PCN Penicillin Oxacillin Amipicillin Amoxicillin P1 P2 P2 P2

Ticarcillin/Timentin P3 Piperacillin/Tazocin P3 P4 P4

Augmentin(Amoxicillin+Clavulanate) Unazym(Ampicillin+Subactam) 1s- Cefazolin 2nd-Cefuroxime/Cefoxitin

rd

Cephalosporin P5 P5

3 -Cefotaxime/Ceftriaxon(Rocephin ) P5 3rd-Ceftazidim) 4 -Cefepime

th

P6 P7

Carbapenem Carbapenem(Imipenem)/ Tienam Meropenem Ertapenem P8 P8 P8 P9 P9 P10 P10 P10 P10 P11 P12 P13

Macrolide Clindamycin Tetracycline Chloramphnicol Metronidazole Aminoglycoside Vancomycin Quinolone

Reference: / by

Written by YM Med99
2010.04

-lactam Penicillin G(+) Anaerobic(Oxacillin !!) Enterococcus( abx: PCN Ampicillin + GM Streptomycin + VM )

Penicillin GPC Staph. aureus(99%)X Streptococcus. spp. Enterococcus. spp. GPB Listeria monocytogenes Atypical Syphillis Lyme -hemolytic(GBS) Streptococcus viridians s. S. Bovis Endocarditis!! Colorectal ca!! S. constellatus S. anginosus PCN

Leptospirosis GNC Niesseria meningitis(+/-) [severe3rd Cefa]

S. intermedius [ Abscess ] Streptococcus agalactiae :/ :A-AIDS B-Beer() C-Cirrhosis D-DM -hemolytic(GAS) GAS: S.pyogens [/Cellulites/Necrotizing fasciitis][] [ PCN allergyCefa/Clinda] MIC Non-CNS (pneumonia) CNS (meningitis) High PCN S. pneumonia S PCN I High PCN
rd th

Anaerobic (Ccr/7)+4=renal dose(daily dose) Aspiration pneumonia/Lung abscess CAP(Community-acquired pneumonia) Strept. bacterial meningitis Syphillis endocarditis

R High PCN

3 /4 Cefa +Vancomycin

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Oxacillin PCN-ase resistant PCN Staphylococcus. Aureus!!(MSSA)[:MRSA:Vancomycin]

( !) 50-100mg/kg day SSTI

100-150(150)mg/kg day Bacteremia(ex: 2gm q8h) 150-200(200)mg/kg day(Mycotic aneurysm/ Endocarditis) (meningitis/Brain abscess) (osteomyelitis /septic arthritis) (prostitis)

Oxacillin sodium base(CHF)(Cirrhosis)(Nephrotic syndrome) -lactam -Fever/skin rash -Bone marrow/Plt/WBC/Agranulocytosis -CNS toxicity/Myclonus -AIN(Acute interstitial nephritis)
-Hepatitis( -lactam 2:Oxacillin/Ceftriaxone)

Oxacillincholestasis Jaundice Ceftriaxonehepatocyte cytoxic GOT/GPT

Ampicillin (40% absorption) [4-12gm] Amoxicillin(95% absorption,)[250-500mg q8h] GPC(Enterococcus sp.) GPB(Listeria) G(-) E-E. coli P-P. mirabilis H-H. influenza -lactamase(+): -lactamse inhibitor -lactamase(-): Ampicillin S-Samonella/Shigella K-K. pneumonia K. pneumonia wild type: Ampicillin/Piperacillin !! Cefalosporin !!

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3rd PCN Ticarcillin Ticarcillin 3gm+ Clavulanate 200mg = Timentin 4th PCN Piperacillin PCN Anti-pseudomonass !!! pseudo GNB !!! E-E. coli P-P. mirabilis H-H. influenza

: Anti-pseudomonass!! 1. PCN 2. Cefa 3rd-Ceftazidime (Fortum) 4th-Cefepime Levofloxacin Ciprofloxacin Imipenem(+Cilastatin =Tienam) Meropenam 3. Quinolone 3rd -Ticarcillin 4th-Piperacillin

S-Samonella/Shigella Piperacillin+GM/Amikacin +WBC GNB (ex:Pseudomonas Endocarditis/UTI/pneumonia) !! pneumonia pseudomonas GNB cover !!

4. Carbapenam

Tazocin= Piperacillin + Tazolactam Piperacillin pseudo GNB ! Tazolactam ! Piperacillin(2000mg) pseudomonas Tazocin(4 PCN) Cefepime(4 cefa)
th th

other GNB

Tazolactam(250mg): GNB !!! G(+) G(-) pseudomonas OK! OK!

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+-lactamase inhibitor Augmentin (Amoxicillin+ Clavulanate) Clavulanate Amoxicillin 250mg+ 125mg clavulanate (oral ) Amoxicillin 500mg+ 125mg clavulanate (oral ) Amoxicillin 1000mg+ 200mg clavulanate (IV ) Augmentin/Unazym bacteria load GPC(S.aureus/ Strepto. viridian/Strpto. pneumonia ) GNB ( Amoxicillin/Ampicillin ) E-E. coli/ P-P. mirabilis/H-H. influenza/K-K. pneumonia

Unazym(Ampicillin+Subactam) Ampicillin 1000mg + 500 mg subactam (IV) Unazym Ampicillin 1000mg PCN 1.5MU pneumonia( PCN 3MU q6h) 1.5amp Unazym+1.5 MUPCN =3MU Ampicillin 500mg + 250 mg subactam(oral)

Augmentin (polymicrobial)/ Acute tonsillitis/ sinusitis/AOM Deep neck infection CAP Aspiration pneumonia, lung abscess COPD with acute exacerbation DM foot, pressure sore // (Ex: PPUperitonitis) PID

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Cephalosporin G(-) Anaerobic (: Cefa 2nd Cefa: Cefoxitim) Enterococcus(!!!) 1st Cefazolin GPC Staphylococcus aureus group A strept. (GAS)/Streptococcus pneumonia E-E. coli /P-P. mirabilis/ K-K. pneumonia

GNB

GPC Enterococcus(Cefa !!) GNB H-H. influenza Pseudomonass Enterobacter 2nd [G(-) > G(+)] [+ H. influenza/ + M. cartarrhalis]

Cefuroxime = 1st Cefa+ H.influeza Cefoxitin = Cefuroxime + Cefa cover Anaerobic !!! 3rd

Ceftzidime group G(+): Strep. pneumonia /Strep. viridan G(-): 2nd Cefa + GNC(Niseeria) + PECK group H-H. influenza N-N.gonorrhoea/N. meningitis M-Morexalla cartarrhalis

PECK group Cefotaxime (q8h) Ceftriaxone(Rocephin ) (qd)

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Ceftazidime group : 3rd G(-) G(+) G(+): (!!!) G(-): = 3rd Cefa + pseudomonas+ Enterobacter

Ceftazidime (q8h)

3rd Cefa( Cefotaxime, Ceftizoxime, Ceftriaxone) GNB Empirical S.pneumoniae therapy

Salmonellosis (: salmonella abx: ABCCC) Gonorrhea

3rd Cefa

Ceftriaxone: pseudo/ GPC Ceftazidime: pseudo/ GPC !

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 ESBL(Extended spectrum -lactamase) 3rd Cefa 4th Cefa!! ESBL---Extented Spectrum -Lactamase: GI/GU infection! E. coli K. pneumonia 4th Cefepime ( 3rd Cefa) G(+) = Cefotaxime G(-) = Ceftazidime

Cefpirome

4th Cefa( Cefepime) Neutropenic fever AmpC - lactamase bacteria infection P.aeruginosa Enterobacter spp Serratia marcescens Citrobacter spp Indole-positive Proteus Providancia spp. M.morganii

4th Cefa v.s 4th PCN

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Carbapenem G(+):OK! G(-):OK!( pseudomonass) Anaerobic: OK! (Clostridium difficle) MRSA VRE Enterococcus faecium Stenotrophomonas maltophylia Burkholderia cepacia

Carbapenem(Imipenem) Imipenem + cilastatin = Tienam(Mepem) anti(G+ G- Anaerobic 90%) Tienam ( aminoglycoside &) Cefa pseudomonas Neutropenic fever(as monotherapy) Acinetobacter ESBL(ex: E.coli/ K. pneumoniae) AmpC -lactamase bacteria: Enterobacter.spp/ pseudomonass

Tienam ? Pseudomonas pneumonia MRSA/VRE/Enterococcus faecalis

Meropenem Imipenem ( imipenem pseudomonas )( GPC) CNS infection Ertapenem ESBL!! pseudomonas !! AB !

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Macrolide Mycoplasma Legionella Chlamydia

Rhickettsiae S.A/Strep.viridan N.meninigitis/N. gonorrhea H. influenza

Erythromycin Azithromycin [ ] > [ ] Once daily/ short-course Tx Clarithromycin H. pyloric infection Clindamycin Clindamycin GPC: Group A streptococcus/S.A Anaerobic: Toxoplasma/ Pneumocystic carinii -lactam Lung abscess/ aspiration pneumonia

CNS toxoplasmosis/ Pneumocystic carinii C.difficle diarrhea!!!!

Clindamycin + GM () (penicillin ) DM foot/ Pressure sore

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Tetracycline Rickettsia (Q fever) Spirochete leptospirosis Mycoplasma

Chlamydia Tetracycline()(250-500mg Q6H) Minocycline()(100mg Q12H) Chloramphenicol

iv GNB Anaerobic Richettsia Tetracycline Typhoid fever Aplastic anemia!!!( dose related) G6PD Metronidazole

/( abx !!) Anaerobic infection Loading:15mg/kg Amebiasis!! 750mg TID 10 Aminoglycoside Maitain:7.5mg/kg q6h C. difficle colitis!! 250mg TID 7~10

/ BBB

Streptomycin GM !!

Amikin: !!! GPC: S.aureus/ Enterococcus! GNB: ( Enterobacter/ Pseudomonas/Acinetobacter) For Synergestic effect: q6h/q12h (ex: 80mg q12h) Ex: Enterococcus Amipicillin()+ GM()

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For Treatment: qd ( frequency) GM Loading Maintain 2mg/kg st ex: 60kg=120mg/day 3-5mg/kg(full dose) x(Ccr/100) Maintainance: Ccr!! Amikin: 500mg Q(Cr X 9) hour Amikacin 7.5mg/kg st 15mg/kg(full dose) x(Ccr/100)

[]Conventional

Loading Maintain

GM: 80mg Q(Cr X 8) hour

[]Once-daily Once-daily

GM 3-5mg/kg QD CCr >50: QD/ 40~50: Q36H/ 30~40:Q48H

Amikacin 15mg/kg QD GM Toxic Peak Trough >12 ug/ml 6-8 ug/ml Amikacin 35ug/ml 25-30ug/ml

: 50kg + 0.9 * (height-152.4) : 45kg + 0.9* (height-152.4) Ccr = [(140-Age) x BW] ( x0.85) 72xCr Vancomycin For G(+): MRSA!! G(-):!!

1.5-2ug/ml 4-6ug/m

Anaerobic: G(+) OK!! (ex: C. difficile/ C. perfingens)

Vancomycin MRSA Prosthesis / CNS shunt Red man syndrome Flushing /BP/(histamine release) slow drip 500mg iv 60 / anti-histamine /

Teicoplanin Vancomycin/ IM OK Vancomycin / Teicoplanin ORSA OSSA -lactam S.epidermidis Enterococci C. difficile
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Quinolone . 1 2nd -Ciprofloxacin 3 -Levofloxacin 4 Moxifloxacin Tendinitis / !! QT-prolong (Cipro-/Moxi-) Antacid(MgO/Al2OH3/H2-blocker/PPI) UTIs. bacterial prostatitis bacterial diarrhea gonorrhea and chancroid. Pneumonia skin and soft tissue infection osteomyelitis caused by susceptible bacteria
th rd st

Pseudomonas!! G(-) Cipro +G(+) GU tract infection Levo+!!

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Dosage adjustments of drugs in renal failure

Adjusted dosing interval (hrs) or % dose Creatinine clearance (ml/min) Medication Aminoglycosides Amikin 5~7.5mg/kg
(loading dose)

During <10 Dialysis 250mg TIW AD

Dose

> 50 60~90% Q12H 60~90% Q8~12H 50~90% Q12H Q8~6H

10~50 30~70% Q12~18H

20~30% Q24~48H

Gentamicin

1.5~2mg/kg
(loading dose)

30~70% Q12H

20~30% Q24~48H (20~30mg QN)

2/3normal dose AD 2/3normal dose AD With 0.6 gm after each H/D

Netilmicin Penicillins AmoxicillinClavulanate (Augmentin) Ampicillin inj. AmpicillinSulbactam (Unasyn) Oxacillin Penicillin G

1.5~2mg/kg
(loading dose)

20~60%Q12H

10~20% Q24~48H

1.2gm

Q12H, LD:1.2gm IV, then 0.6 gm IV Q12H(10~30ml/min)

LD:1.2gm IV , then 0.6 gm IV q24H Q12H Q24H

0.5~2 gm 1.5~3 gm

Q4~6H Q6H

Q8H Q8H
(30~50ml/min),

Q12H
(15~29ml/min)

0.5~2 gm 0.5~4 MU

Q4~6H Q4~6H

N Q6~8H

Reduce dose in the elderly 0.5~2 MU Q6H

6MU/day upper limit dose in ESRD

Piperacillin PiperacillinTazobactam (Tazocin) TicarcillinClavulanate (Timentin)

3~4 gm 2.25gm

Q4~6H 4.5 gm Q8H

Q6~8H 2.25 gm Q6H

2 gm Q8H 2.25 gm Q8H H/D: dose for CrCl <10 +0.75gm AD

1.6~3.2 gm

Q6~8H

Q8H, 1.6 gm Q8H

(10~30 ml/min)

1.6 gm Q12H

H/D: dose for CrCl <10 + 3.2 gm AD

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Cephalosporins Cefazolin 0.5 gm~2 gm Q8H 0.5~1 gm Q8~12H 0.5~1gm Q18~24H H/D:0.5-1gm AD CAPD: 0.5gm q12h Cefmetazole Cefoxitin Cefepime Cefoperazone Cefotaxime Ceftazidime 1~2 gm 1~2 gm 0.5~2 gm 1~2 gm 0.5~2 gm 1~2 gm Q6~12H Q8H Q12H Q8~12H Q8~12H Q8~12H Q12~24H Q12~24H 1~2 gmQ24H N Q12~24H Q12~24H Q48H 0.5~1gm Q12~48H 0.5~1 gm Q24H N Q24H 0.5~1 gm Q24 H/D:1gm AD H/D:1gm AD H/D:1gm AD H/D:1gm AD During <10 LD: 1gm, then 0.5 gm q24H 1 gm Q24H Q24H Dialysis H/D: 0.5gm Q24H +0.25gm AD 1~2 gm Ceftriaxone Flomoxef Cefaclor 0.5~2 gm 1~2 gm 250~500 mg Q8H Q12H Q12H Q8H 1 gm Q12H Q12~24H 1gm AD H/D: dose AD H/D:1gm AD

Adjusted dosing interval (hrs) or % dose Creatinine clearance (ml/min) Medication Cefpirome Dose 1~2 gm > 50 Q12H 10~50 LD: 1gm, then 0.5 gm BID

Require dosage reduction 50%~100% normal dose 50% normal dose H/D: 250mg AD CAPD: 250mgQ8-12H

Cephalosporins(oral form)

Cefadroxil

0.5~1 gm

Q12H

LD: 1gm, then 0.5 gm Q12h (25-50ml/min); LD: 1gm, then 0.5 gm Q24h (10-25ml/min)

LD: 1gm, then 0.5 gm Q48h

H/D: 0.5~1 gm AD CAPD: 0.5 gm/day

Ceftibuten Cephalexin

400mg 250-500mg

QD Q6H

200mg QD Q8~12H

100 mg QD Q12H

H/D: 300mg AD

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Carbapenem Imipenem 0.5 gm Q6~8H 0.25 gm Q6~12H 0.25 gm Q12H H/D: 0.25gm AD +q12H Meropenem Quinolones Ciprofloxacin Levofloxacin(po) 400mg In URI 500mg In UTI 250mg Ofloxacin Pefloxacin 400mg 400 mg Q12H QD 200~300 mg Q12H LD: 500mg ,then 250mg QD QD Q12H Q12H QD 200 mg Q12H N 200mg Q12H LD: 500mg ,then 250mg Q48H LD: 250mg ,then 250mg Q48H 200mg Q24H 50% (in the elderly) Other anti-bacterial drugs Aztreonam Bactrim 1~2 gm 2 amp Q8H Q12H Q12H Ccr < 30 ml/min Half the dose Clindamycin Erythromycin lactobionate IV Metronidazole Minocycline 0.5gm 100 mg Q6~8H Q12H N N N N 0.3~0.9 gm 0.5~1 gm Q6~8H Q6H N N N N Q24H avoid 0.5 gm On dialysis patient, 2 amp after each H/D H/D: 100mg q12H H/D: dose For CrCl<10 1 gm Q8H 0.5 ~1gm Q12H 0.5 gm Q24H H/D: Dose AD

Adjusted dosing interval (hrs) or % dose Creatinine clearance (ml/min) Medication Teicoplanin (Targocid) Vancomycin Dose 400 mg (12 mg/kg as loading dose) 1 gm, (15mg/kg as loading Dose) Q12H Q24~48H 1gm Q1wk (add 1gm on 4 day)
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th

During <10 Dialysis N

> 50 Q24H

10~50 200mg Q24H

400 mg Q72H

Aantifungal drugs Amphotericin B Fluconazole Itraconazole Ethambutol Isoniazid Pyrazinamide Rifampin Antiviral drugs Acyclovir IV 5~10 mg/kg Q8H Q12H
(26~50ml/min),

0.4~1mg/kg/da y 100~400mg 100~200mg 15 mg/kg/day 5 mg/kg/day 25 mg/kg/day 10 mg/kg/day

Q24H Q24H Q12H 100% 100% 100% 100%

Q24H 50% Q12H 10mg/kg/day 100% 100% 100%

Q24~48H 25% Q24H 7.5mg/kg/day 50% 50% 100% 2.5~5mg/kg/QD

N 200mg AD N

Antituberculous drugs

Dose AD

Q24H
(11~25ml/min)

Acyclovir PO

200mg

Q4H, 5x /day

Q4H, 5x /day

Q12H

Amantadine PO

100 mg

BID

200 mg on 1st day, then 100mg QD

(30~50 ml/min),

200mg Q7 day

200 mg on 1st day, then 100 mg Q2D

(15~29 ml/min)

Ganciclovir IV

5mg/kg

Q12H
(70 ml/min), (50~69 ml/min)

2.5 mg/kg Q24H

(25~49 ml/min), (10~24 ml/min)

1.25 mg/kg after each H/D

2.5 mg/kg Q12H 1.25 mg/kg Q24H Lamivudine PO Valacyclovir PO Antilipemic drugs Acipimox Bezafibrate (Bezalip) Gemfibrozil 600 mg BID 300 mg BID 300 mg QD 150mg 1 gm 250 mg 200 mg BID Q8H BID~TID TID 100 mg~150 mg QD Q12~24H BID~QD BID~QD 0.5 gm Q24H QD~Q2D QD~Q2D Dose AD 25~50 mg QD Dose AD

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Antiulcer drugs Cimetidine IV PO 300 mg 400 mg Q6H BID Q8H BID Creatinine clearance (ml/min) Medication Ranitidine IV PO Captopril Enalapril Fosinopril Lisinopril Perindopril Quinapril Acebutolol Atenolol Nadolol Opioid analgesics Codeine Meperidine Morphine Other drugs Allopurinol Colchicine
rd

Q12H HS During <10 Q24H HS 50% 50% N 25% 50% 25% 25% 25% 50% 50% 50% 10~25% 50% N Y Y Y Y N Y Dialysis

Adjusted dosing interval (hrs) or % dose Dose 50 mg 150 mg 25 mg TID 5~20 mg QD 10 mg QD 10 mg QD 4 mg 10 mg QD 400 mg BID 100 mg QD 80 mg QD > 50 Q6 ~8H BID N N N N QD N N N N N N N N N 10~50 Q8~12H BID N 75% N 50% 2 mg QD 75% 50% 50% 50% 75% 75% 75% 50% N

Angiotensin-converting enzyme inhibitors

2 mg Q2D on dialysis day

Beta-adrenergic antagonists

1. Drugs facts and comparisons 53 ed.1999 2. MICRODEX (http://ccis.vghtc.gov.tw/) 3. Mandell, Douglas and Bennetts principles and Practice of Infectious Diseases 4 th ed. 1995 4. Richard E. Reese and Robert F. Betts, A Practical Approach to Infectious Diseases 4 th ed.,1996 5. The SANFORD Guide to Antimicrobial therapy, 1999 H/D= hemodialysis, AD= after hemodialysis, Y= Yes, N= None LD= loading dose

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