Internal Medicine Mini-Lecture

Learning Points

Basics
Choosing antibiotics
Overview

Basics

Make sure you try to collect cultures before

starting antibiotics
Many antibiotics require renal dosing, such as
vancomycin. If youre unsure the dose call the
pharmacist.
ID approval is required for many antibiotics
such as vancomycin, levofloxacin,
ciprofloxacin. Call the ID fellow for approval
when required.
Use your Sanford Guide and hospital
antibiograms to help guide you
Sanford Guide now has an app for iphones
very useful on the wards!
Epocrates app also has useful guides

Case

A 62-year-old man with history of poorly

controlled Diabetes, HTN, and
Hyperlipidemia presents with worsening
left lower extremity pain. Physical exam
reveals cellulitis and possible wound
infection, with concern for osteomyelitis.

Factors to consider when choosing

antibiotics

patient's recent antibiotic therapy

Hospital flora
presence of underlying diseases
available culture data current AND past
risk for drug resistant pathogens:
receipt of antibiotics within the preceding 90

days
current hospitalization of 5 days
antibiotic resistance in the community
immunosuppressive disease and/or therapy
presence of risk factors for resistance

Choosing an antibiotic:

Think about Location:

Where did the patient become ill? Travel?
Exposure?
Where did the infection anatomically originate?
Where in the body, has or will the infection
spread to?

Think about the bug you are treating:

Consider
your bugs!
What are
you treating
or covering
empirically?

Antibiotic classes

Beta-lactams*
Aminoglycosides
Quinolones*
Macrolides*
Lincosamides*
Metronidazole*
Glycopeptides
Oxazolidinones
Streptogramins
Lipopeptides
Tetracyclines
Chloramphenicol
Polymyxins
Sulfonamides
Trimethoprim
Rifamycins
Nitrofurantoin

* These groups will be reviewed

further

B-Lactams: Penicillins

Penicillin
Use: pneumococcus, strep, enterococcus, N. meningitidis, syphilis,
listeria, leptospirosis and oral anerobes: peptostreptococcus and
prevotella
Amoxicillin
Use: Covers same stuff as penicillin and expanded activity against
gram negatives ( E.coli, Proteus,H. influenza, H. pylori, N.
meningitidis, shigella, klebsiella); covers most spirochetes including
lyme disease. Clavulanate enhances the gram negative spectrum to
include additional anaerobes such as bacteroides.
Oxacillin/Nafcillin/Dicloxacillin
Use: Only good for staphylococcal spp (except MRSA),
pneumococcus and other streptococci
Piperacillin and Ticarcillin
Use: Piperacillin covers pneumococcus, streptococcal spp including
enterococcus, gram negative including pseudomonas.
Does not cover MRSA.

B-Lactams: Cephalosporins
1st generation
Cefazolin:
Use: staph, non-enterococal strep; prophylactic in clean
surgeries, cellultis, folliculitis
Limitations: respiratory tract infections, animal bites or surgeries
involving the colon
2nd Generation
Cefuroxime:
Use: respiratory infections--Strep pneumoniae, H.influenzae and
M.cattarhalis; , meningitis due to pneumococcus,H.flu and
N.meningitidis.
Limitations: enteric organisms/abdominal anaerobes
Cefoxitin/Cefotetan:
Use: intra-abdominal infections especially anerobes
Limitations: staph and other gram positives

B-Lactams: Cephalosporins
3rd Generation

Cefotaxime & Ceftriaxone:

Use: Good for staph and non-enterococcal strep; broad
coverage of gram negative and oral anaerobes, CNS,
pulmonary, endovascular, GI infections (excluding gut
anaerobes), sinusitis, otitis, head & neck.
Limitations: does NOT cover Pseudomonas; ceftriaxone can
cause biliary sludging and limits its utility in treating biliary tree
infections

Ceftazidime:
Use: Good gram negative coverage including Pseudomonas;
febrile neutropenia CNS infections- good for Pseudomonas
meningitis
Limitations: reduced activity against the gram positives and oral
anaerobes.
4th Generation

Cefepime & Cefpirome:

Use: Enterobacter, Citrobacter and Serratia;Pseudomonas; gram
positives; used in neutropenic fever and CNS infections.

Beta-Lactams: Carbapenems

Imepenem:
slightly more activity against gram positive
bacteria than meropenem or ertapenem
Ertapenem:
Good for aerobic gram negatives
poor coverage of pseudomonas ,E. faecalis,
nocardia
Meropenem:
Good for aerobic gram negatives
Doripenem:
Good for CNS coverage and pseudomonas

Beta-Lactams

Cautions:
Beta-lactam allergy can occur in up to 10%
5%-10% cross-sensitivity in penicillin,

cephalosporins, and carbapenems

Side effects:
diarrhea, nausea, rash

Quinolones:

Ciprofloxacin:
Use: Covers most aerobic gram negatives including

Pseudomonas.
penetrates CNS, prostate, lungs
Limited against staph
Non-ciprofloxacin quinolones: Ofloxacin, Levofloxacin,
Moxifloxacin: Gemifloxacin:
Use: Great for respiratory pathogens, most enteric gram
negatives
Only levofloxacin covers pseudomonas
Covers some atypicals: Mycoplasma, Chlamydia, Legionella

Cautions:
Can cause Qt prolongation, tendon rupture, CNS toxicity
Do not use in patients with epilepsy or existing CNS lesions or

inflammation

Side effects:
Commonly causes C diff

Macrolides:
Erythromycin, Clarithromycin, Azithromycin
Use:
Broad spectrum against gram positives including
strep, staph aureus (MSSA)
Good for atypical oganism such as Mycoplasma,
Chlamydia, Legionella
Covers N.gonorrhea, H flu, Legionella

Caution:
can interact with statin to cause myopathy
Can cause Qt prolongation
Side effects:
GI upset

Lincosamides: Clindamycin

Use:
Reasonable gram positive aerobic coverage against

strep and many staph including MRSA

Special role in treating strep in necrotizing fascitits
Anaerobic coverage better then penicillin but not as
good as metronidazole

Caution:
can interact with neuromuscular blocking agents

and cyclosporine

Side effects:
Diarrhea, commonly causes C difficileavoid

clindamycin if other good options exist.

Metronidazole

Use:
No aerobic activity
Does not stand alone for mixed infections
Good coverage of anaerobes
Can be used for C diff, parasites, bacterial

vaginosis

Caution:
May require reduced dose in liver disease
Can increase effect of warfarin

Side effects:
Nausea, GI toxicity, antabuse reaction with Etoh;

headache, seizure, peripheral neuropathy with

prolonged therapy.

Antibiotic Coverage Quick Guide

1. Pseudomonas:
Zosyn
Aminoglycosides
Cephalosporins: Ceftazidine,
Cefepime
Fluoroquinolones: Cipro, Levaquin
Carbipenems: Imipenem, Meropenem
Aztreonam
Colistin

3. MRSA:
Bactrim
Clindamycin
Doxycyclin
Vancomycin
Linezolid
Tigecycline
Daptomycin cannot use in lungs!

2. Anaerobes:
Flagyl PO
Clindamycin PO
Zosyn IV
Unasyn IV
Augmentin PO
Carbipenem
Moxifloxacin
Tigecycline

4. VRE:
Linezolid
Tigecycline
Daptomycin