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4/9 Antibacterials I/II: Cell Wall Agents Flashcards

1
Q

what does Penicillin, Cephalosporin, Monobactam, Carbapenem have in common? What confers each specificity?

A

common structure: ß lactam ringspecificity

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2
Q

Penicillin, Cephalosporin, Monobactam, Carbapenem all have a common function:

A

Antimicrobial agents that work by inhibiting cell wall synthesis

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3
Q

in general, how are Penicillin, Cephalosporin, Monobactam, Carbapenem inactivated?

A

ß lactamase enzymes - cleave the ß-lactam ring (essential for activity)

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4
Q

Why do carbapenems additional stability (more resistant to ß lactamases) over the rest of the drugs?

A

the H next to the keto group is oriented ABOVE the plane, and this configuration seems to stabilize the molecule, and make it more resistant to ß-lactamases (others: below)

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5
Q

What type of hypersensitivity reaction does penicillin usually cause?What type of physical manifestations?

A

IgE Type I Hypersensitivity(rash, hives, angioedema, anaphylaxis).

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6
Q

If one is severely allergic to penicillin, what other drugs are they likely to be allergic too as well?

A

Cephalosporin, Monobactam, Carbapenem

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7
Q

Which one is the safest to use if if the patient had a mild allergic reaction? Why?

A

monobactam, since it looks the least like penicillin (it doesn’t have the second ring) and is least likely to trigger IgE compared to the other ones

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8
Q

Structure of penicillin?

A

all contain Ring A (thiazolidine ring) attached to Ring B (ß-lactam ring)

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9
Q

MoA of penicillin?

A

bind covalently to Penicillin-binding proteins (PBP’s) at the active site, thereby interfering with the transpeptidase reaction, a reaction that is critical in bacterial cell wall synthesis”bactericidal”

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10
Q

how does resistance develop against penicillin?

A

1) Inactivation by ß-lactamase
2) Modification of target PBP
3) Impaired penetration of the cell (ex: ∆ porin channel)
4) Presence of a new efflux pump

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11
Q

how does MRSA develop?

A

Modification of target PBP

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12
Q

What drugs are in the Benzopenicillin class?

A

Penicillin G

Penicillin V

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13
Q

sensitivity of penicillin G to ß lactamases?

A

sensitive

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14
Q

How is Penicillin G administered?

A

parenteral (poor oral bioavailability)

  • Procaine suspn (IM); duration 1-2 days
  • Benzathine suspn (IV); duration 1-4 wks; great for kids
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15
Q

How is Penicillin V administered?

A

PO; very stable in stomach acid

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16
Q

Penicillins are effective in treating these bugs

A
  • Gram (+)
    • strep. pneumo
    • S. pyogenes
    • Actinomyces
  • GNC
    • N. meningitides
  • Spirochetes (T. pallidum)
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17
Q

what bugs are resistant to penicillin?

A

Staph (>85%)

Pneumococcus (10-30%)

bowel anaerobes

gonorrhea (Pen G)

most GNR’s

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18
Q

Contraindications of penicillin?

A

Pen-allergic patients

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19
Q

Side Effects of penicillins?

A

1) drug allergy especially rash, anaphylaxis
2) anemia (binds to RBC and induces hemolysis)
3) Seizures following high doses

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20
Q

Drug interactions with penicillins?

A
  • synergy with gentamicin against staph and enterococcus
  • probenecid inhibits renal active tubular secretion
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21
Q

What situations would warrant penicillin treatment?

A
  1. Streptococcal pharyngitis and skin infections
  2. Pneumonia
  3. Meningitis
  4. Endocarditis - if organism is sensitive
  5. Dental infection (by microaerophilic streptococcus)
  6. Syphilis
  7. Prevent rheumatic fever (GrpA ß hemolytic strep complication)
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22
Q

Drugs in the Aminopenicillins class?

A

Ampicillin

Amoxicillin

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23
Q

sensitivity of aminopenicillins to ß lactamases?

A

sensitive (its nearly identical to penicillin)

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24
Q

mechanism of action of aminopenicillins?

A

binds PBP’s and inhibits the assembly of the bacterial cell wall, bactericidal

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25
Q

How is ampicillin different than amoxicillin?

A

Ampicillin - PO or IV

Amoxicillin - PO (higher oral bioavailability) - newer version of ampicillin with slightly wider spectrum of action; less likely to cause diarrhea

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26
Q

what bugs are sensitive to aminopenicillins?

A

extended spectrum of action

  • Haemophilus influenza
  • E. coli
  • Listeria monocytogenes
  • Proteus mirabilis
  • Salmonella
  • Shigella
  • Enterococcus

Amp HELPSS to kill enterococci

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27
Q

What bugs are resistant to aminopenicillins?

A
  1. most staph
  2. some pneumococcus (>30%)
  3. some H. flu
  4. bowel anaerobes
  5. some GNRs
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28
Q

SE of aminopenicillins?

A
  1. drug allergy especially rash, anaphylaxis
  2. seizures following high doses
  3. antibiotic-associated colitis
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29
Q

Contraindications of aminopenicillins?

A

Pen-allergic patients

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30
Q

drug interactions with aminopenicillins?

A
  • synergy with gentamicin against enterococcus
  • probenecid inhibits renal active tubular secretion of ampicillin
  • ampicillin may inhibit tubular secretion of MTX
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31
Q

indications for aminopenicillins?

A
  1. otitis media
  2. neonatal sepsis
  3. Lyme disease (early)
  4. simple UTI’s (GNRs, such as E. coli, klebsiella, enterobacter, proteus)
  5. meningitis with sensitive pathogens
  6. URI
  7. endocarditis w. sensitive pathogens
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32
Q

What are examples of “semi-synthetic” penicillins?

A
  1. Nafcillin
  2. Dicloxacillin
  3. Oxacillin
  4. Methicillin - original
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33
Q

sensitivity of nafcillin to ß lactmases?

A

more resistant to ß lactamases (have more complex side chains; more stable)

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34
Q

MoA of nafcillin?

A

binds PBP’s and inhibits the assembly of the bacterial cell wall, bactericidal

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35
Q

There are various types of semi-synthetic penicillins. How would you use them clinically?

A

nafcillin or oxacillin - IV; serious infections with MSSA

dicloxacillin - PO; less severe infections

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36
Q

bugs sensitive to nafcillin?

A

Same as penicillin, but narrow spectrum

  • S. aureus (except MRSA, resistant due to altered PBP target site)

“use naf for staph”

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37
Q

bugs resistant to nafcillin or within the same class?

A
  1. MRSA (usually bc they have a different PBP)
  2. pneumococcus
  3. oral/bowel anaerobes
  4. GNR (most)
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38
Q

contraindications for semi-synthetic pencillins?

A

Pen-allergic patients

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39
Q

SE of semi-synthetic penicillins (ie nafcillin)?

A
  • drug allergy HSR
  • neprotoxic - allergic interstitial nephritis
  • Methicillin – highly nephrotoxic (causes allergic interstitial nephritis) and resistant to ß-lactamase; not used anymore
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40
Q

drug interactions with nafcillin?

A
  • synergy with gentamicin against enterococcus
  • probenecid inhibits renal active tubular secretion
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41
Q

indications for nafcillin or semi-synthetic pencillins within the same class?

A

Staph aureus infections, especially if pathogen is sensitive (in skin, soft tissue, bone, lung, endocarditis)

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42
Q

Drugs in the Anti-Pseudomonas class?

A
  • Piperacillin
  • Carbenicillin
  • Ticarcillin
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43
Q

Piperacillin - sensitivity to ß lactamases?

A

sensitive

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44
Q

MoA of Piperacillin?

A

binds PBP’s and inhibits the assembly of the bacterial cell wall, bactericidal

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45
Q

What is one thing that you have to consider when dosing Piperacillin and Carbenicillin?

A

resistance w. monotherapy; given in combination therapy with gentamycin or tobramycin to decrease resistance

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46
Q

How is Piperacillin and Carbenicillin administered?

A
  • Piperacillin - IV
  • Carbenicillin - PO
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47
Q

bugs sensitive to Piperacillin and Carbenicillin?

A

Same as penicillin, but with extended spectrum

  • Pseudomonas
  • GNR
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48
Q

bugs resistant to Piperacillin and Carbenicillin?

A
  1. GPC
  2. Anaerobes
  3. Enterococcus
  4. pneumococcus
  5. most S. aureus
  6. increasing # of resistant pseudomonas and GNRs
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49
Q

contraindications of anti-pseudomonal agents??

A

Pen-allergic patients

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50
Q

SE of Piperacillin and Carbenicillin?

A
  1. drug allergy especially rash, anaphylaxis
  2. antibiotic-associated colitis
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51
Q

drug interactions of Piperacillin and Carbenicillin?

A
  1. synergy with gentamicin against Pseudomonas
  2. probenecid inhibits renal active tubular secretion of Piperacillin
  3. Piperacillin may inhibit tubular secretion of MTX
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52
Q

indications for Piperacillin and Carbenicillin?

A
  1. Pseudomonas infections (usually given in combination with gentamycin or tobramycin for synergy)
  2. Carbenicillin – used treat non-life threatning infections (ie UTI) caused by Pseudomonas)
  3. intra-abdominal infections (mixed GNR, anaerobes, and enterococcus)
  4. nosocomial pneumonia (because often caused by GNR in the ICU)
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53
Q

What are some ß-lactamase inhibitors that are manufactured with penicillins?

A

Clavulanic acid, sulbactam, and tazobactam

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54
Q

How do ß-lactamase inhibitors work?

A

resemble ß lactam molecules and prevents cleavage of ß lactam rings, but have very weak antimicrobial activity themselves

thus they are added to amoxicillin or ampicillin or pipercillin, whose “range” is extended by the inhibitor

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55
Q

3 types of Penicillins w. ß-lactamase inhibitors?

A
  1. Amoxicillin & clavulanate (Augmentin)
  2. Ampicillin & sulbactam (Unasyn)
  3. Piperacillin & Tazobactam (Zosyn)
56
Q

bugs sensitive to Penicillins w. ß-lactamase inhibitors?

A

Augmentin (Amoxicillin & clavulanate): PO; broadest spectrum

Unasyn (Ampicillin & sulbactam): IV; broadest spectrum

Zosyn (Piperacillin & Tazobactam): IV; widest scope of activity

57
Q

bugs resistant to Penicillins w. ß-lactamase inhibitors (ie clavulanic acids)?

A

ß-lactamases produced by

  1. enterobacter
  2. citrobacter
  3. serratia
  4. pseudomonas
58
Q

indications for augmentin?

A

otitis media, sinusitis, lung, skin, urine infections, bites

59
Q

indications for unasyn?

A

skin, intra-abdominal, pelvic, bite, head/neck infections

60
Q

indications for Zosyn?

A

pneumonia, UTI, skin, gyn, bone, intra-abdominal, septicemia infections

61
Q

How are cephalosporins similar than penicillins? different?

A

similar to penicillins in that they both have:

  • structure (A ring + ß lactam ring)
  • mechanism of action
  • toxicities/allergic reactions

different in that cephalosporins are:

  • more stable to many ß-lactamases
  • broader spectrum of activity (good for polymicrobial infections or infections where you don’t know what it is)
  • not as good as the penicillins against enterococcus and it is essentially worthless against listeria
62
Q

What is the difference btwn the first generation cephalosporins and the later generations?

A
  • 1st generation - more active against GP organisms (e.g. staph, streptococci)
  • later drugs (2nd, 3rd, 4th gen) - are more active against GN aerobic organisms (e.g. E. coli, etc.)
63
Q

Why is it bad to use cephalosporin if the bug is known?

A

bad to always use if the infection/pathogen is known because normal flora may be wiped out and cause c. diff, candidal infection, BV, or cause resistance! USE A MORE SPECIFIC ONE.

64
Q

5 generations of cephalosporin? Which ones have good CSF penetration?

A

5 classes (know the highlighted ones)

  • 1st gen: cefazolin iv, cephalexin po
  • 2nd gen: cefuroxime – not that impt to know
  • 3rd gen: ceftriaxone, ceftazidime, Cefotaxime, cefpodoxime
  • 4th generation: cefepime
  • 5th generation: ceftaroline

Good CSF penetration: 3rd, 4th, 5th

65
Q

Drugs in the Cephalosporins 1st gen?

A
  • Cefazolin
  • cephalexin
66
Q

MoA of Cefazolin?

A

binds PBP’s and inhibits the assembly of the bacterial cell wall, bactericidal

67
Q

CSF penetration of Cephalosporins 1st gen?

68
Q

bugs sensitive to cefazolin?

A

broad spectrum of activity

  • GPC
  • Proteus mirabalis
  • E. coli
  • Klebsiella

PEcK

69
Q

bugs resistant to cefazolin?

A
  • MRSA (about 30% and growing)
  • enterococcus,
  • Listeria
  • nosocomial GNRs
  • some pneumococcus
  • bowel anaerobes
70
Q

contraindications of cefazolin?

A

Pen-allergic patients (cross-reactivity)

71
Q

SE of cefazolin?

A
  • drug allergy especially rash, anaphylaxis
  • anemia
  • vitamin K deficiency
  • antibiotic-associated colitis
72
Q

drug interactions of cefazolin?

A
  • probenecid inhibits renal active tubular secretion, prolongs half-life
  • increase nephrotoxicity of aminoglycosides
73
Q

indications of cefazolin?

A
  • soft tissue infections (strep and staph)
  • UTI
  • patients with mild allergies (but not anaphylaxis) to penicillins
  • surgical prophylaxis (ie just before appendectomy or hysterectomy) to lower chance of developing wound infection against GNR
74
Q

Rx in the Cephalosporins 3rd gen that we should know?

A
  • Ceftriaxone
  • Ceftazidime
75
Q

MoA of Ceftriaxone?

A

binds PBP’s and inhibits the assembly of the bacterial cell wall, bactericidal

but it is more active against GNRs which produce ß-lactamases

76
Q

Why is Cefotaxime/cefpodoxime given to pediatric patients in lieu of the standard 3rd generation ceftriaxone?

A

it is less likely to cause biliary sludging

77
Q

bugs sensitive to ceftriaxone?

A

Given to serious GN infections that are resistant to other ß lactams

  • meningitis
  • gonorrhea
78
Q

bugs resistant to ceftriaxone?

A
  • MRSA (~30% and growing)
  • pneumococcus (5-10%)
  • enterococcus
  • nosocomial GNRs
  • bowel anaerobes
  • pseudomonas
  • Listeria
79
Q

CI of ceftriaxone?

A

Pen-allergic patients

80
Q

SE of ceftriaxone?

A
  • drug allergy especially rash, anaphylaxis
  • anemia
  • antibiotic-associated colitis
  • vitamin k deficiency
81
Q

Drug interactions with ceftriaxone?

A
  • probenecid inhibits renal active tubular secretion
  • synergistic with gentamicin against some GNR
  • may enhance effects of warfarin
  • increase nephrotoxicity of aminoglycosides
82
Q

indications for ceftriaxone?

A
  • meningitis
  • serious pneumonia
  • otitis
  • sinusitis
  • neisseria gonorrhea
  • GNR
  • lyme dz
83
Q

MoA for Ceftazidime?

A

binds PBP’s and inhibits the assembly of the bacterial cell wall, bactericidal, but more activae against GNRs which produce ß-lactamases

84
Q

bugs sensitive to ceftazidime?

A

Given to serious GN infections that are resistant to other ß lactams

  • Pseudomonas
85
Q

bugs resistant to ceftazidime?

A
  • large majority of staph
  • some pneumococcus
  • bowel anaerobes
86
Q

CI for ceftazidime?

A

Pen-allergic patients

87
Q

SE of ceftazidime?

A
  • drug allergy especially rash, anaphylaxis
  • antibiotic-associated colitis
  • vitamin k deficiency
88
Q

drug interactions with Ceftazidime?

A
  • synergistic with gentamicin against some GNR, especially Pseudomonas
  • may enhance effects of warfarin
  • increase nephrotoxicity of aminoglycosides
89
Q

indications for ceftazidime?

A
  • infections where resistant GNRs and Pseudomonas are likely
  • meningitis or sepsis where GNR is likely pathogen
  • bacteremia
  • UTI
  • urosepsis
  • empiric Rx of febrile neutropenic pts
90
Q

What generation is Ceftaroline in?

A

Cephalosporins, 5th gen

91
Q

MoA of ceftaroline?

A

binds PBP’s and inhibits the assembly of the bacterial cell wall, bactericidal, but more activae against GNRs which produce ß-lactamases

92
Q

Why do you have to monitor ceftaroline in the elderly?

A

renal excretion – must monitor in elderly, who have reduced GFR

93
Q

bugs sensitive to ceftaroline?

A

Broadest spectrum of activity

  • GN
  • GP – strep pneumonia, staph aureus (MSSA and MRSA)
  • does not cover Pseudomonas
94
Q

bugs resistant to ceftaroline?

A

still being defined

95
Q

CI of ceftaroline?

A

Pen-allergic patients

96
Q

SE of ceftaroline?

A
  • drug allergy especially rash, anaphylaxis
  • Clostridium difficile-associated diarrhea
  • convert to a positive direct Coombs test (10% of patients)
97
Q

ceftaroline drug interactions?

A

none reported

98
Q

indications for ceftaroline use?

A
  • community acquired bacterial pneumonia (CABP)
  • acute skin infection

but only for pathogens likely to be sensitive, and only used when a broad spectrum drug is needed

99
Q

drugs in the Carbapenems class?

A
  • Meropenem
  • Imipenem
  • irbepenem
  • ertapenem
  • doripenem
100
Q

How are carbapenems different than penicillins?

A

has an additional ring structure to the ß lactam ring

101
Q

What do you often administer with Imipenem and why?

A

Imipenem - RESISTANT to ß lactamases; often given with cilastatin inhibitor of renal dehydropeptidase I) to reduce inactivation of drug in renal tubules “with imipenem, the kill is ‘lastin with cilastatin”

102
Q

CSF penetration of Meropenem?

103
Q

Why would you not use carbapenems as a first-line tx?

A

significant side effects and $$$ (not used as a first-line tx; use limited to life-threatening infections or after other drugs have failed)

104
Q

bugs sensitive to carbapenem?

A

Broadest spectrum against the widest group of bacteria

  • most GPC (including staph)
  • most GNR (including pseumomonas)
  • Anaerobes
105
Q

bugs resistant to carbapenem?

A
  • MRSA
  • enterococcus
  • rare pneumococcus; but can develop resistance rapidly
106
Q

CI for using carbapenem?

A

Pen-allergic patients

107
Q

SE of carbapenem?

A
  • antibiotic-associated colitis
  • seizures (at high plasma levels)
  • GI distress
  • skin rash
108
Q

Rx interactions wtih carbapenem?

A
  • probenecid inhibits renal active tubular secretion
  • synergistic with gentamicin against some GNR
  • may enhance effects of warfarin
109
Q

Indications of carbapenem?

A
  • mixed nosocomial infections with resistant GNRs (do not use for single-organism infections or when the infection is unknown (ie patient comes in with septic shock))
  • complicated meningitis
  • peritonitis
  • serious pneumonia
  • sepsis
110
Q

drugs in the monobactam class?

A

Azetreonam

111
Q

What is unique about Azetreonam?

A
  • resistant to ß lactamases
  • NO cross-allergenicity with penicillin
112
Q

bugs sensitive to azetreonam?

A
  • NARROW coverage - only aerobic GNR (e. coli, pseudomonas
113
Q

side effects of azetreonam?

A
  • Usually non-toxic
  • Occasional GI upset
114
Q

drug interactions of azetronam?

A
  • synergistic with aminoglycosides
115
Q

When is azetreonam used??

A
  • penicillin allergic patients
  • those with renal insufficiency who cannot tolerate aminoglycosides
116
Q

Example of Glycopeptides?

A

Vancomycin

117
Q

MoA of vancomycin?

A

binds to free carboxyl (COOH) end of the D-Ala-D-Ala chain, thereby preventing cross linking of peptidoglycan

118
Q

How is vancomycin usually administered?

CSF penetration?

A
  • IV, or PO only when it is used to treat a infection within the bowel lumen
  • FAIR CSF penetration if the meninges are inflamed
119
Q

How do VREs develop?

A

Remember the MoA of vancomycin is to bind the free carboxyl (COOH) end of the D-Ala-D-Ala chain, thereby preventing cross linking of peptidoglycan

resistance in enterococci and S. aureus occurs because they convert D-Ala –> D-lactate, thereby reducing vancomycin efficacy (VRE)

120
Q

bugs sensitive to vancomycin

A

GPC only – serious MDR organisms, including

  • MSSA
  • MRSA
  • enterococcus
  • C. diff (only PO)
  • coagulase (-) staph
121
Q

bugs resistant to vancomycin?

A
  • All GNRs
  • anaerobes other than clostridia sp,
  • very rare S. aureus and enterococcus (VRE)
122
Q

Why should you give vancomycin very slowly?

A

if given too fast, it can cause the red man syndrome (rapid rate of infusion can cause histamine release; trmt: slow infusion over 60min)

123
Q

SE of vancomycin?

A
  • nephrotoxicity
  • neutropenia
  • ototoxicity
  • thrombophlebitis
  • red man syndrome
124
Q

Rx interactions with vancomycin?

A
  • additive nephrotoxicity if given with other nephrotoxic drugs, including aminoglycosides, amphotericin
  • synergistic when given with gentamicin against staph aureus, enterococcus, and staphylococci
125
Q

Indiations of vancomycin?

A
  • Empiric treatment of serious infections likely caused by GPC pending culture results (e.g meningitis, sepsis, pneumonia, endocarditis)
  • treatment of serious infections caused by GPC resistant to other drugs (e.g. MRSA)
  • oral treatment of C. difficile colitis
126
Q

Example of Cyclic lipopeptides?

A

Daptomycin

127
Q

MoA of Daptomycin?

A

antibacterial - binds to cell membrane, depolarizes the cell, which inhibits protein, DNA, and RNA synthesis, leading to cell death; does not enter the cytoplasm itself

128
Q

why is daptomycin not used for pneumonia?

A

because it is inactivated by pulmonary surfactant

129
Q

What must you do if you give a patient daptomycin?

A

check CPK weekly due to myopathy risk; stop Rx if CPK rise to 10x normal limit

130
Q

bugs sensitive to daptomycin?

A

most GPC (strep, staph, enterococcus)

131
Q

bugs resistant to daptomycin?

132
Q

SE of daptomycin?

A
  • cardiac failure
  • pseudomembranous colitis
  • hypoglycemia
  • myopathy
133
Q

Drug interactions with daptomycin?

A
  • cautiously with statins (may increase risk of myopathy)
  • may alter levels of tobramycin
  • may alter response to warfarin
134
Q

indications for daptomycin?

A

serious infections caused by resistant GPC (ie MRSA, VRE) such as bacteremia, endocarditis, skin and soft tissue infections

135
Q

MRSA - drugs that it is resistant to? senstive?

A
  • resistant to all penicillins (penicillin, methacillin, nafcillin, oxacillin, and Dicloxacillin) and cephalosporins (except ceftaroline, 5th generation)
  • sensitive to Ceftaroline, Vancomycin – use vanco because it is cheaper and it is more specific (wont encourage other bugs to develop resistance).
136
Q

Pseudomonas treatments?

A

treatments = pipercillin or ceftazidime

very good at becoming resistant at every drug; can cause life threatening infections in compromised patients in a setting where antibiotics or chemotherapy are used; classic cases

  • little old lady with indwelling foley who lives in a nursing home where antibiotics are widely used
  • cancer patients on chemotherapy
137
Q

organisms typically not covered by cephalosporins?

A

*organisms typically not covered by cephalosporins are LAME:

Listeria

Atypicals (Chlamydia, Mycoplasma)

MRSA

Enterococci

exception: ceftaroline covers MRSA

x. ID (40 decks)

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