Bugs & Drugs Flashcards
Staphylococcus epidermidis Staphylococcus aureus Streptococcus A, B, C, G Streptococcus pneumoniae Enterococcus faecalis Enterococcus faceium
What are they?
Gram Positive Aerobes
Staph/strep live on the skin.
Enterococcus live in the gut.
Peptostreptococcus sp.
Peptococcus sp.
Clostridium difficile
Clostridium perfringens
What are they?
Gram positive Anaerobes
Cocci live in the mouth. When treating animal bites, this bacteria should be covered.
C. diff is a common ADR to Abx. Abx kill off gut flora so C. diff. colonizes (causes cholitis).
Haemophilus influenzae
Moraxella catarrhalis
Salmonella
Shigella
What are they?
Wimpy Gram Negatives; very susceptible to antibiotics.
Eschericha coli
Klebsiella pneumoniae
Proteus marabalis
Proteus vulgaris
What are they?
Medium Gram Negatives
What are the SPACE bugs?
Serratia marcescens Pseudomonas aeruginosa Acinetobacter baumanii Citrobacter freundi Enterobacter
Gram negative group that is likely to develop resisitance to drugs.
How do you treat MDR pathogen?
Use one toxic drug to treat them. Broad spectrum drugs have selective pressure and can create resistant bugs.
Where are anaerobes found?
Survive without oxygen; found on normal flora of skin and mucous membranes.
Places of infection: GI, deep puncture wounds, URTI, dental, female genital area, bone.
Where does peptostreptococcus live?
Mouth
Where does backteroides and clostridium live?
the gut
What are three examples of Atypicals?
Chlamydia, Mycoplasma (lack cell wall), Legionella
Do not absorb color with gram stains.
Zoonotic - can be spread by animals.
Most Abx have poor coverage for ATYPICALS.
What is the heteropolymeric component of a cell wall that provides rigid mechanical stability and has cross-linked latticework structures and peptides?
Peptidoglycan
Gram NEG have LESS peptidoglycan than GRAM POS.
What is LPS?
A rich outer coating in gram negative bacteria; makes it more difficult to treat.
Bacteria by Site of Infection: Staphylococcus aureus Staphylococcus epidermidis Streptococcus pyogenes Pasteurella spp.
Skin/soft tissue
Lots of Gram POS and some anaerobes.
Bacteria by Site of Infection: Staphylococcus aureus Staphylococcus epidermidis Streptococcus spp. Neiserria gonorrheae Gram negative rods
Bone and Joint
Mostly gram positive.
Infection is bad when there’s gram negative rods appearing. I/C pt can have atypicals (Neisseria).
Bacteria by Site of Infection: Streptococcus pneumoniae Neisseria meningitidis Haemophilus influenzae Group B streptococcus Listeria spp. E. Coli
Meningitis
Gram POS and NEG
Bacteria by Site of Infection: E. Coli Proteus spp Klebsiella spp. Enterococcus spp. Bacteroides spp.
Abdomen
Mostly anaerobes
Bacteria by Site of Infection: E. coli Proteus spp. Klebsiella spp. Enterococcus spp. Staphylococcus saprophyticus
Urinary Tract = need gram neg coverage.
Catheters have increased risk of infection, so Gram POS may appear.
Bacteria by Site of Infection:
Peptococcus spp.
Peptostreptococcus spp.
Actinomyces spp.
Mouth
Land of anaerobes
Bacteria by Site of Infection: S. pneumoniae H. influenzae Moraxella catarrhalis Streptococcus pyogenes
Upper Respiratory Tract - gram positives and negatives
Bacteria by Site of Infection: S. pneumoniae H. influenzae K. pneumoniae Legionella Mycoplasma pneumoniae Chlamydia pneumoniae
Lower Resp. Tract (Community acquired)
Bacteria by Site of Infection: MRSA Pseudomonas aeruginosa Enterobacter spp. K. pneumoniae Serratia spp.
Lower Resp. Tract (NOSOCOMIAL)
SPACE BUGS
PK
What the body does to the drug!
ADME
PD
What the drug does to the body!
What is absorption?
How drug enters the blood, which is affected by acid and food. Ex: high fat diet = less absorption.
What is distribution?
How drug travels in the bloodstream, which is affected by protein binding. Used to pinpoint med to the site of infection.
What is metabolism?
How the body chemically changes the drug to prepare for excretion, which is often affected by other drugs.
What is excretion?
How the body gets the drug out; usually stool or urine and is affected by other drugs.
Bioavailability
How much of a drug is absorbed.
IV push = 100%.
First pass effect?
Can be metabolized by liver before getting into the bloodstream.
The ____ the distribution, the more it’ll be in the tissues.
Higher; good for skin infections.
The _____ the distribution, the more drug will be in central circulation.
Lower; good for blood infections
What is primary hepatic metabolism?
CYP450
What is the most common hepatic metabolism?
CYP3A4 - metabolizes HALF of all drugs.
Phase 1 - makes drug polar for excretion to the kidneys or to go to Phase 2 metabolism.
Phase 2 - add onto molecule to make it more polar (i.e. sulfination).
What’s MIC?
Minimum concentration of drug needed to visibly reduce the growth of bacteria.
Bactericidal
Eradicates infection without host defense mechanisms; KILLS BACTERIA. Good for I/C.
Bacteriostatic
Inhibits growth, requires host defense to eradicate infection. DOESNT KILL.
Therapeutic Index
Range between toxicity and effective dose. Need to be above the MIC, but not near the lethal dose if there’s a small therapeutic index.
Classes of bactericidal antibiotics?
SIX CLASSES
Disrupts bacterial function so much that cell death will occur.
CSNs, Aminoglycosides, PCNs, Vancomycin, Fluroquinolones, Metronidazole
Classes of bacteriostatic antibiotics?
FIVE CLASSES
Inhibits a vital pathway used in the growth of bacteria, but doesn’t directly cause death.
Erythromycin, Tetracyclines, Sulfonamides, Trimethoprim, Clindamycin
Synergy
Combined activity is greater than either component alone.
Peak
Maximum concentration achieved
Trough
Minimum concentration achieved; usually lowest and what is hit until administration of next dose.
When QD, it can drop to zero.
AUC
Area under curve = Total drug exposure; important for a concentration vs. time dependent killer.
CDK
antimicrobial activity directly impacted by how high Cmax is above the MIC. Higher the peak, the better it works.
Even when below MIC, bacteria will not grow for a period of time (Post Abx Effect).
When is a loading dose used?
For concentration dependent killers; loading dose is used to get to a steady state quicker.
TDK
antimicrobial activity directly related to the time spent above the MIC.
Ex: PCN half life is short – need to be given several times per day.
Risk with TDK?
Without continuous infusion, there’s vacillation.
Risk: fall below MIC if you ever miss a dose.
Delay before microorganisms recover and reenter a log-growth period.
Affected by?
Post Abx Effect
Affected by size of innoculum, type of growth medium, and bacterial growth phase.
Empiric Therapy
Prescribing without knowing causative agent; BSA used.
Cultures come back - switch to a focused antibiotic.
How do you choose a drug?
- Spectrum of activity - consider the causative organism in location.
- PK - Consider patients ADME function.
- PD - bacteriostatic or bactericidal? Check immune function.
- Toxicity - consider all risks (GI, skin, hematologic, CNS, hepatic, RENAL).
Why are tetracyclines bad for kids?
They stain teeth; can’t give to anyone under 8yo.
Why is Chloramphenicol bad for kids?
Gray baby syndrome; can’t metabolize it themselves because of their immature hepatic enzymes.
When is combination therapy used?
Life-threatening infections; causative agent unknown. Early therapy improves outcomes.
Polymicrobial infections.
Enhance antimicrobial activity.
Treatment of resistant strains.
What is synergistic in pseudomonas aeruginosa infections?
Penicillins-Aminoglycosides
Do you take cultures before or after starting antibiotics?
Cultures BEFORE - Do not want abx to affect culture results (organism could have died off).
How do we know if abx is effective against bacterium?
Greater the zone of inhibition, the more effective at killing.
Resistant bugs
GPOS - MRSA, VRE, VRSA
GNEG - ESBL & KPCs
Extended sp. beta lactamase (Kill antibiotics).
Kelebsiella producing carbamases
What practices cause resistance?
Indiscriminate abx use
Prolonged hospital stay
Greater than 7 days on mechanical ventilation
Prophylaxis use and BSA.
What is a mechanism of resistance in GNEG bacteria?
Plasmid exchange allows bacteria to communicated and share resistance.
Ex: changing PBP so PCN can’t bind. Also can make pumps to clear medicine out of cell.
MOA: Penicillin
D-alnine is important for cross linking in the cell wall. B-lactam ring micmics D-alanine and this bond prevents propagation of cell wall.
Allergies to PCN occur where?
R-side chain
Beta lactams - Bacteriostatic or Bactericidal?
Bactericidal
What do natural PCNs cover?
G+, no staph
Anaerobes, no bacteroides
What are PCN’s drug of choice for?
Meningococcus, gas gangrene, syphillis
PCNs - TDK or CDK?
TDK
Name the natural penicillins and route of administration?
PCN G - Given IV.
PCN V Potassium - Oral version, stable in stomach acid because of potassium.
PCN G Benzathine - Given IM; one time dose.
Why do you never push a suspension through an IV line?
Risk of emboli.
What do aminoPCNs cover?
Ampicillin
Amoxicillin
Cover G+, no staph, AN, no bacteroides
What are aminoPCNs used for?
Enterococcus, Listeria, Endocarditis prophylaxis, URI.
Why don’t you give aminoPCN to someone on anticoagulants?
Causes abnormal prolongation of PT.
What must you tell a female patient when prescribing aminoPCNs?
Decreases effectiveness of birth control, due to loss of enterohepatic recycling of estrogen in the gut.
Side effects of AminoPCNs?
Hepatic dysfunction, hepatitis, jaundice, increase in serum AST, ALT, bilirubin, ALP., C.diff possible, SJS and TEN, interstitial nepritis, hematuria, crystalluria, Anemia, thrombocytopenia.
CI of aminoPCN?
PMHx of cholestatic jaundice, hepatic dysfunction, allergy
PCN dosing consideration
Renal
What labs do you monitor for patients on PCN?
Renal, Hepatic, PLT
How do microbes have resistance to PCN?
Beta lactamase enzyme cleaves the ring in the antibiotic inactivating it.
What are beta lactamase inhibitors?
Chemicals wit no antibacterial activity that inactivate beta lactamase resistant enzyme.
Sublactam and Ampicillin
Tazobactam and Pipericillin
Clauvanate with Amoxicillin
What do AminoPCNs with Beta Lactamase inhibitors cover?
GPOS, now with MSSA
Anaerobes PLUS Bacteroides,
AminoPCNs with Beta Lactamase inhibitors are drug of choice for?
BITES, skin and soft tissue, diabetic foot, and intra-abdominal infections.
What is another name for PCN-ase Resistant PCNs?
Antistaphylococcal PCNs
Name 3 Antistaphylococcal PCNs
Nafcillin, Oxacillin, Dicloxacillin
Antistaphylococcal PCNs - designed to cover?
Cover MSSA and gram positives only.
Dosing considerations for Antistaphylococcal PCNs?
What do you monitor?
Hepatic FXC
Montor Hepatic, CBC, anaphylaxis.
What bug is resistant to Antistaphylococcal PCNs?
MRSA
What is an Antipseudomonal PCN?
Piperacillin/Tazobactam
What is piperacillin and tazobactam used for?
Pseudomonas treatment! And MSSA.
Covers GPos, An, and GNeg.
Piperacillin/Tazobactam is DOC for what?
Polymicrobial infections, nosocomial infections, intra-abdominal infections, and pseudomonal infections.
Dosing consideration for Antipseud PCNs?
What do you monitor?
RENAL
Anaphylaxis, Renal FXC, CBC
What type of PCN is effective against MRSA?
NONE
What type of pt’s would pipericillin and tazobactam be good for? Who would it be a poor choice for?
Good for geriatrics from nursing homes who need empiric coverage.
Poor choice for children.
MOA: Cephalosporins
Act on PBP and cell wall.
Cephalosporins have good penetration of what?
CSF
Why can patients who are sensitive to PCN, be able to take Cephalosporins?
PCN cross sensitivity is less than one percent.
What cephalosporins have anti-pseudomonal activity?
Ceftazadime (FORTAZ) and Cefepime.
How are cephalosporins metabolized?
Renally
What are the 1st generation CS? Coverage?
Ancef and Keflex
GPos and some GNeg – Proteus, Klebsiella, E.coli
What is Ancef used for?
Surgical prophylaxis, MSSA, UTI
What is Keflex used for?
Skin/soft tissue infections, cellulitis, UTIs.
What are the second generation CS? Coverage?
Metfoxin
Zinacef
Cefzil
Gram positive and gram negative
What are ___ used for?
Metfoxin
Zinacef
Cefzil
UTI, URI, surgical prophylaxis.
2nd generation is LEAST used clinically.
What are third generation CS? Coverage?
Rocephin
Fortax
Claforan
Cover GPos and GNeg; extra coverage against Serratia and Moraxella catarrhalis.
Why is Rocephin coverage important?
What two times can’t you use it?
Good strep coverage.
Can’t use during first 30 days of life.
Don’t mix with calcium.
What drug is preferred for neonatal fever and sepsis From 3rd generation of CS?
Claforan
Why can’t you use Rocephin during first 30 days of life?
It will bind to albumin in neonates and cause toxicity.
The free drug kicks off bilirubin to bind to albumin causing jaundice.
What is the 4th generation CS? Coverage?
Cefepime (MAXIPIME) - GPos, GNeg only.
Has pseudomonal activity. NO MRSA or enterococcus.
What patients would you use Cefepime (Maxipime) for?
Good for neutropenic patients, fever, AIDS, chemo patients, hospital acquired pneumonias, and ventilator acquired pneumonias
Nosocomial/pseudomonal cases
What is the 5th generation CS? What does it cover?
Teflaro - Has GPos, GNeg, and MRSA coverage!
Treats MRSA and pseudomonas.
»Skin infection and CAP
Ceftolozane / tazobactam - GNeg, GPos, NO MRSA or enterococcus.
What is Ceftolozane / tazobactam?
5th generation CS. Covers Gram Neg and Pos, but doesn’t cover MRSA or eneterococcus.
What is ceftolozane and tazobactam DOC?
Complicated UTI that failed a round of antibiotics or a complicated abdominal infection with METRONIDAZOLE.
How do we use Ceftolozane and tazobactam to treat intra-abdominal infection?
It doesn’t cover enough anaerobes, so treats well when paired with METRONIDAZOLE.
MOA: Monobactams
Inhibit cell wall synthesis; bactericidal.
Aztreonam.
What is Aztreonam coverage??
Gram negative coverage only; includes enterobacter and pseudomonas.
What is the dosing consideration for Teflaro?
RENAL
What microbes does Teflaro cover?
GPos, GNeg, Pseudomonas, MRSA
What’s a benefit of a monobactam? Why?
Can be used on patients with allergies to PCN. NO cross reactivity with beta-lactams.
What are the carbapenems? Name them.
Broad spectrum (no MRSA) - used for resistant infections, like meningitis, VAP, etc. >>Susceptible to KPC - Klebsiella producing carbamases.
Imipenem, Meropenem, Ertapenem, Doripenem.
Carbapenemds DOC for?
MDR GNeg infection (pseudomonas), Extended spectrum beta lactamase producing bacteria (ESBL), nosocomial infections, and meningitis.
Monobactam - Dosing considerations? Monitoring?
Renal
LFT, symptoms anaphylaxis, diarrhea.
What don’t carbapenems cover?
MRSA
What coverage do they provide?
GPos, Neg, and Anaerobes
What carbapenem doesn’t cover pseudomonas?
Ertapenem
What labs are monitored in carbapenems?
Renal, hepatic, CBC
If your patient is on a carbapenem and has a siezure, which medication will you discontinue?
Ertapenem
MOA: Vancomycin
Cell wall synthesis - inhibits by blocking the cross linking mechanisms by binding to D-alanine. More difficult to develop resistance.
Vancomycin coverage? DOC?
Gram positive ONLY.
DOC for PCN allergy infections, MRSA, C.diff, endocarditis, osteomyelitis, and surgical prophylaxis.
Why does vanco treat C. diff?
When taken orally, stays in GI tract to kill infection.
Why is vanco used as a surgical prophylaxis when a patient has a PCN allergy?
It targets gram positives that are on the skin flora, such as staph and strep.
When would you draw a trough for vancomycin? Why?
Troughs drawn a half hour before the forth dose to give indication of steady state.
Takes 4-5 half lives to reach steady state.
Your patient is receiving vanco Q8hrs, but you check labs and his creatinine is elevated. What is your nexxt move?
Space out the dose since the renal clearance has decreased; needs more time to metabolize drug.
What types of toxicity does vanco cause?
Ototoxicity
Nephrotoxicity
What are some infusion related reactions with vancomycin?
Red man syndrome
Fever and chills
Phlebitis
How do you prevent red man syndrome?
Caused by infusing vanco too rapidly, slow infusion rate first.
What do protein synthesis inhibitors do?
They target the bacterial ribosome to prevent it from making proteins.
T/F: All protein synthesis inhibitors are bacteriostatic, except for aminogycosides.
True
MOA: Macrolides
Inhibit protein synthesis by blocking transpeptidation.
What are the macrolides?
Erythromycin, Clarithromycin, Azithromycin
What is the coverage of macrolides?
Why is this significant??
GPos aerobles, like S. pneumoniae, MSSA, S. pyogenes, L. monocytogenes.
GNeg aerobes - H influenzae, Mcatarrhalis, N meningitides, N. gonorrhea.
Atypicals - Legionella, Mycoplasma pneumoniae, chlamydophilia pneumoniae, chlamydia trachomatis.
Macrolides DOC for?
RTI, CAP, AOM, pharyngitis, tonsillitis, bronchitis.
Mycobacterium avium complex for prophylaxis and treatment.
Chlamydia = azi and ery treat it. H pylori (stomach ulcers) - treated by Prevpac.
Patient with Mycobacterium Avium Complex, how do you treat?
Clarithromycin, Azythromycin, and Ethambutol.
Patient with H. pylori, how do you treat?
Clarithromycin, Amoxicillin, Lansoprazole
What treats Chlamydia trachomatis?
Azithromycin
Erythromycin
What’s another use of erythromycin?
Stimulates motility of bowels; prokinetic effect.
Why can’t you prescribe a Macrolide with a Class IA and III antiarrythmic?
QT segment is prolonged, causing Torsades de Pointes.
Can lead to cardiac arrest, because potassium channel is blocked and ventricles repolarize slower.
What role to macrolides play when interacting with CYP enzymes?
Macrolide metabolites bind to CYP3A forming inactive complex. This INCREASES drug levels of CYP drugs (Digoxin, carbamasepine, cyclosporine, miazolam, theophylline, etc.).
You get lab results and realize patient has high level of digoxin. You notice patient has been taking a macrolide for a URI. Whats your next move?
Macrolides inhibit the enzymes to metabolize digoxin; take patient off macrolide.
MOA: Tetracyclines
Blocks translation by binding to ribosome.
Binds to rRNA to prevent tRNA from binding.
Bacteriostatic.
Tetracycline, Minocycline, Doxycycline – Why is their coverage so important?
Atypicals, such as animal borne organisms, i.e. Yersinia pestis, Brucella Borrelia burgdorferi, rickettsiae.
Also do Enterococcus, MRSA, some GNeg and Anaerobes, T. pallidum, and H. Pylori.
NO MRSA or PSEUD.
If your patient got a tick bite in the woods, how would you treat them?
Tetracyclines - treat borellia burgedorferi (Lyme disease tx)
How would you treat Yersinia Pestis (the plague)?
Tetracyclines (covers atypicals).
Your patient is an older woman with osteoporosis, why should you not prescribe her tetracyclines?
Depression of skeletal growth. Also, chelates with iron and calcium.
If you drink milk, medication won’t be absorbed and it’ll lead to treatment failure.
What tetracycline treats chlamydia?
Doxycycline
What is Glycylcycline?
Tigecycline (TYGACIL)
MOA: Tygacil
Inhibits protein syntesis by binding to ribosome.
Bacteriostatic.
Your patient has a skin infection caused by E. coli, MRSA, S. anginosus, S. pyogenes, and B. fragilis. What do you treat them with?
Tygacil
Your patient has a complicated intra-abdominal infection caused by C. freundi, E coli, K. pneumoniae, E faecalis, MSSA, B. fragilis, etc. How do you treat?
Tygacil
Whats the dosing consideration for Tygacil?
Hepatic dysfunction
Tetracycline uses:
Tetracyclines also teat acne, pneumonia, Lyme Disease, Rocky Mt. Spotted Fever, and STDs.
Bad people to prescribe tetracyclines to?
Under 8yo or pregnant females
Dose adjustment for tetracyclines?
RENAL
What doesn’t Tygacil cover?
VRE
When is it ok to use Tygacil?
Last resort; used to prevent resistance.
MOA of aminoglycosides?
Inhibition of protein synthesis
Aminoglycosides
Amikacin
Gentamicin
Tobramycin
Aminoglycoside coverage? Importance?
Gram negatives: pseudomonas, enterobacter, E. coli, Klebsiella pneumoniae, Proteus, Serratia.====SPACE BUGS.
Enterococcus when paired with PCN.***
Aminoglycoside DOC for?
Febrile neutropenia, sepsis, enterococcus (synergy with PCN).
Dosing considerations and adjustments of Aminoglycosides?
Renal toxicity, ototoxic, renal adjustment
REQUIRE THERAPEUTIC DRUG MONITORING
Aminoglycosides - bacteriostatic or bactericidal?
Bactericidal
Your pt has a high trough level on gentamycin, next course of action?
Extend dose until its under 1.
Tobramycin level of 1.6, too high. Action?
Extend dose until its under 1.
Oxazolinodinone
Linezolid
What is Linezolid DOC for?
Note: Resistant gram positives finally are covered. MDR Pneumococcus, MRSA, and VRE.
DOC - HAP MRSA and CA MRSA
Toxicity warnings for Linezolid?
Thrombocytopenia
Seratonin Syndrome
MOA: Daptomycin
Bacterial depolarization whic inhibits DNA, RNA, and protein syntehsis
Labs monitored on daptomycin?
CPK and pneumoniae.
Why can’t daptomycin be used for a pneumoniae?
The surfactant deactivates it.
MOA: Fluroquinolones
Inhibit DNA Gyrase and inhibit bacterial topoisomerase.
Name the FQs.
Levofloxacin
Ciprofloxacin
Moxifloxacin
Your pt has CAP, what FQ is not used for this?
Cipro; also not used for skin.
If your pt has a UTI, which FQ would you not use?
Moxifloxacin
What conditions are FQ’s used for?
Sinusitis, otitis, HAP at high doses, UTI, diarrhea, skin and osteomyelitis.
Why can’t you drink dairy products with FQ?
They interact iwth iron, antacids, vitamins, calcium, and dairy.
Why avoid a FQ to a cardiac patient? WHy not to elderly?
Risk of QT prolongation.
Warfarin interactions.
Cipro
Gram negatives, atypical coverage, and pseud
All FQ have renal dosing consideration, except:
Moxifloxacin, bc metabolized in liver.
Levofloxacin
Moxifloxacin
CAP, Strep PNA and atypical coverage.
MOXI IS NOT USED FOR UTI.
FQ ADR?
Complexes with cations Photosensitivity Renal Elim QT prolongation Tendon rupture under eighteen years old
Clindamycin
G+ and AN coverage
DOC for toxin mediated disease, i.e. TSS Cellulitis Osteomyelitis Surgical prophylaxis for PCN allergy INtraabdominal combination
Clindamycin has a high risk of?
C. diff.
ALso neutropenia, thrombocytopenia, and pseudomembranous colitis.
Sulfamethoxazole and Trimthoprim
Septra and Bactrim
MOA: Septra and Bactrim
Inhibits conversion of PABA to DHF which inhibits folic acid use in the cell.
What is a good prophylactic for AIDS, neutropenic, and chemo patients?
Septra and Bactrim.
Clinical uses of Septra?
UTI, prostatitis, RTI, traveler’s diarrhea, shigella
What three atypicals does septra cover?
Pneumocystis carinii, nocardia, toxoplasma gondii.
Why shouldn’t you give Septra to a patient taking warfarin?
It will prolong INR time.
MOA: Metronidazole
interacts with bacterial DNA to cause helical structure loss and strand breakage.
Bactericidal
Metronidazole coverage?
Parasites, GPos, GNeg
Metronidazole DOC?
C. Diff
Intra-abdominal combination
STI
Why can’t you drink on motronidazole?
Dislfiram like reaction with ethanol.
Polymixin B & E
MOA: Detergentlike mechanism allows for interaction with the LPS of outer membrane. DIsplaces mangesium and calcium disrupting the membrane = bactericidal.
Gram Negative coverage, but not used because of nephrotoxicity, neurotoxicity (paralytic).
Why is there no resistance to Polymixin B & E?
Have not been used because of toxicity.
BLACKBOXED
Rocephin - dosing consideration?
NO DOSE ADJ FOR RENAL INSUFFICENCY.
