.. ..

1.


parasite

(upper respiratory tract
infection, URI)
(systemic symptoms)




2.
acid-fast ( modified acid-fast )


3. (Antimicrobial activity)
pharmacokinetics pharmacodynamic

4.




1.

1.1 -lactams penicillins
cephalosporins carbapenems
1.2 Glycopeptide vancomycin teicoplanin
1.3 Fosfomycin
2.

2.1 Aminoglycoside
2.2 Macrolides erythromycin, roxithromycin, azithromycin,
clarithromycin) lincosamide (clindamycin)
2.3 Tetracycline tetracycline, minocycline, doxycycline
2.4 Glycylcyclines tigecycline

trimethoprim sulfa
4.
3.

fluoroquinolone
5. Metronidazole

-lactams


Penicillin derivatives ampicillin, amoxycillin (amoxicillin), cloxacillin,
piperacillin streptococci Grampositive anaerobes ampicillin amoxycillin Enterococcus faecalis
penicillin cloxacillin S. aureus
piperacillin anti-pseudomonal penicillin
penicillin Pseudomonas aeruginosa
ampicillin, amoxycillin, piperacillin sulbactam, clavulanate,
tazobactam -lactamase inhibitor

-lactamase ( sulbactam A.
baumannii ) -lactamase inhibitor ampicillin

amoxycillin S. aureus tazobactam

piperacillin -lactamase anaerobes lactamase inhibitors -lactamase P. aeruginosa1
piperacillin/tazobactam piperacillin

piperacillin/tazobactam 4.5 piperacillin 4 tazobactam

0.5
Cephalosporins
1 S. aureus
1 cefazolin cephalexin cephalosporin 2
1 cefuroxime cefoxitin
cephamycin anaerobes
cefoxitin -lactamase
cephalosporins 3
P. aeruginosa
(ceftriaxone cefotaxime) (cefditoren, cefdinir,
cefpodoxime, cefixime) P. aeruginosa

ceftazidime cefoperazone cefoperazone anaerobes
sulbactam cefoperazone/sulbactam 2:1
(1.5 gram vial)
A. baumannii cephalosporin
4 anti-pseudomonal cephalosporin
cefepime cefpirome P. aeruginosa
ceftazidime ceftazidime
S. aureus cloxacillin
minimal inhibitory concentration (MIC) 2-4 MIC
cloxacillin 0.5 2
cephalosporins


methicillin-resistant S. aureus (MRSA)
ceftobiprole MRSA lactams

Carbapenems
4
imipenem/cilastatin, meropenem, doripenem, ertapenem

anaerobes, Nocardia spp., imipenem rapidly
growing mycobacterium extendedspectrum -lactamase P. aeruginosa A. baumannii
ertapenem ertapenem empirical therapy

imipenem MIC
MIC meropenem MIC ertapenem ( P. aeruginosa A.
baumannii) MIC meropenem MIC doripenem
MIC imipenem MIC P.
aeruginosa A. baumannii MIC meropenem3-5
pharmacokinetics -lactams

piperacillin, cefazolin, cefoperazone
cefoperazone
ceftriaxone

ceftriaxone cefoperazone 12 ertapenem
1
pharmacodynamic time above MIC
(25oC)
MIC
ceftazidime, cefoperazone, doripenem

-lactams

ceftazidime, cefoperazone, piperacillin, carbapenems

Glycopeptides
Vancomycin teicoplanin MRSA

S. aureus lactams glycopeptide -lactams

 MRSA glycopeptide
S. aureus vancomycin
-lactams
histamine anaphylaxis
MRSA fosfomycin,
fusidic acid, linezolid, tigecycline clindamycin

Aminoglycoside


bactericidal

permeability
RNA
6
pharmacodynamic
MIC


gentamicin
amikacin P. aeruginosa
streptomycin
second line mycobacteriostatic
3
vestibular auditory system

aminoglycosides

amikacin

gentamicin 5.1 mg/kg/day amikacin 15 mg/kg/day
2-3

Amikacin P. aeruginosa

piperacillin
aminoglycoside -lactams
-lactams



Gentamicin
Enterococcus spp. bacteremia immunocompromised host bacterial
endocarditis streptococci penicillin (MIC penicillin >0.06
) Enterococcus spp. S. aureus
synergistic effect aminoglycoside
1 mg/kg/day 8-12
aminoglycosides


Macrolides erythromycin, roxithromycin, azithromycin, clarithromycin)

lincosamide (clindamycin)
macrolides clindamycin
streptococci staphylococci
macrolides lincosamide atypical
(Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella pneumophila)
azithromycin clarithromycin nontuberculous mycobacteria M. avium-intracellulare complex
Tetracycline tetracycline, minocycline, doxycycline

Rickettsia murine
scrub typhus 24-48 doxycycline
Glycylcyclines
minocycline
tigecycline streptococci, enterococci
vancomycin, staphylococci (methicillin-susceptible methicillin-resistant)

 Enterobacteriaceae (with or without

ESBL production), A. baumannii




0.4-0.6
MIC 1


(complicated skin and soft tissue, complicated intra-abdominal
infection)


sulfadiazine
pyrimethamine toxoplasmic encephalitis
pyrimethamine sulfadiazine

trimethoprim sulfamethoxazole (TMP/SMX) 80/400 co-trimoxazole
Nocardia spp., Pneumocystis jirovecii
ceftazidime melioidosis
Pneumocystis jirovecii

Shigella spp.
TMP/SMX




Steven-Johnsons
syndrome toxic epidermal necrolysis
fixed-drug eruption

 7, 8
Fluoroquinolone fluorine
nalidixic acid quinolone fluorine side chain
fluoroquinolones
fluoroquinolones

norfloxacin, ofloxacin, levofloxacin, ciprofloxacin, moxifloxacin
ciprofloxacin
P. aeruginosa levofloxacin
norfloxacin ofloxacin P. aeruginosa
levofloxacin moxifloxacin
fluoroquinolones atypical pneumonia
Mycoplasma pneumoniae, Legionella pneumophila, Chlamydia pneumoniae
respiratory fluoroquinolones moxifloxacin MIC
MIC levofloxacin Mycobacterium
tuberculosis, Mycobacterium avium-intracellulare, Brucella spp.

fluoroquinolones

mutation DNA gyrase
topoisomerase

Enterobacteriaceae Neisseria gonorrhoeae

fluoroquinolones
norfloxacin
30-50
ciprofloxacin 50-85 ofloxacin, levofloxacin, moxifloxacin
85-100

multivalent cations aluminum, magnesium, calcium, iron, zinc
cations fluoroquinolones

 cations fluoroquinolones

ciprofloxacin
moxifloxacin


mutation MIC
mutation MIC

P.
aeruginosa -lactams

fluoroquinolones
(ciprofloxacin, moxifloxacin)


isoniazid, rifampicin




Empirical therapy

(Empirical therapy)
3-5
empirical therapy

1. Chamber FH. Other -lactam antibiotics. In: Mandell GL, Bennett JE, Dolin R,
eds. Principles and Practice of Infectious Diseases 6th ed. Philadelphia: ElsevierChurchill Livingstone 2005:311-8
2. Chamber FH. Penicillins. In: Mandell GL, Bennett JE, Dolin R, eds. Principles
and Practice of Infectious Diseases 6th ed. Philadelphia: Elsevier-Churchill
Livingstone 2005:291-93
3. Curran M, Simpson D, Perry C. Ertapenem: a review of its use in the management
of bacterial infections. Drugs. 2003;63(17):1855-78.
4. Keam SJ. Doripenem: a review of its use in the treatment of bacterial infections.
Drugs. 2008;68(14):2021-57.
5. Pfaller MA, Jones RN. A review of the in vitro activity of meropenem and
comparative antimicrobial agents tested against 30,254 aerobic and anaerobic
pathogens isolated world wide. Diagn Microbiol Infect Dis. 1997 Aug;28(4):15763.
6. Gilbert DN. Aminoglycosides. In: Mandell GL, Bennett JE, Dolin R, eds.
Principles and Practice of Infectious Diseases 6th ed. Philadelphia: ElsevierChurchill Livingstone 2005:328-56
7. Hooper DC. Quinolones. In: Mandell GL, Bennett JE, Dolin R, eds. Principles
and Practice of Infectious Diseases 6th ed. Philadelphia: Elsevier-Churchill
Livingstone 2005:451-73
8. Amsden GW. Tables of antimicrobial agent pharmacology. In: Mandell GL,
Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases 6th ed.
Philadelphia: Elsevier-Churchill Livingstone 2005:634-700

 1 ( empiric
)

Bacterial meningitis
Community-acquired
(normal host)
Community-acquired,
(immunocompromised/elderly)
Post-operative

Acute sinusitis

paranasal sinus
87 viral URI

Streptococcus suis,
Streptococcus pneumoniae
N. meningitides
Listeria monocytogenes and above
organisms
S. pneumoniae (esp. with CSF
leakage), Pseudomonas aeruginosa,
Coagulase-negative staphylococci,
Staphylococcus aureus, Other Gramnegative bacilli
S. pneumoniae, H. influenzae, M.
catarrhalis, group A streptococci

Ceftrixaone 2 g IV q 12 h
Vancomycin 500-750 mg IV q
6h
Add ampicillin 2 g IV q 6 h to
the above regimen
Ceftazidime 2 g IV q 8 h +
vancomycin 500-750 mg IV q 6
h

Cefotaxime 2 g IV q 4-6 h
Vancomycin 500-750 mg IV q
6h

decongestant
1
high dose

Amoxycillin/clavulanate
2000/125 mg bid, moxifloxacin
400 mg q 24 h, levofloxacin
750 mg q 24 h x 5 days or 500
mg q 24 h x 14 days,
cephalosporins (cefdinir,
cefditoren 200 mg bid)

amoxicillin (1 g tid)
Chronic sinusitis

Acute
phayngitis/pharyngotosillitis

Prevotella spp., anaerobic strep,

Fusobacterium, aerobic streptococci,
P. aeruginosa, S. aureus, & M.
catarrhalis
Group A, C, G streptococci, virus
( EBV infectious
mononucleosis), C. diphtheria,
Arcanobacterium haemolyticum, M.
pneumoniae

Cefepime 2 g IV q 8 h or
meropenem 2 g IV q 8 h +
vancomycin 500-750 mg IV q
6h

Antibiotic not effective, need

otolaryngologic intervention

Penicillin V 500 mg bid or 250

mg qid

Benzathine penicillin 1.2 mU

im X 1 dose, cefuroxime acetil
250 mg bid X 4 days,
clindamycin, clarithromycin
250 mg bid X 10 days,
azithromycin 500 mg then 25o
mg q 24 h X 4 days

Pneumonia
Community-acquired

Mild to moderate (walking

pneumonia), no co-morbidity

Atypicals (Mycoplasma. pneumoniae,

Chlamydia pneumoniae, Legionella
pneumophilia), S. pneumoniae, virus

Azithromycin 0.5 g X 1 then

0.25 g per day, clarithromycin
500 mg bid

Doxycycline 100 mg bid

Levofloxacin 750 mg/d or
moxifloxacin 400 mg/d

Alcoholism

3rd generation cephalosporin

clindamycin
3rd generation cephalosporin

Levofloxacin or moxifloxacin

Post obstruction of airways

S. pneumoniae, anaerobes, Gramnegative rods

H. influenza, M. catarrhalis, S.
pneumoniae
S. pneumoniae, anaerobes

Amoxycillin-clavulanate

3rd generation cephalosporin

clindamycin

Post influenza

S. pneumoniae, S. aureus

Exposure to tropical
environment/multiorgan
involvement (aseptic
meningitis, hepatitis,
nephritis)
Diabetes, thalassemia,
chronic kidney disease,

Leptospira spp., Rickettsia spp.

2nd - 3rd generation

cephalosporins
3rd generation cephalosporin +
doxycycline or azithromycin

COPD

Levofloxacin or moxifloxacin

Melioidosis

Ceftazidime 2 g IV q 8 h
trimethoprim-sulfamethoxazole
12-15 mg TMP/kg/d

Imipenem/cilastatin,
meropenem

Pneumocystis jirovecii (PCP)

Trimethoprim/sulfamethoxazole

Clindamycin 600 mg q 8 h +
primaquine 30 mg q 24 h

farmer,

(
)

tuberculosis

Gram negative

Interstitial pneumonia

15 mg/kg/dayTMP q 8-12 h




pneumonia


HIV

oral candidiasis
oral hairy leukoplakia

viral

pO2 <70 mmHg

prednisolone 40 mg bid 5

20 mg bid 11

pneumonia)
Healthcareassociated/ventilatorassociated, early onset

Healthcareassociated/ventilatorassociated, late onset

5

(Gram

A. baumannii, P. aeruginosa, K.
pneumoniae, E. coli (with or without
ESBL production), Enterobacter spp.,
MRSA

A. baumannii:
cefoperazone/sulbactam P.
aeruginosa: antipseudomonal
penicillin/cephalosporins, K.
pneumoniae, E. coli: 3rd
generation cephalosporins

A. baumannii: colistin,
tigecycline
P. aeruginosa: carbapenem
MRSA: linezolid

negative coccobacilli A.

fluoroquinolone; carbapenem

baumannii, GNR

fluoroquinolone
ESBL, Enterobacter

capsule P. aeruginosa,
GNR


capsule
Enterobacteriaceae K.

spp.: piperacillin,
fluoroquinolone
MRSA: vancomycin,
teicoplanin

pneumoniae, E. coli,
Enterobacter spp.
Aspiration pneumonia

Bacterial endocarditis
Acute

Sub-acute

Anaerobes

Clindamycin

High dose penicillin G,

Amoxycillin/clavulanate

Host: IV drug users

Clinical: sepsis or bloodborne pneumonia, congestive
heart failure common
Host: valvular heart disease
Clinical: prolonged fever (24 weeks), embolic
phenomena

S. aureus (MSSA)

Cloxacillin 2 g IV q 4 h X 4-6
weeks + gentamicin 1 mg/kg q
8 h X 3-5 days

Cefazolin 2 g iv q 8 h +
gentamicin 1 mg/kg q 8 h X 35 days

Viridans streptococci, enterococci

Ampicillin 2 g IV Q 4 h
penicillin 3 mU iv q 4 h +
gentamicin 1 mg/kg q 8 h X 3-5

Ceftriaxone + gentamicin 1
mg/kg q 8 h X 3-5 days

days (

major
Intra-abdominal infection

Enterobacteriaceae anaerobes

emboli, heart failure)

Third-generation cephalosporin
metronidazole

Enterobacteriaceae anaerobes, P.
aeruginosa, A. baumannii,
enterococci

Anti-pseudomonal penicillin,
cephalosporins, or
fluoroquinolone

S. aureus

Cloxacillin 2 g IV q 4 h

Normal host
Steroid user
Prosthetic joint
Cellulitis/necrotizing fasciitis
Salt- or fresh-water
including water animal
exposure
Animal bite

S. aureus
Salmonella spp.
Staphylococci, Streptococci, GNR

Cloxacillin 2 g IV q 4 h
Ciprofloxacin 400 mg IV q 12 h

Vibrio vulnificus, Aeromonas spp.,

other Gram-negative bacilli

3rd generation cephalosporins,

fluoroquinolones

Pasteurella multocida

Doxycycline

Previous surgery of the

affected limb, impaired venous
or lymphatic drainage
Community-acquired sepsis,
unknown primary site

Streptococcus pyogenes

Amoxycillin/clavulanate,
ampicillin/sulbactam
Penicillin, clindamycin

Ceftriaxone 2 g IV q 24 h

Cefuroxime 750 mg IV q 8 h,
Amoxycillin/clavulanate 1.2-

Complicated intra-abdominal
infections ( post-operative
infections)
Osteomyelitis

epidural

Anti-pseudomonal
carbapenems

space (epidural abscess)

Septic arthritis

empiric

E. coli, S. pyogenes, S. agalactia

(group B streptococci), Salmonella
spp. (esp. in HIV infected patients),
S. suis (

)
Community-acquired sepsis,
unknown primary site

Diabetes, thalassemia,
chronic kidney disease,

B. pseudomallei

Ceftazidime 2 g IV q 8 h
trimethoprim-sulfamethoxazole
12-15 mg TMP/kg/d

Ceftriaxone 2 g IV q 24 h

2.4 g IV q 8 h,
ampicillin/sulbactam 1.5 3 g
IV q 8 h + gentamicin 5.1
mg/kg q 24 h
Imipenem/cilastatin,
meropenem

farmer,

Acute febrile illness without

localizing sign

(
)

Leptospirosis ( )
scrub typhus (
)

murine typhus (
interstitial

pneumonia, aseptic
)
meningitis, encephalopathy,
abnormal liver enzymes,

carditis Dengue virus infection

1




leptospirosis
Rickettsia
doxycycline 100 mg q 12 h