.. ..

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
3.
trimethoprim sulfa
4.
fluoroquinolone
5. Metronidazole

-lactams


Penicillin derivatives ampicillin, amoxycillin (amoxicillin), cloxacillin,
piperacillin streptococci Gram-
positive 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
 4
Carbapenems
imipenem/cilastatin, meropenem, doripenem, ertapenem

anaerobes, Nocardia spp., imipenem rapidly
growing mycobacterium extended-
spectrum -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 non-
tuberculous 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

1. Chamber FH. Other -lactam antibiotics. In: Mandell GL, Bennett JE, Dolin R,
eds. Principles and Practice of Infectious Diseases 6th ed. Philadelphia: Elsevier-
Churchill 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):157-
63.
6. Gilbert DN. Aminoglycosides. In: Mandell GL, Bennett JE, Dolin R, eds.
Principles and Practice of Infectious Diseases 6th ed. Philadelphia: Elsevier-
Churchill 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 Streptococcus suis,
(normal host) Streptococcus pneumoniae
N. meningitides
Community-acquired, Listeria monocytogenes and above
(immunocompromised/elderly) organisms
Post-operative S. pneumoniae (esp. with CSF
leakage), Pseudomonas aeruginosa,
Coagulase-negative staphylococci,
Staphylococcus aureus, Other Gram-
negative bacilli
Acute sinusitis S. pneumoniae, H. influenzae, M. decongestant
catarrhalis, group A streptococci
paranasal sinus 1 400 mg q 24 h, levofloxacin
87 viral URI
Chronic sinusitis Prevotella spp., anaerobic strep,
Fusobacterium, aerobic streptococci,
P. aeruginosa, S. aureus, & M.
catarrhalis
Acute Group A, C, G streptococci, virus
phayngitis/pharyngotosillitis ( EBV infectious mg qid
mononucleosis), C. diphtheria,
Arcanobacterium haemolyticum, M.
pneumoniae
Ceftrixaone 2 g IV q 12 h Cefotaxime 2 g IV q 4-6 h
Vancomycin 500-750 mg IV q Vancomycin 500-750 mg IV q
6h 6h
Add ampicillin 2 g IV q 6 h to
the above regimen
Ceftazidime 2 g IV q 8 h + Cefepime 2 g IV q 8 h or
vancomycin 500-750 mg IV q 6 meropenem 2 g IV q 8 h +
h vancomycin 500-750 mg IV q
6h
Amoxycillin/clavulanate
2000/125 mg bid, moxifloxacin
750 mg q 24 h x 5 days or 500
high dose mg q 24 h x 14 days,
amoxicillin (1 g tid) cephalosporins (cefdinir,
cefditoren 200 mg bid)
Antibiotic not effective, need
otolaryngologic intervention
Penicillin V 500 mg bid or 250 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 Atypicals (Mycoplasma. pneumoniae, Azithromycin 0.5 g X 1 then Doxycycline 100 mg bid
pneumonia), no co-morbidity Chlamydia pneumoniae, Legionella 0.25 g per day, clarithromycin Levofloxacin 750 mg/d or
pneumophilia), S. pneumoniae, virus 500 mg bid moxifloxacin 400 mg/d

Alcoholism S. pneumoniae, anaerobes, Gram- 3rd generation cephalosporin Levofloxacin or moxifloxacin

COPD
Post obstruction of airways
Post influenza
Exposure to tropical
environment/multiorgan
involvement (aseptic
meningitis, hepatitis,
nephritis)
Diabetes, thalassemia,
chronic kidney disease,
farmer,
negative rods
H. influenza, M. catarrhalis, S.
pneumoniae
S. pneumoniae, anaerobes
S. pneumoniae, S. aureus
Leptospira spp., Rickettsia spp.
Melioidosis
12-15 mg TMP/kg/d
clindamycin
3rd generation cephalosporin Levofloxacin or moxifloxacin
Amoxycillin-clavulanate 3rd generation cephalosporin
clindamycin
2nd - 3rd generation
cephalosporins
3rd generation cephalosporin +
doxycycline or azithromycin
Ceftazidime 2 g IV q 8 h Imipenem/cilastatin,
trimethoprim-sulfamethoxazole meropenem

(
)

tuberculosis

Gram negative

Interstitial pneumonia Pneumocystis jirovecii (PCP) Trimethoprim/sulfamethoxazole Clindamycin 600 mg q 8 h +
15 mg/kg/dayTMP q 8-12 h primaquine 30 mg q 24 h
 pO2 <70 mmHg
prednisolone 40 mg bid 5
20 mg bid 11
pneumonia

HIV

oral candidiasis
oral hairy leukoplakia


(

viral
pneumonia)
Healthcare-
associated/ventilator-
associated, early onset 5

Healthcare- A. baumannii, P. aeruginosa, K. A. baumannii: A. baumannii: colistin,
associated/ventilator- pneumoniae, E. coli (with or without cefoperazone/sulbactam P. tigecycline
associated, late onset 5 ESBL production), Enterobacter spp., aeruginosa: antipseudomonal P. aeruginosa: carbapenem
MRSA penicillin/cephalosporins, K. MRSA: linezolid
pneumoniae, E. coli: 3rd
(Gram generation cephalosporins
 negative coccobacilli A.
baumannii, GNR
capsule P. aeruginosa,
GNR
capsule
Enterobacteriaceae K.
pneumoniae, E. coli,
Enterobacter spp.
Aspiration pneumonia Anaerobes
Bacterial endocarditis
Acute Host: IV drug users
Clinical: sepsis or blood-
borne pneumonia, congestive
heart failure common
Sub-acute Host: valvular heart disease
Clinical: prolonged fever (2-
4 weeks), embolic
phenomena
Intra-abdominal infection
fluoroquinolone; carbapenem
fluoroquinolone
ESBL, Enterobacter
spp.: piperacillin,
fluoroquinolone
MRSA: vancomycin,
teicoplanin
Clindamycin High dose penicillin G,
Amoxycillin/clavulanate
S. aureus (MSSA) Cloxacillin 2 g IV q 4 h X 4-6 Cefazolin 2 g iv q 8 h +
weeks + gentamicin 1 mg/kg q gentamicin 1 mg/kg q 8 h X 3-
8 h X 3-5 days 5 days
Viridans streptococci, enterococci Ampicillin 2 g IV Q 4 h Ceftriaxone + gentamicin 1
mg/kg q 8 h X 3-5 days
penicillin 3 mU iv q 4 h +
gentamicin 1 mg/kg q 8 h X 3-5
days (
major
emboli, heart failure)
Enterobacteriaceae anaerobes Third-generation cephalosporin
metronidazole
Complicated intra-abdominal
infections ( post-operative
infections)
Osteomyelitis
Septic arthritis
Normal host
Steroid user
Prosthetic joint
Cellulitis/necrotizing fasciitis
Salt- or fresh-water
including water animal
exposure
Animal bite
Previous surgery of the
affected limb, impaired venous
or lymphatic drainage
Community-acquired sepsis,
unknown primary site
Community-acquired sepsis,
unknown primary site
Enterobacteriaceae anaerobes, P.
aeruginosa, A. baumannii,
enterococci
S. aureus Cloxacillin 2 g IV q 4 h
epidural
space (epidural abscess)
empiric
S. aureus
Salmonella spp.
Staphylococci, Streptococci, GNR
Vibrio vulnificus, Aeromonas spp.,
other Gram-negative bacilli
Pasteurella multocida
Streptococcus pyogenes
E. coli, S. pyogenes, S. agalactia
(group B streptococci), Salmonella
spp. (esp. in HIV infected patients),
S. suis (
) IV q 8 h + gentamicin 5.1
Diabetes, thalassemia, B. pseudomallei
chronic kidney disease,
Anti-pseudomonal penicillin, Anti-pseudomonal
cephalosporins, or carbapenems
fluoroquinolone
Cloxacillin 2 g IV q 4 h
Ciprofloxacin 400 mg IV q 12 h Ceftriaxone 2 g IV q 24 h
3rd generation cephalosporins,
fluoroquinolones
Amoxycillin/clavulanate, Doxycycline
ampicillin/sulbactam
Penicillin, clindamycin
Ceftriaxone 2 g IV q 24 h Cefuroxime 750 mg IV q 8 h,
Amoxycillin/clavulanate 1.2-
2.4 g IV q 8 h,
ampicillin/sulbactam 1.5 3 g
mg/kg q 24 h
Ceftazidime 2 g IV q 8 h Imipenem/cilastatin,
trimethoprim-sulfamethoxazole meropenem
12-15 mg TMP/kg/d
 farmer,
(
)
Acute febrile illness without Leptospirosis ( )
localizing sign
scrub typhus (
) 1
murine typhus (
interstitial
pneumonia, aseptic )
meningitis, encephalopathy,
abnormal liver enzymes,
carditis Dengue virus infection leptospirosis
Rickettsia
doxycycline 100 mg q 12 h