)
- Gram pos = streptococcus (including PRSP), staph aureus (including MRSA), CoNS, enterococcus (not VRE)
Ceftriaxone class and coverage
- 3rd gen cephalosporin
- Gram pos = strep, staph aureus (not MRSA), not enterococcus
- Gram neg = proteus mirabilis, E. coli, Klebsiella
What does ceftriaxone have good coverage against?
- Strep pneumoniae
- Serratia (gram neg), not ESBLs
Metronidazole class, function, and coverage
- Nitroimidazole
- Inhibits ribosome, DNA via intracellular active metabolites (bactericidal)
- Anaerobes
Levofloxacin class and coverage
- 3rd gen fluoroquinolone
- Increased strep pneumoniae compared to ciprofloxacin (2nd gen fluoroquinolone)
Cloxacillin class and coverage
- Penicillinase-stable penicillin
- Gram pos = streptococcus and staph aureus (not MRSA)
Trimethoprim/ sulfamethoxazole class, function, and coverage
- Sulphonamide
- Inhibits dihydrofolate reductase and dihydropteroate synthetase
- Gram pos = variable streptococcus, staph aureus (including MRSA)
- Gram neg = E. coli, H. influenzae
- Pneumocystitis
Occasional adverse effects of azithromycin
- GI disturbance
- Headache
- Dizziness
- Vaginitis
Occasional adverse effects of carbapenems
- Phlebitis (inflammation of a vein)
- Pain at injection site
- Fever
- Urticaria
- Rash, pruritus
- GI disturbance
- Transient hypotension during IV infusion
Common adverse effects of cephalosporins
- Thrombophlebitis w/ IV use
- Serum-sickness-like reaction w/ prolonged parenteral admin
- Moderate to severe diarrhea
Occasional adverse effects of clarithromycin
- GI disturbance
- Abnormal taste
- Headache
- Dizziness
- QT prolongation
Common adverse effects of clindamycin
- Diarrhea
- Hypersensitivity reactions
Occasional adverse effects of daptomycin
- GI disturbance
- Rash
- Injection site reaction
- Fever
- Headache, dizziness
- Insomnia
Occasional adverse effects of fluoroquinolones
- GI disturbance
- Dizziness
- Tremors
- Oral/vaginal candida infections
- Neutropenia, leukopenia
- Hyper and hypoglycemia
- Increased serum creatinine
- Photosensitivity reactions
- QT prolongation
- CDI
What is 1 common and 1 occasional adverse effect of fosfomycin
- Common = diarrhea
- Occasional = vaginitis
Common adverse effects of linezolid
- GI disturbance
- Thrombocytopenia
- Risk greater w/ tx for > 10 days
Common adverse effects of nitrofurantoin
- GI disturbance
- Allergic reactions (including pulmonary infiltrates)
Common adverse effects of penicillins
- Allergic reactions (rarely anaphylaxis)
- Erythema multiforma or SJS
- Rash
- Diarrhea, N/V
Common adverse effects of tetracyclines
- GI disturbance
- Bone lesions and staining and deformity of teeth in children up to 8 y/o
Common adverse effects of trimethoprim / sulfamethoxazole
- Hypersensitivity reactions (rash, photosensitivity, fever)
- N/V
- Anorexia
Common adverse effects of vancomycin
- Thrombophlebitis
- Fever/chills
Purpose of antimicrobial stewardship
Optimize antimicrobial use to improve pt outcomes (maximize efficacy and minimize toxicity), limit dev’t of resistance, and reduce healthcare costs
What are the 5 key components of antimicrobial stewardship?
1) Limit transmission of infectious diseases
2) Avoid unnecessary antimicrobial use
3) When warranted, use antimicrobials appropriately
4) Target antimicrobials at highest risk of inappropriate use and clinically significant pathogens w/ highest risk of antimicrobial resistance (ESKAPE bacteria)
5) Target infections (URTI, asymptomatic bacteruria) and pt populations (critically ill, dialysis, immunocompromised) at highest risk of inappropriate antimicrobial use
How can unnecessary antimicrobial use be avoided?
- Educate px on appropriate use
- Educate prescribes and other HCP’s on appropriate use
- Develop institutional practice guidelines or clinical pathways for treating specific infections
- Develop specific antimicrobial restriction policies
- Monitor institutional antimicrobial use and identify potential areas for improvement
How can you make sure antimicrobials are being used appropriately?
- Select appropriate agent
- Avoid unnecessary duplication of antimicrobial spectrae (only use 2 antimicrobials when absolutely need to)
- Optimize dosing based on local susceptibility profiles and PK-PD principles to maximize efficacy and minimize toxicity
- Minimize antimicrobial-related adverse effects, including CDI
- Prevent or minimize antimicrobial-drug interactions
- De-escalate antimicrobial spectrae when appropriate (changing from broad to narrow spectrum when infecting agent is known)
- Step-down to oral therapy when appropriate
- Use shortest effective duration of therapy
What are the ESKAPE bacteria?
- Enterococcus faecium
- Staph aureus
- Klebsiella pneumoniae
- Acinetobacter baumanii
- Pseudomonas aeruginosa
- Enterobacter species
