Microbiology Flashcards
Site of Campylobacter jejuni infection
Usually infects caecum and terminal ileum.
Relation of lymph with campylobacter jejuni
Local
lymphadenopathy is common
Extra intestinal manifestations of campylobacter jejuni
lymphadenopathy,
Reactive arthritis is seen in 1-2% of cases
What are Enterobacteriaceae organisms?
The Enterobacteriaceae are a large family of Gram-negative bacteria, including many of the more familiar pathogens, such as Salmonella, Shigella and Escherichia coli. Members of the Enterobacteriaceae are bacilli (rod-shaped), facultative anaerobes, fermenting sugars to produce lactic acid
Treatment of shigella
Usually self limiting, ciprofloxacin may be required if
individual is in a high risk group
Disease by shigella
Clinically causes dysentery
Transmission of salmonella
usually transmitted by infected meat
(especially poultry) and eggs
Types and disease of E coli
Enteropathogenic
Enteroinvasive: dysentery, large bowel
necrosis/ulcers
Enterotoxigenic: small intestine, travelers diarrhoea
Enterohaemorrhagic: 0157, cause a haemorrhagic
colitis, haemolytic uraemic syndrome and thrombotic
thrombocytopaenic purpura
Cause of travellers diarrhoea and site
Enterotoxigenic E coli
Small intestine
Which E coli causes TTP
Enterohemorrhagic E coli O157
Shape of Yersinia
enterocolitica
coccobacilli
Gram test of iYersinia
enterocolitica
Negative
Disease of Yersinia enterocolitica
Typically produces a protracted terminal ileitis that
may mimic Crohns disease
Treatment of Yersinia
enterocolitica
Usually sensitive to quinolone (inhibits DNA gyrase and topoisomerase IV, to prevent DNA replication -nalidixic acid, ciprofloxacin, levofloxacin and moxifloxacin) or tetracyclines (binding to the 30S inhibits protein synthesis-Doxycycline,Minocycline)
Severe complication of Yersinia enterocolitica
Septicemia
Surgical DD of Yersinia enterocolitica
Appendicitis
Symptoms of cholera
Symptoms include sudden onset of effortless
vomiting and profuse watery diarrhoea
What is the mechanism of action of macrolides?
Inhibits protein synthesis
What is P450 inhibitor
A cytochrome P450 (CYP450) inhibitor is a substance that prevents the activity of enzymes in the liver and intestines that metabolize drugs, hormones, and other substances. CYP450 inhibition is a common cause of drug-drug interactions
What does the P450 enzyme do?
The cytochrome P450 family is a group of enzymes found mainly in the liver which perform oxidation and reduction reactions using iron. These reactions are part of phase 1 metabolism enhancing water solubility thus aiding excretion.
Adverse effects of erythromycin
•gastrointestinal upset
•cholestatic jaundice: risk may be reduced if erythromycin stearate is used
•P450 inhibitor
Antibiotics Inhibit cell wall formation
penicillins
cephalosporins
Antibiotics Inhibit protein synthesis
aminoglycosides (cause misreading of mRNA)
chloramphenicol
macrolides (e.g. erythromycin)
tetracyclines
fusidic acid
Antibiotics Inhibit DNA synthesis
Queen’s DNA in a Sulphur containing Metro
quinolones (e.g. ciprofloxacin)
metronidazole
sulphonamides
trimethoprim
Antibiotics Inhibit RNA synthesis
rifampicin
Examples of protein synthesis inhibitors aminoglycosides
gentamicin, tobramycin, amikacin, plazomicin, streptomycin, neomycin, and paromomycin
Benefits of protein synthesis inhibitor chloramphenicol
Chloramphenicol is a widely used topical ointment applied routinely to suture lines and skin grafts, particularly those on the face and around the eyes (bacterial conjunctivitis),otitis externa,also been used for the treatment of typhoid and cholera.
Examples of protein synthesis inhibitor. Macrolides
Erythromycin
Clarithromycin
Azithromycin
Examples of protein synthesis inhibitor tetracycline
Doxycycline
Minocycline
Along with tetracycline itself
Something about protein synthesis inhibitor fusidic acid
Fusidic acid is most effective against gram-positive organisms, such as staphylococcus aureus and staphylococcus epidermidis, including methicillin-resistant staphylococcus aureus (MRSA).
some examples of sulfonamides with caution
Sulfamethoxazole/trimethoprim
Sulfasalazine
Furosemide
Caution
They can interact dangerously with other drugs, including prescription and over-the-counter medications, and PABA sunscreens.
Which organism is transported to humans through eating watercress.
Fasciola hepatica
What is Fasciola hepatica
(parasitic trematode)
illness phase of fasciola hepatica
2 acute and chronic
Acute symptoms of fasciola hepatica
during the acute phase, the immature worms
begin penetrating the gut, causing symptoms of fever, nausea, swollen liver,
skin rashes, and extreme abdominal pain.
Chronic symptoms of fasciola hepatica
The chronic phase occurs when
the worms mature in the bile duct, and can cause symptoms of intermittent
pain, jaundice, and anemia.
Treatment of Fasciola hepatica
Treatment is with triclabendazole. Some patients may need ERCP
common cause of food borne illness
C. Perfringens
its ability to form
spores may make it relatively resistant to cooking
Basis of MRSA
mec Operon
toxic shock syndrome causing bacteria
Staphylococcus aureus
Protector of staphylococcus aureus against antibiotics
Beta lactamase
mec Operon
By what does streptococcus pyogens destroy tissue
Streptokinase
Hyaluronidase
Importance of superantigen released by streptococcus pyogens
superantigens such as pyogenic exotoxin A which results in
scarlet fever
Urease secreting bacteria
Helicobacter pylori
Bacteria a
Which bacterial septicaemia is associated with carcinoma of the colon
Streptococcus bovis
both aerobic and anaerobic organisms must be present In which infection
Fournier’s gangrene
What is advancing soft tissue infection associated with fascial necrosis
Necrotising fasciitis
Haemorrhagic bullae mostly found in which type of infection
Necrotising fascitis
Dirty Dishwater fluid discharge from Which infection
Necrotising fascitis
Treatment of necrotising fascitis
Radical surgical debridement
Sterile dressing
Reconstructive surgery
Diarrhea of immunocompromised
Mostly by cryptosporidium
Also
Salmonella
Shigella
Campylobacter
Which infection may complicate administration of broad spectrum antibiotics and produce foul smelling diarrhea
Clostridium deficile
Contamination of Salmonella
Food
Poultry, eggs
Contamination of vibrio cholerae
Contaminated water
Sea food
painless penile ulcer and marked inguinal
lymphadenopathy. lesion is sent for microscopy.
Treponema pallidum
What lesions characteristically affect the proximal aspect of the
aorta and can result in atypical aneurysms
Syphilic
typical lesion of primary syphilis
chancre which appears after
10-90 days. It is an indurated papule that breaks down to form an ulcer.
How syphilis can mimic carcinoma
The appearances of a hard ulcer with enlarged
regional lymph nodes can mimic carcinoma.
Jarisch- Herxheimer reaction associated with Which disease
Treatment of syphilis can precipitate a Jarisch- Herxheimer reaction with fever and
malaise occurring after treatment has been started and is due to the release
of antigens as the organisms die.
Precautions to prevent SSI (surgical site infection)
Preoperatively
Don’t remove body hair routinely
If hair needs removal, use electrical clippers with single use head (razors
increase infection risk)
Antibiotic prophylaxis if:
- placement of prosthesis or valve
- clean-contaminated surgery
- contaminated surgery
Use local formulary
Aim to give single dose IV antibiotic on anaesthesia
If a tourniquet is to be used, give prophylactic antibiotics earlier
Intraoperatively
Prepare the skin with alcoholic chlorhexidine (Lowest incidence of SSI)
Cover surgical site with dressing
A recent meta analysis has confirmed that administration of supplementary
oxygen does not reduce the risk of wound infection. In contrast to previous
individual RCT’s(1)
Wound edge protectors do not appear to confer benefit (2)
Post operatively
Tissue viability advice for management of surgical wounds healing by secondary
intention
statement relating to actinomycosis
gram positive bacilli
may be a cause of chronic multiple abscesses
Abdominal cases may develop in the appendix
Open biopsy of the lesions is the best diagnostic test
They are facultative anaerobes
difficult to culture
easiest way to
make a diagnosis of actinomycosis infection
Direct visualisation
of organisms and sulphur granules from lesions themselves
Which lessons contain Sulphur granules
Actinomycosis
DD of actinomycosis
hydradenitis
supprativa,
particularly if it is occurring in odd locations and with deeper
abscesses than usual.
Which infection has evidence of both worms and eggs in the stool.
Ascaris lumbricoides
Enterobiasis treatment
Mebendazole
Site of infection of hookworm
proximal small bowel
Stool findings difference between round and hook worn
Round has both larva and eggs
Hook has only larva
Treatment of hookworm
Mebendazole
Infection of hookworm
Infection occurs as a result of cutaneous
penetration
Infection of roundworms
Infections begin in gut following ingestion,
Which nematode may cause autoinfection
Strongyloidiasis
Cryptosporidium type
Protozoa
Spread of Cryptosporidium
Organisms produce cysts which are excreted and
thereby cause new infections
Which hepatic disease will have pain, fever and jaundice
Cholangitis
Courvoisier’s Law
painless
jaundice with
palpable
gallbladder
Mirizzi syndrome
In Mirizzi syndrome
the stone may compress the bile
duct directly- one of the rare
times that cholecystitis may
present with jaundice
Most common cause of cholangitis
Ascending infection of the bile
ducts usually by E. coli and by
definition occurring in a pool of
stagnant bile.
Basis of TPN jaundice
hepatic dysfunction
and fatty liver which may occur
with long term TPN usage.
severe peritoneal infections, pus has a pungent aroma. Which organism
Bacteroides fragilis
Echogenicity of amebic liver? Haemangioma
hyperechoic
Which liver disease is Linked to use of oral contraceptive pill
Liver cell
adenoma
Liver cell
adenoma consistency in CT
hypodense
Liver abscess echogenicity
fluid filled cavity,
hyperechoic walls may be seen in chronic abscesses
most common extra intestinal
manifestation of amoebiasis
Liver abscess
anchovy paste consistency found in which lesion
Amoebic
Liver abscess
Treatment of amebic liver abscess
Metronidazole
intense fibrotic reaction occurs around
sites of Which infection
Hyatid cysts of liver
Treatment of Hyatid cysts
sterilisation of the cyst with
mebendazole and may be followed by surgical
resection. Hypertonic swabs are packed around the
cysts during surgery
Genetic relation of Polycystic liver
disease
Autosomal dominant
Reason of pain inPolycystic liver
disease
as a result of capsular stretch
Cystadenoma of liver
solitary multiloculated lesion ,large anechoic,
fluid filled area with irregular margins. Internal echos
may result from septa
Why hepatic Cystadenoma is serious and what to do
Rare lesions with malignant potential
Surgical resection is indicated in all cases
incubation period of double stranded HBV
6-20 weeks
Which microorganism is needed to produce vaccine for HBV
prepared from yeast cells using recombinant DNA technology
Unit of Anti-HBs
level
mIU/ml
What to do for Non-responder to HBV vaccine
Test for current or past infection.
3 doses again
If still
fails to respond then HBIG
Complications of hepatitis B infection
Chronic hepatitis (5-10%)
Fulminant liver failure (1%)
Hepatocellular carcinoma
Glomerulonephritis
Polyarteritis nodosa
Cryoglobulinaemia
Management of hepatitis B
Pegylated interferon-alpha used to be the only treatment available
Because due to its side-effects
Oral antiviral medication is increasingly used
Antivirals for HBV
lamivudine, tenofovir and entecavir
Organisms of necrotizing fasciitis
Bacteroides
E coli
MRSA
Causative organism for cellulitis surrounding leg ulcer with treatment
group A streptococcal infection
penicillin
Example of alpha hemolytic streptococcus
S. pneumoniae
S. viridans
Example of group A beta hemolytic streptococcus
S. pyogenes
Example of group B beta hemolytic streptococcus
S.agalacticae
Pneumococcus is a common cause of
pneumonia,meningitis and otitis media
Streptococcus pyogenes responsible for
erysipelas, impetigo, cellulitis, type 2 necrotizing fasciitis
and pharyngitis/tonsillitis
immunological reactions of streptococcus pyogenes
rheumatic fever or post-streptococcal
glomerulonephritis
scarlet fever indicates what
erythrogenic toxins of streptococcus pyogenes
vegetations on the mitral valve with previous rheumatic fever indicates which organism
Streptococcus viridans
most common organism affecting previously ABNORMAL heart valves.
Streptococcus viridans
feature of Campylobacter jejuni infection
A prodromal period of fever and generalised malaise precedes abdominal pain
(which may mimic appendicitis) and diarrhoea.
Relation of Campylobacter jejuni with Guillain-Barre syndrome
Infection accounts for 26% case of Guillain-Barre syndrome
commonest cause of infective diarrhoea arising from non viral
causes
Campylobacter jejuni
Most common cause of acute bacterial infective diarrhoea
Campylobacter
jejuni
Organisms May mimic appendicitis
Campylobacter
jejuni
Yersinia
enterocolitica
Which bacterial infection may mimic Crohns disease?
Yersinia
enterocolitica
bile spill is an indication for what
broad spectrum intravenous
antibiotics
Gram test of Clostridium difficile
Positive
pseudomembranous colitis a feature of which infection
Clostridium defficile
Cause of pseudomembranous colitis.
exotoxin
Risk factors of infection with clostridium defficile
Broad spectrum antibiotics
Use of PPI and H receptor antagonists
Contacted with persons infected with c.difficile
Features of infection with clostridium defficile
Diarrhoea
Abdominal pain
A raised white blood cell count is characteristic
If severe, toxic megacolon may develop
toxic megacolon may develop in which infection
Severe case of clostridium defficile
Diagnosis of clostridium defficile
CDT in the stool
(Clostridium difficile toxin)
Management of clostridium defficile
(Specially when intervened by surgeons)
First-line therapy is oral METROnidazole for 10-14 days
If severe, or not responding to metronidazole, then oral VANCOmycin may be
used
Patients who do not respond to vancomycin may respond to oral
FIDAXOmicin
Patients with SEVERE and UNREMITTING colitis should be considered for
colectomy
Which organism has risk of transfer in swimming pools and why?
Giardia lamblia
It is resistant
to chlorination
Macroscopic identification of giardiasis diarrhoea
greasy stool
Effect on absorption by giardia lamblia
(took away the lamb - lamb lia)
causes fat malabsorption
Differ acute and chronic diarrhoea
Acute diarrhoea < 14 days
Chronic diarrhoea > 14 days
Example of acute diarrhoea
Gastroenteritis
Diverticulitis
Antibiotic therapy
Constipation causing
overflow
Example of chronic diarrhea
IBS
Ulcerative
colitis
Crohn’s
disease
Colorectal
cancer
Coeliac
disease
Classical feature of diverticulitis
Classically causes LEFT lower quadrant pain,diarrhoea and fever
Associated Features of IBS
lethargy, nausea, backache and bladder
symptoms
most consistent features of IBS
abdominal pain, bloating and change in bowel habit
features of Crohn’s disease
Crampy abdominal pain
diarrhoea.
malabsorption,
mouth ulcers
perianal disease
intestinal
obstruction
Features of ulcerative colitis
Bloody diarrhoea
Crampy abdominal pain
weight loss
Faecal urgency and tenesmus
How can appendicitis cause diarrhea
Appendicitis with pelvic abscess or pelvic appendix
Which thyroid dysfunction may cause diarrhoea
Thyrotoxicosis
anti endomysial antibodies used to diagnose which disease
Endomysial antibodies (EMA) are a marker for celiac disease and dermatitis herpetiformis. They are produced by the body in response to gluten, which is found in wheat, barley, and rye products.
most common organism causing Septic arthritis
Staphylococcus aureus
In young adults who are sexually active Neisseria gonorrhoeae should also
be considered
Treatment of septic arthritis
Penicillin
flucloxacillin
clindamycin
For several weeks
Needle aspiration should be used to decompress the joint
Arthroscopic lavage may be required
reservoir of campylobacter.
Birds are a recognised reservoir of campylobacter.
Which organism will cause diarrhea with local lymphadenopathy
Campylobacter jejuni (from birds)
Treatment of shigellosis
Ciprofloxacin
Relation of salmonella and campylobacter
Salmonella from dead bird(poultry meat)
Campylobacter from bird BEAK contamination
Most common organism to invest prosthetics and why with treatment
Staphylococcus epidermidis
This tends to colonise plastic devices and forms a biofilm which allows
colonisation with other bacterial agents. It is notoriously difficult to eradicate once
established and the usual treatment is removal of the device.
Most common route of osteomyelitis
Is the result of haematogenous spread in most cases
Most common cause of osteomyelitis
Is due to Staphylococcus aureus in 50% cases
Why Plain radiographs are of less importance in case of osteomyelitis
Plain radiographs may be normal in the early stages
Effect of septic joint on osteomyelitis
The presence of associated septic joint involvement will significantly alter
management
Conservative vs washout
Management of osteomyelitis
It is managed medically in the first instance (with an antistaphylococcal antibiotic).
This differs from the situation in septic joints where early joint washout is
mandatory.
Causes of osteomyelitis
S aureus and occasionally Enterobacter or Streptococcus species
In sickle cell: Salmonella species
Clinical features of osteomyelitis
Erythema
Pain
Fever
X-ray of late case of osteomyelitis
Lytic centre with a ring of sclerosis
Role of surgery in case of osteomyelitis
1.If associated with septic arthritis
2.Sequestra may need surgical removal
What is Quinsy
Peritonsillar abscess
accumulation of pus due to an infection behind the tonsil.
Complications may include blockage of the airway or aspiration pneumonitis.
Cause of Quinsy
This can happen when a bacterial infection spreads from an infected tonsil to the surrounding area.
Acute tonsillitis features
pharyngitis, fever, malaise and lymphadenopathy.
DD of bacterial tonsillitis
Infectious mononucleosis
What is Infectious mononucleosis
Infectious mononucleosis, also known as glandular fever/Pfeiffer’s disease/ Filatov’s disease/kissing disease, is an infection usually caused by the Epstein–Barr virus. Most people are infected by the virus as children, when the disease produces few or no symptoms.
What is Monospot test and when to do
A monospot test is a blood test that detects antibodies in the blood that indicate an infection with the Epstein-Barr virus (EBV), which causes infectious mononucleosis (mono). The test is a type of heterophile antibody test that uses equine erythrocytes as a substrate.
The test is performed when symptoms of mononucleosis, or mono, are present, such as:
Fatigue
Fever
Large spleen
Sore throat
Tender lymph nodes along the back of the neck
What is HIV seroconversion
Seroconversion is the period when the body’s immune system responds to HIV infection by producing antibodies that can be detected by an HIV test. It usually occurs within a few weeks of infection, but can take up to three months.
Time for HIV seroconversion
It typically occurs 3-12 weeks after infection
Features of HIV seroconversion
typically presents as
a glandular fever type illness.
Features
sore throat
lymphadenopathy
malaise, myalgia, arthralgia
diarrhoea
maculopapular rash
mouth ulcers
rarely meningoencephalitis
Early test for HIV
antibodies to HIV may not be present
HIV PCR and p24 antigen tests can confirm diagnosis
p24 antigen test
usually positive from about 1 week to 3 - 4 weeks after infection with HIV
sometimes used as an additional screening test in blood banks
Late test for HIV
HIV antibody test
most common and accurate test
usually consists of both a screening ELISA (Enzyme Linked Immuno-Sorbent
Assay) test and a confirmatory Western Blot Assay
most people develop antibodies to HIV at 4-6 weeks but 99% do by 3
month
Relation of shaving with surgical incision
Shaving one day prior to surgery will increase the risk.
Treatment of surgical drape
Iodophor impregnated drapes have been demonstrated to reduce the risk of wound
infection
Importance of Charcots triad and what to do
Surgical emergency.
Patients need: Biliary decompression and broad spectrum antibiotics.
Reynolds pentad
Fever
Right upper quadrant pain
Jaundice
confusion
hypotension
Treatment if Charcot’s triad/?Reynolds pentad
Treatment
ERCP -usually after 72 hours of antibiotics
Percutaneous transhepatic cholangiogram and biliary drain
Best antibiotic for MRSA
Vancomycin+Rifampicin(resistance may develop)
Relatively new antibiotics such as linezolid, quinupristin/dalfopristin combinations
and tigecycline have activity against MRSA but should be reserved for resistant
cases
MRSA is acquired mostly where
Hospital
How to Suppress of MRSA from a carrier once identified
nose: mupirocin 2% in white soft paraffin, tds for 5 days
skin: chlorhexidine gluconate, od for 5 days. Apply all over but particularly to
the axilla, groin and perineum
Some strains may be sensitive to the antibiotics listed below but they should not
generally be used alone because resistance may develop against MRSA
rifampicin
macrolides
tetracyclines
aminoglycosides
clindamycin
Disease of salmonella
Enteric fever
Typhoid & paratyphoid
Features of enteric fever
initially systemic upset as above
relative bradycardia
abdominal pain, distension
constipation: although Salmonella is a recognised cause of diarrhoea,
constipation is more common in typhoid
rose spots: present on the trunk in 40% of patients, and are more common in
paratyphoid
complications of enteric fever
osteomyelitis (especially in sickle cell disease where Salmonella is one of
the most common pathogens)
GI bleed/perforation
meningitis
cholecystitis
chronic carriage (1%, more likely if adult females)
commonest cause of lactational mastitis.
Staphylococcus aureus
carried in the infants oropharynx
Complication of mastitis
mammary duct
fistula from. underlying abscess
Rapid cause of vomiting from bacterial food poisoning
Staphylococcus aureus
What infection can cause spontaneous splenic rupture?
Epstein - Barr Virus may cause generalised lymphadenopathy. This may be
associated with splenomegaly. This enlargement has been associated with
spontaneous rupture.
Development of spleen
It
develops from the upper dorsal mesogastrium
Destination of splenic artery
to the white pulp transporting plasma then branches off to go into red pulp
Site of Production of properdin, and tuftsin
Spleen
Causes of Massive splenomegaly
Myelofibrosis
Chronic myeloid leukaemia
Visceral leishmaniasis (kala-azar)
Malaria
Gaucher’s syndrome
What will happen to spleen in Sickle-cell
initialy spleenomegally then autosplenectomy (due to
repeated infarction)
causes of splenomegaly
Myelofibrosis
Chronic myeloid leukaemia
Visceral leishmaniasis (kala-azar)
Malaria
Gaucher’s syndrome
Portal hypertension e.g. secondary to cirrhosis
Lymphoproliferative disease e.g. CLL, Hodgkin’s
Haemolytic anaemia
Infection: hepatitis, glandular fever
Infective endocarditis
Sickle-cell*, thalassaemia
Rheumatoid arthritis (Felty’s syndrome)
commonest cause of wound infection following cardiac or colonic surgery
enterobacter
Most common cause of SSI of skin
Staphylococcus aureus
Epstein-Barr virus related cancers
Burkitt’s lymphoma
Hodgkin’s lymphoma
Post transplant lymphoma
Nasopharyngeal carcinoma
Human papillomavirus 16/18 related cancers
Cervical cancer
Anal cancer
Penile cancer
Vulval cancer
Oropharyneal cancer
Human herpes virus 8 related cancer
Kaposi’s sarcoma
Nervous lesion by Human T-lymphotropic virus 1
Tropical spastic paraparesis
a slowly progressive viral immune-mediated disorder of the spinal cord
Percentage of SSI
Surgical site infections (SSI) comprise up to 20% of all healthcare
associated infections and at least 5% of patients ( a clean procedure and carries the lowest risk of SSI) undergoing surgery will
develop an SSI as a result.
feature of enteroinvasive E.coli.
Necrosis and ulcers of the large bowel
dysentery type illness similar to shigellosis.
Ascending infection of the genitourinary tract is most commonly caused by
E-Coli.
(Like sepsis with a history
of a UTI that was treated)
features of malignant otitis externa
Severe pain, headaches and granulation tissue within the external auditory meatus
commonest risk factor for malignant otitis externa
Diabetes mellitus
(immunocompromised
individuals)
Infective organism of malignant otitis externa
Pseudomonas aeruginosa
Progression of malignant otitis externa
Infection commences in the soft tissues of the external auditory meatus,
then progresses to involve the soft tissues and into the bony ear canal
Progresses to temporal bone osteomyelitis
Key features of Malignant otitis externa
immunosuppression (illness or treatment related)
Severe, unrelenting, deep-seated otalgia
Temporal headaches
Purulent otorrhea
Possibly dysphagia, hoarseness, and/or facial nerve dysfunction
Treatment of Malignant otitis externa
Treatment
Anti pseudomonal antimicrobial agents
Topical agents
Hyperbaric oxygen is sometimes used in refractory cases
Antipseudomonal antibiotics
penicillins-with beta-lactamase inhibitors
cephalosporins-ceftazidime, cefepime
Aminoglycosides - Amikacin
Piperacillin/tazobactam, -Piperacillin is a fourth-generation β lactam antimicrobial that is enhanced by the addition of tazobactam, a β lactamase inhibitor.
