The "Other Guys" Antibiotics Flashcards
Fluoroquinolones
Ciprofloxacin (Cipro): 200-400mg IV q12h or 250-740mg PO q12h
Levofloxacin (Levaquin): 250-750 mg IV/PO daily
Moxifloxacin (Avelox)
MOA: Inhibits DNA Gyrase (topo II) - for G(-) and Topoisomerase IV for G(+).
Coverage:
G(+): Respiratory Quinolones (Levofloxacin/Moxifloxacin) covers S.pneumo, E. faecalis, and S.viridans
G(-): All enterobacteriaceae, H. flu, M.cat, Neisseria. Cipro > Levo for P. Aeruginosa
Anaerobes: Moxifloxacin
Uses: CAP, UTIs, intra-abdominal infections
ADR: QT prolongation, CNS affects, increased C. diff, Tendonitis/ Tendon rupture (BBW), Dysglycemia (Hypo or Hyper), impaired cartilage formation (avoid in prengnacy)
Pearls: Avoid with multivalent cations, DDI CYP1A2, Levofloxacin/Ciprofloxacin require renal dose adjustment.
Nitroimidazoles
Metronidazole (Flagyl): 500mg PO/IV q 6-8h
MOA: produces reactive radicals that cause cell death
Coverage:
Anaerobes: Bacteroides, Clostridium + C.diff, Peptostreptococcus
Parasitic Anaerobe: Trichomonas vaginalis (STD)
Uses: Anaerobic infections (DOC for B. fragilis), brain abscesses, intra-abdominal infections, bacterial vaginosis, trichomoniasis. 1st line for Bacteroides, 2nd line for C.diff
ADR: Metallic taste, Stomatitis, Peripheral neuropathy, Avoid in pregnancy and breastfeeding.
Pearls: Avoid alcohol use (x48 hours after use)
Sulfonamides (Antimetabolite)
Trimethoprim/Sulfamethoxazole (Bactrim)
MOA: Inhibits microbial folic acid synthesis cause bactericidal activity.
Coverage:
G(+): CA-MSRA, MSSA
G(-): E. coli, Klebsiella
Uses: SSTI, UTI, PJP/PCP Pneumonia, opportunistic infections/prophylaxis
ADR: Hypersensitivity (Sulfa allergies), photosensitivity, GI, hematologic (G6PD deficient), Avoid in pregnancy
Pearls: needs renal dose adjustment
Nitrofurans
Nitrofurantoin (Macrobid, Macrodantin): ER dose: 50-100mg PO q12h
MOA: Blocks translation and inhibits bacterial respiration and metabolism
Coverage:
G(+): S. saprophyticus
G(-): E. coli
Uses: uncomplicated UTI - cystitis (in young women)
ADR: GI (N/V), loss of appetite
Pearls: Contraindicated when CrCl < 30.
Fosfomycin
Fosfomycin PO
MOA: Inactivates enzyme used in early step of bacterial peptidoglycan synthesis
Uses: G(-) UTIs (not first line)
ADR: GI (N/V)
Pearls: Safe for pregnant women, often used for UTIs during pregnancy
Rifamycins
Rifampin IV/PO
Rifabutin PO
Rifaximin PO
MOA: inhibits RNA polymerase, preventing transcription
Coverage/Use:
Atypical: Mycobacteria
Rifampin: G(+): MSSA/MRSA in synergy
Rifampin/Rifabutin: tuberculosis combination regimens
ADR: Discolored body fluids (orange-red), Hepatotoxicity, Rifampin decreases effectiveness of oral contraceptives (Use Rifabutin instead)
Pearls: Rifampin PO/IV greatly induces 3A4 decreases oral contraceptives effectiveness, use Rifabutin intstead.
Rifaximin is used to kill E.coli
Polymyxins
Colistin
Polymyxin B
MOA: displaces calcium and magnesium, causing leakage of intracellular contents due to increased membrane permeability. (bactericidal -concentration dependent)
Coverage: A. baumanii, P. aeruginosa, Klebsiella
Uses: Last-line agents against multidrug-resistant and extensively drug-resistant G(-) pathogens)
MRSA agents
CA-MRSA (SSTI):
Bactrim, Clindamycin, Doxycycline, Tedizolid, Oritavancin, Dalbavancin
HA-MRSA: Vancomycin (DOC), Daptomycin (not for pneumonia), Linezolid, Ceftaroline, Televancin, Synervid (avoid use), Tigecycline (last line, CI bacteremia)
Enterobacteriaceae
Penicillins: Amino PCNs
Cephalosporin: 1st to 3rd gen
Carbapenem: Any (overkill)
Aztreonam: use (if theres an allergy)
KPC enzymes:
Avycaz, Vabomere, Recarbrio
Pseudomonas Aeruginosa
Zosyn, Ceftazidime, Cefepime, Carabapenems (not ertapenem), Aztreonam, Cipro/Levofloxacin, Amikacin > Torbramycin > Gentamicin
Enterococcus
Ampicillin ± Gentamicin
Vancomycin ± Gentamicin
Linezolid, Daptomycin, Carbapenems, Tigecycline, Lipoglycopeptides (Vancins)
A. baumanii
Carbapenems (50% of strains are resistant)
Polymyxin B and Colistin
High dose Unasyn
Atypicals
Macrolides
Tetracyclines
Fluoroquinolones
Anaerobes Bacteroides
Metronidazole, BL/BLI combo, carbapenems, Moxifloxacin, Cefoxitin, Cefotetan, Cindamycin
Anaerobes Clostridium
PO vancomycin, PO fidoxamicin, PO/IV metronidazole (potentially)
No Renal Dose Adjustments
Nafcillin/Oxacillin
Ceftriaxone
Azithromycin
Bacteriocidal
β-lactams, Vancomycin, Daptomycin, Quinolones, Aminoglycosides, Polymyxins, Nitrofurantoin, Metronidazole, Fosfomycin
Bacteriostatic
Protein synthesis inhibitors except aminoglycosides.
Macrolides, Tetracyclines, Linezolid/Tedizolid, Clindamycin
CPJE Outpatient Pearls
All β-lactam suspensions are refrigerated EXCEPT Cefdinir (do not refrigerate), Amoxicillin (refrigeration recommended but room temp is OK)
All other antibacterial suspensions are room temp. EXCEPT Vancomycin
Take antibacterials with food EXCEPT: Pen VK, Levaquin solution, Zithromax ER Suspension, Metronidazole ER, Diclofloxacin, Lefamulin
CPJA IV Pearls
NS only: Ertapenem, Daptomycin, Ampicillin, Unasyn
D5W only: Bactrim, Amphotericin B, Synercid
AVOID with Lactated Ringer’s Ca2+ solutions: Ceftriaxone, Zosyn without EDTA
Short stablities: Bactrim, Rifampin
Protect from light: Doxycycline, Rifampin
Adverse Events Shared by Classes
Photosensitivity: Bactrim, Tetracyclines, Quinolones
Avoid with multivalent cations: Tetracyclines, Quinolones
Nephrotoxicity: Vancomycin, Aminoglycosides, Polymyxins,
Hypersensitivity reactions: β-lactams (not Aztreonam), Sulfamethoxazole (component of bactrim)
Stewardship Prospective Audit and Feedback
Pros: Visibility of program and potential to build collegial relationships. More clinical data available. More flexibility. Resource flexibility. Educational benefit for prescribers. Prescriber autonomy maintained Adresses de-escalation and DOT
Cons:
Variable success depending on feedback to prescribers.
Labor intensive.
Prescriber compliance is voluntary.
Prescriber reluctance to change therapy if patient is improving.
Technological limitations.
May take more time to decrease antimicrobial use
Stewardship Preauthorization
Pros: Prevent initiation of certain agents Optimize empiric therapy. Direct control over antimicrobial use. Decrease antimicrobial costs. Rapid response to shortages. Encourage a more thorough review of available clinical data.
Cons: Only impacts restricted agents Downstream use neglected. Shift to other agents Loss of prescriber autonomy May delay therapy Approver skill impact effectiveness. Resource intensive
