PHARM_MOD_II_DOC_BAC

P.O. MACROLIDE

(AZITHROMYCIN OR CLARITHROMYCIN)

P.O. "RESPIRATORY" FQ = LEVOFLOXACIN

OR

• MOXIFLOXACIN
• (A "RESPIRATORY" FQ IS A FQ GOOD ACTIVITY AGAINST STREP PNEUMO)

I.V. CEFTRIAXONE or I.V. CEFOTAXIME

PLUS

I.V. OR P.O AZITHROMYCIN

OR

I.V. MOXIFLOXACIN OR LEVOFLOXACIN

I.V. MOXIFLOXACIN OR LEVOFLOXACIN

I.V. PIPERACILLIN - TAZOBACTAM,

OR

I.V. CEFEPIME

I.V. PEN G

SEND HOME ON P.O. AMOXICILLIN

2ND GEN CEFOXITIN AND CEFOTETAN

Tx PID AND INTRA-ABD INF

DOC FOR INTRA-ABD SURGERY

I.V. CEFOTAXIME

OR

I.V. CEFTRIAXONE

I.V. VANCOMYCIN,

OR

I.V. MOXIFLOXACIN

OR

HIGH-DOSE I.V. LEVOFLOXACIN

INH PROT SYNTH - 30S; STATIC

MOD G+, POOR G-

• G+
• --65% STAPH AUR INCLUD MRSA
• --STREP, BUT NOT GrpB, SO COMBO AMOX OR CEPHALEXIN FOR SSTI

• EXCEL INTRACELLULAR
• --MYCOPLASMA
• --CHALMYDIA
• --RICKETTSIA
• --ATYP PNEUMO ie legionella

• OTHERS
• --BORRELIA
• --YERSNIA
• --ENTAMOEBA HISTO
• --PLASMOD FALC (MALARIA)

ACNE Tx -- MINO

BUG RESISTANCE THROUGH CHANGED BINDING SITE OR EFFLUX PUMP

• WIDESPREAD USE IN LIVESTOCK INC R
• -----------------------------------------------------

• KINETICS
• --BOTH IV AND PO (NO PO TIGE
• --DO NOT GIVE w MILK, MULTI-VIT, Ca, Mg, Al, Fe, bc CHELATE & PREVENT ABS
• --F OF DOXY & MINO 100%, LONG t1/2
• --HIGH CONC IN BILE (CHECK LFTs)
• --MINO --> PARTLY MET IN LIVER
• --DOXY ELIM FECALLY, SO DOC FOR RENAL DYSF
• ---------------------------------------

• TOX
• --N/V esp TIGECYCLINE
• --REDUCED w FOOD BUT CATIONS AFFECT ABS
• --TEETH DISCOLORATION AND BONE FORMATION. DONT GIVE PREGOs OR <15yrs
• --PHOTOSENSITIVITY
• --LARGE DOSE HEPATOTOXIC
• --SUPERINFECTIONS ie C.DIFF

• --PRSP (PENICILLIN-RESISTANT
• STREPTOCOCCUS PNEUMONIAE)

--PENICILLIN, 2ND GENERATION CEPHALOSPORINS, E.G., CEFUROXIME, MACROLIDES, TETRACYCLINES AND TRIMETHOPRIM/SULFAMETHOXAZOLE.

I.V. AZITHROMYCIN,

OR

I.V. LEVOFLOXACIN OR MOXIFLOXACIN

• TRIMETHOPRIM-SULFAMETHOXAZOLE
• (LARGER THAN NORMAL DOSES)

I.V. OR P.O. CLINDAMYCIN

• P.O. MACROLIDE
• (CLARITHROMYCIN, OR AZITHROMYCIN)

P.O. CLINDAMYCIN (TEXTBOOKS)

P.O. FQ = LEVO OR MOXI (REAL WORLD)

I.M. PROCAINE PEN G,

OR

I.M. BENZATHINE PEN G

DO NOT GIVE I.V.!!!

I.V. PIPERACILLIN-TAZOBACTAM

I.M. BENZATHINE PENICILLIN

I.V. PENICILLIN G

SINGLE DOSE P.O. CEFIXIME,

OR

I.M. CEFTRIAXONE

(IN THE ER, ABOUT 50% OFPATIENTS WILL RECEIVE P.O. CEFIXIME AND 50% WILL RECEIVE I.M. CEFTRIAXONE - IT HURTS!)

COVERS G+ INCLUDING ANAEROBES

NO G-

DOC FOR SEVERE MRSA, AMP-R ENTERO

LARGE MOL --> NOT ABSORBED BY GUT. GIVE IV

RENAL EXCRETION / TOXICITY PROB OVERESTIMATED

OTOTOXICITY

RED-MAN SYND --> NOT ALLERGY, FROM GIVING TOO RAPIDLY --> HIST RELEASE

po VANC FOR C.DIFF ONLY IF METRONIDAZOLE-R

• 1 MONTH TO 50 yr:
• I.V. CEFTRIAXONE OR I.V. CEFOTAXIME

PLUS

I.V. VANCOMYCIN

• <1 MONTH OR > 50 yr
• ADD I.V. AMPICILLIN TO COVER LISTERIA

P.O. AMPICILLIN CAUSES DIARRHEA!!!

I.V. CEFOTAXIME,

OR

I.V. CEFTRIAXONE

I.V. PIPERACILLIN-TAZO OR I.V. CEFEPIME

PLUS

I.V. VANCOMYCIN TO COVER GRAM (+) BUGS

• I.V. OXACILLIN OR I.V. NAFCILLIN
• (TEXTBOOK = $$$)

• I.V. CEFAZOLIN
• (REAL WORLD = CHEAP)

OXACILLIN, NAFCILLIN, CLOXACILLIN, AND DICLOXACILLIN ARE ALWAYS SUPERIOR TO VANC

THEY KILL QUICKLY

• 1) iv CEFAZOLIN
• --DOC FOR srg PROPHYL, SSTI, AND MSSA (mssa better than vanc ~ cefazolin oxacillin nafcillin)

• 2) po CEPHALEXIN
• --SSTI, SAFE FOR PREG

• 3) po CEPHRADINE
• --rarely used

• 4) CEPHALEXIN & CEPHRADINE
• --rarely used

• 1) iv CEFOXITIN
• 2) iv CEFOTETAN
• --both only 2 cephs that cover anaerobes; doc for prophyl abd srgy

• 3) po CEFUROXIME
• 4) po CEFACLOR
• --both tx pedi and fp outpt

• 1) iv CEFOTAXIME*
• --renal cl, t1/2 1h, pcn-r s.pneumo ~ low mic; meningitis n.gono, b-hemo strep. h-flu

• 2) iv CEFTRIAXONE*
• --can give im, hep elim, t1/2 8h, s.pneumo & b-hemo ~ low mic; meningitis

• 3) iv CEFTAZIDIME*
• --only 3rd for pseudomonas and 'bacters. w genta until S known. no g+

• 4) iv CEFTAROLINE*
• --mrsa and 'triaxone-r s. pneumo

• 5) po CEFPODOXIME
• --bitter taste, kids spit up. uti

• 6) po CEFDINIR
• --good taste; strep pneumo. otitis media after no-go amox or amox+clav

• 7) po CEFIXIME
• --oral n. gono, uti. no good s. pneumo or mssa

*GOOD CNS ~ MENINGITIS

iv CEFEPIME

INC R TO b-LACTAMASES

GOOD PSEUDOMONAL ACTIVITY

EXCELLENT G- & MOD G+

1st + 3rd = 4th

GOOD CNS ~ MENINGITIS

BETTER 'BACTER COVERAGE THAN CEFTAZIDINE

P.O. DICLOXACILLIN,

OR

P.O. CEPHALEXIN

P.O. CLINDAMYCIN,

OR

P.O. DOXYCYCLINE

P.O. CLINDAMYCIN,

OR

P.O. TRIM-SULFA,

OR

P.O. DOXYCYCLINE

I.V. VANCOMYCIN

I.V. DAPTOMYCIN,

OR

I.V. OR P.O. LINEZOLID,

OR

I.V. CEFTAROLINE

(IF YOU SURVEYED HOSPITALS ACROSS THE USA, THE DOC WOULD BE 1/3 DAPTO, 1/3 LINEZOLID AND 1/3 CEFTAROLINE

I.V. VANCOMYCIN,

OR

I.V. LINEZOLID

OR

I.V. CEFTAROLINE

P.O. CLINDAMYCIN

I.V. VANCOMYCIN

• I.V. PEN G
• (INPATIENT)

• P.O. AMOXICILLIN
• (OUTPATIENT)

CLAVULANATE

SULBACTAM

TAZOBACTAM (tazo)

P.O. AMOXICILLIN,

OR

P.O. AMOXACILLIN +CLAVULANATE,

OR

P.O. CEFDINIR

SAME MOA AS PCNs, BUT GIVEN IV ONLY

COVER MANY NOSOCOMIAL G- RODS

GOOD TISSUE PENETRATION

DRUGS OF LAST RESORT FOR MULTI-RESISTANT BUGS (FAILED PIP-TAZO OR CEFTEPIME)

MULTI-BUG & LIFE-THREATENING INF ex INTRA-ABD TRAUMA AND NOSOCOM INF BY CITROBACTER, ENTEROBACTER etc

MAY CROSS-REACT WITH 10-15% PCN ALLERGIC Pt

DIHYDROPEPTIDASE (DHP) INHIBITOR

DHP = RENAL ENZYME

IMIPENEM (CARB) + CILA = PRIMAXIN

COVER G- RODS ex PSEUDOMONAS

GIVEN IV IN ICU

TREAD PSEUDOMONAS AND OTHER NOSOCOMIAL G-

GOOD MSSA AND STREP PNEUMO COVERAGE

EXCELLENT ANAEROBE ACTIVITY

I.V. PIPERACILLIN – TAZOBACTAM,

OR

I.V. CEFTAZIDIME,

OR

I.V. CEFEPIME

FQs INH DNA SYNTH -- TOPOISOM II & IV

RAPIDLY CIDAL

po & iv

CATION CHELATION DEC ABS

GOOD G-, BAD G+

• DOC: MDR STREP PNEUMO
• --LEVO, MOXI, GEMI. NO CIPRO
• --FQ-R IN NURSING HOMES, Tx AS IF NOSOCOMIAL ie anti-pseudomon pip-tazo or cefepime
• --IF CRITICAL ADD AMINOGLYC (GENTA) AND FQ (levo=cipro)

• G+
• MOXI=GEMI > LEVO > CIPRO

• G-
• LEVO = CIPRO = MOXI = GEMI

• ANTI-PSEUDOMONAL IF CULTURE-S 1st
• LEVO = CIPRO

• ANAEROBIC: DON'T USE
• --MOXI > LEVO=CIPRO
• --USE PIP-TAZO
• --OR FQ WITH METRONIDAZOLE

• GOOD INTRACELLULAR
• --ATYPICAL CAP

NO MRSA!!!

NO VRE OR ENTEROCOCCUS

• GROWING R IN E.COLI
• -------------------------------------

CIPRO 20% MET BY CYP 1A2 IN LIVER & MANY CYP450 INTERACTIONS including inh caffeine met

LEVO ELIM RENALLY; NO CYP450

MOXI HEP MET, BUT NO CYP450

• NO MOXI FOR UTI -- LOW po CONC IN URINE
• ------------------------------------------------

ADVERSE

MAY DAMAGE GROWING CARTILAGE

• Q-T PROLONG
• --CONGENITAL
• --DRUGS THAT INC Q-T: SOTALOL, AMLODARONE
• --TORSADE DE POINTES

TENDON RUPTURE

PHOTOTOXICITY esp CIPRO

-FLOXACIN

• TIME:
• --b-LACTAMS
• --VANCOMYCIN
• --CONC ABOVE MIC DOESN'T ENHANCE KILLING

• CONC:
• --FLUOROQUINOLONES
• --AMINOGLYCOSIDES (GENTAMYCIN, AMIKACIN, TOBRAMYCIN

ex FLUOROQUINOLONES AND AMINOGLYCOSIDES

ex TRIM-SULFA

TRIMETHOPRIM + SULFAMETHOXAZOLE

• GIVEN SINGLY = STATIC
• GIVEN TOGETHER = STATIC / CIDAL

MOA SAME AS PCNs AND BUGS GET RESISTANCE DUE TO CHANGE IN BINDING SITE

RELATIVELY RESISTANT TO B-LACTAMASES

• 1st ~ G+
• 2nd ~ G+ and some G-
• 3rd ~ G- and some G+
• 4th ~ *G- and mod G+ (1st + 3rd = 4th gen)

NO ACTIVITY AGAINST ENTEROCOCCUS, LISTERIA, PCN-R STREP PNEUMO, & MRSA. EXCEPTION ~ CEFTAROLINE FOR 'TRIAXONE-R STREP PNEUMO AND MRSA

CROSS-REACTIVE WITH PCN ALLERGIES. AS GEN INC ~ CROSS REACTIVITY DEC.

THROMBOPHLEBITIS esp CEFOXITIN

• INC PROTHROMBIN TIME (PT)
• --INH VIT K --> BLEEDING
• --esp CEFOTETAN (metabolite nmtt side chain inh vit k)

PENs (PCN's)

CEPHALOSPORINS

CARBAPENEMS

AZTREONAM

• STREPTOMYCIN
• GENTAMYCIN
• TOBRAMYCIN
• AMIKACIN

• VERY DANGEROUS
• --CONC AND TIME TOX
• --NEPHRO, 2+ wks, inc w other neph tox vanc, ampho-b, cyclospor, nsaid
• --OTO irrev, 5+ days high conc
• --ADJUST CONC DOWN FOR OBESE bc DOESN'T DISTRIBUTE INTO FAT

--IV bc POORLY ABSORBED FROM GI LIKE VANC

• IRREV INH OF PROT SYNTH
• --30S SUBUNIT
• --RAPIDLY CIDAL

• G- SEVERE INF
• --HIGH DOSE ONCE DAILY ALLOWS WASHOUT TO GIVE LIVER REST
• --nL GIVEN w ANOTHER G- DRUG ie b-lac

• G+ INF
• --NEVER USE AS MONOTHERAPY
• --LOW DOSE
• --SYNERGISTIC w PCNs CEPHs AND VANC bc THEY IHN CELL WALL SYNTH ALLOWING AGs TO ENTER CELL

• GENTA
• --ADJUST IF RENAL PROBS bc ELIM RENALLY
• --POST-ANTIBIOTIC EFFECT
• --OTO TOX
• --WIDELY USED AS EAR/EYE DROPS & TOPICAL

• NEOMYCIN
• --DECONTAMINATE GUT PRIOR TO SRGY

• BUGS R BY
• --BAC TRANSFERASE ENZ --> ADDS PHOS, ADENYL, OR ACETYL TO DRUG
• --DEC TRANSPORT INTO CELL BY PORIN MUTATION
• --CHANGE 30S BINDING SITE

• AMIKACIN
• --ACE-IN-HOLE FOR GENTA-R AND TOBRAMYCIN-R BAC

ANTI-PSEUDOMONAL b-LACTAM

PLUS

AN AMINOGLYCOSIDE

AZTREONAM -- MONOBACTAM

IV ONLY

GOOD PSEUDOMONAS; COMPARABLE TO CEFTAZIDIME

GOOD CNS PERF

CROSS-REACTION WITH MANY 3RD GEN CEPHs, esp CEFTAZIDIME AND 4TH CEFEPIME

I.V. CEFAZOLIN

• P.O. NEOMYCIN
• (NOT ABSORBED FROM GI TRACT)

I.V. CEFOXITIN,

OR

I.V. CEFOTETAN

I.V. PIPERACILLIN + TAZOBACTAM

I.V. CEFOXITIN, OR I.V. CEFOTETAN

PLUS

I.V. DOXYCYCLINE

SINGLE DOSE I.M. CEFTRIAXONE

PLUS

P.O. METRONIDAZOLE (2 WEEKS)

PLUS

P.O. DOXYCYCLINE (2 WEEKS)

I.V. METRONIDAZOLE

I.V. AMPICILLIN,

--IF AMP RESISTANT USE I.V. VANCOMYCIN

--IF VANC RESISTANT USE I.V. OR P.O. LINEZOLID

I.V. VANCOMYCIN

SYNTHETIC ANTIBIOTIC

• INH PROT SYNTH - STATIC
• --23S ON 50S; BLOCKS INITIATION
• --UNIQUE MOA --> NO CROSS-REACTIONS

• EXCELLENT G+
• --MRSA if can't use vanc
• --DOC VRE esp e.faecium
• --PCN-R STREP PNEUMO
• --COMPLICATED SSTI

DONT USE AS EMPIRIC IF BUG UNKNOWN

MIN G-

• GREAT F, iv & po
• --IV VANC Pt SENT HOME WITH po LINEZOLID

• FAIRLY WELL TOLERATED
• --N/V
• --BONE MARROW SUPPRESSION 2+wks
• --NEUROPATHIES 2+wks
• --------------------------------------------

• WEAKNESSES
• --STATIC mrsa vre
• --DEEP-SEATED INF endocarditis/osteomyelitis
• --MITOCHONDRIAL TOX
• --BONE MARROW SUPPRESSION
• --IRREV MOAI --> +SSRI CAUSES 5-HT SYND
• --PERIPH NEUROPATHIES irrev optic neuritis
• --$$, $200-PER DAY. VANC $12-18

DEPOLARIZES CELL

COMLICATED MRSA IF CAN'T TOLERATE VANC

--NO MRSA PNEUMO OR SSTI bc INACTIVATED BY SURFACTANT

MUSCLE TOX

$$$ 250-500 PER DAY

VANC BEATS DAP & LINEZOLID IN HEAD-TO-HEAD

SYNTH DERIV OF VANC

MORE POTENT THAN VANC AGAINST MRSA

2x NEPHROTOX

MOA -- VANC + DAP

G+ ONLY

NO VRE

TRIM-SULFA

• GREAT F
• --po IN SERIOUS INF TO AVOID HUGE IV VOLS

• MOA
• --SULFA COMP ANTAG OF PABA --> INH SYNTH OF DHF

--TRIM INH DHF REDUCTASE --> INH DHF TO THF

GIVEN SINGLY = STATIC; TOGETHER = CIDAL

• BROAD SPECTRUM
• --MRSA, clinda prefered
• --ENTEROBACTER
• --*E.COLI
• --*KLEB
• --DOC PNEUMOCYSTITIS JIROVECI

• *GOOD UTI, HIGH CONC IN URINE
• --UNCOMPLICATED UTI IN HEALTH WOM
• --65% E.COLI SUSEPT

DOC NOCARDIA IN IMMUNO-COMP

• DONT USE
• --PSEUDOMONAS
• --ENTEROCOCCI
• --BACTEROIDES
• --GAS, FOR UNKNOWN SSTI GIVE po (CEPHALEXIN OR AMOX) + TRIM-SULFA TO COVER

• SULF INDUCED ALLERGY
• --RASH IN 30% AFTER 2wks
• --FEVER
• --PHOTOSENSITIVITY
• --URTICARIA (hives)
• --ERYTHEMA MULTIFORME
• --STEVENS-JOHNSON SYND, SEVERE ERYTH MULTI w SEVERE MUCOCUTAN LESIONS OF MOUTH, ANOGENITAL, CONJUNCTIVA
• --TOX EPIDERM NEC (TENS) FULL-THICKNESS EPIDERM NECROSIS
• --HYPERKALEMIA, trim is k-sparing diuretic. older men with prostatitis

BAC ENZ ACTIVATED --> DNA DAMAGE

UNCOMPLICATED UTIs

STATIC AT LOW CONC, CIDAL AT HIGH

• STRENGTHS
• --HIGH F
• --HIGH CONC IN URINE
• --MOST ACTIVE IN ACIDIC URINE (not good pilonephritis)
• --G+ AND G- UTI (e.coli, kleb, enterococc vre, some proteus are r)
• --NO CROSS-REACTION
• --PREGO SAFE

• WEAKNESSES
• --LIMITED TO URINE
• --NO PYELONEPH OR PROSTATITIS
• --MAKES URINE BROWN
• --S/E w PROLONGED USE --> HEP, NEUROP, PULM FIB for recurrent

POLYENE

ANTIFUNGAL

BINDS ERGOSTEROL AND CREATES PORES

• STRENGTHS
• --VERY BROAD SPECTRUM; GOLD STANDARD
• --HIV Pt w CRYPTOCOCCAL MENINGITIS

• WEAKNESSES
• --TOXIC!
• --NEPHROTOX, DOSE DEP. EXACERB BY OTHER NEPH-TOX DRUGS (AGs)
• --RENAL WAISTING OF K & Mg
• --NO PERM RENAL DAMAGE IN HEALTHY Pts
• --SHAKE-N-BAKE SYND. FEVER & CHILLS bc IL-1 IL-6 and TNF
• --ANEMIA bc DEC ERYTHROPOIETIN

• LIPID FORMULATIONS
• --DELAYED TOX
• --$$$

• OTHER POLYENE NYSTATIN
• --ORAL SUSPENTION & TOPICAL
• --TASTES BAD
• --ONLY CANDIDA AND NOT "MET" BUGS
• --CLOTRIMAZOLE FOR TASTE INSTEAD

ANTIFUNGAL -- PREVENTS ERGOSTEROL FORMATION

KILL SLOWLY -- CONSIDERED STATIC

CYP450 INH

• CANDIDA + "MET" BUGS
• --MICROSPORUM
• --EPIDERMOPHYTON
• --TRICHOPHYTON

• FLUCONAZOLE
• --MOST COMMON SYSTEMIC ANTIFUNGAL
• --EXTREMELY ACTIVE FOR C. ALBICANS
• --VERY NARROW SPECT
• --NO C.KRUSEI, 15-20% C.GLABRATA
• --NO ASPERGILLUS
• --PITYROSPORUM ORBICULARE (MALASSEZIA FURFUR yeast --> TINA VERSICOLOR). TAKE THEN EXCERSIZE
• ITROCONAZOLE
• --ASPERGILLUS
• --NO iv, LOW F

• VORICONIZOLE
• --NEW
• --DOC ASPER; BETTER THAN AMPHO-B
• --C.KRUCEI FLUCONAZOLE-R
• --HEP/NEPH TOX
• --VISUAL DISTURBANCES

• POSACONAZOLE
• --NEW
• --VORICONAZOLE + ZYGOMYCETES
• --po ONLY

CANT USE AMPHOTERICIN B AFTER AZOLES bc THEY TAKE AWAY SITE OF ACTION

ANTIFUNGAL

• DOC FOR CANDIDA
• --INVASIVE
• --REPLACED AMPHO-B FOR MOST CANDIDA

MOA -- INH GLUCAN SYNTH FOR CELL WALL

• CASPOFUNGIN
• --SALVAGE FOR AMPHO-R INVASIVE ASPER AND CANDIDA
• --RAPIDLY CIDAL CANDIDA, EVEN FLUCONAZOLE-R
• --WELL TOLERATED
• --NO CROSS REACTION w -AZOLES

$$$

NO po

LIMITED SPECTRUM

ANTIFUNGAL

INH DNA SYNTH

• NARROW SPECTRUM
• --CRYPTOCOCCUS NEOFORMANS MENINGITIS
• --SOME CANDIDA

• STRENGTHS
• --po w RAPID ABS AND CNS
• --ELIM RENALLY
• --SYNERGISTIC w AZOLES AND AMPHO-B

BONE MARROW SUPPRESSION

QID -- 4 TIMES A DAY

RAPID R WHEN USED AS MONOTHERAPY

I.V. OR P.O. LINEZOLID,

OR

I.V. DAPTOMYCIN

(THE DOC IS HOSPITAL SPECIFIC)

• I.V. VANCOMYCIN
• (EMPIRIC THERAPYWHICH SHOULD BE
• ADJUSTED BASED ON CULTURE RESULTS)

PROTOZOAL INFECTIONS

• Tx
• --TRICHOMONIASIS
• --GIARDIASIS
• --AMEBIASIS
• --ANAEROBES (bacteroides frag, c.diff)

• DOC:
• --C. DIFF po
• --OUT Pt PID po (w/ im ceftriaxone & po doxy)
• --ANAEROBE INF IN PCN ALLERGIC Pt iv

• INH FERREDOXINS OF ETC
• --FREE RADS DAMAGE DNA

• INTERACTIONS
• --INC BLEEDING w WARFARIN
• --ETHANOL --> N/V, INC ACETALDEHYDE

METALLIC TASTE

• PREGO CATEGORY B
• --OK BUT AVOID USE IN 1st TRI

P.O METRONIDAZOLE,

• IF DISEASE IS SEVERE, GIVE:
• P.O. VANCOMYCIN

• IF VANC-R, GIVE FIDAXOMICIN
• --LESS RELAPSE (20-30%)
• --BUT $$$

P.O. DOXYCYCLINE,

OR

P.O. MACROLIDE

P.O. DOXYCYCLINE,

OR

P.O. MACROLIDE

P.O. DOXYCYCLINE

po DOXYCYCLINE

TRIM-SULFA

p.o. ciprofloxacin

p.o. trim-sulfa

P.O. LEVOFLOXACIN,

OR

P.O. CIPROFLOXACIN

IV CEFOTAXIME

OR

IV CEFTRIAXONE

OR

PO CEFPODOXIME

I.V. CEFTRIAXONE,

OR

I.V. CEFOTAXIME

SEND HOME ON P.O. CEFPODOXIME

p.o. nitofurantoin

• P.O. RIFAMPIN
• --PLUS
• P.O. ISONIAZID
• --PLUS
• P.O. PYRAZINAMIDE
• --PLUS
• P.O. ETHAMBUTOL

• P.O. RIFABUTIN
• --PLUS
• P.O. ISONIAZID
• --PLUS
• P.O. PYRAZINAMIDE
• --PLUS
• P.O. ETHAMBUTOL

TB

• MOA
• --PRODRUG CONVERTED BY MYCOBACTERIAL CATALASE-PEROXIDASE
• --PREVENTS MYCOLIC ACID SYNTH NEED FOR CELL WALL

• STATIC FOR LATENT (NON-DIVIDING)
• CIDAL FOR RAPIDLY DIVIDING
• --------------------------------------------------

IF PPD+ AND -CXR, THEN TAKE INH FOR 9mths

• SLOW ACETYLATOR "SHIP!"
• --HEPATO & NEUROTOX
• --MONITOR LFTs AS 20% Pts HAVE 2-3X INC. TOX INC w AGE.
• --INC TOX w EtOH

STRUCTURALLY SIMILAR TO PYRIDOXINE (B6) AND HAS ANTAGONISTIC EFFECT MIMICING B6 DEFICIENCY (sensory polymotor neuropathies). GIVE AS COTHERAPY TO PREGOs, DM, UREMIA, MALNUTRITION, HIV, SEIZURES

P.O. ISONIAZID,

OR

P.O RIFAMPIN

TB -- "RIPE"

• MOA
• --INH mRNA SYNTH BY BINDING TO B-SUB OF BAC DNA-DEPENDENT RNA POL

CIDAL -- EASILY PENETRATE TISSUES --> GREAT FOR ABSCESSES

NO MONOTHERAPY DUE TO RAPID RESISTANCE

• INDUCES CYP450!
• --DON'T USE FOR HIV+ Pts bc RAPIDLY METABOLs OTHER DRUGS
• --USE RIFABUTIN bc ONLY INDUCES HALF AS MUCH

• ALSO ACTIVE AGAINST
• --MENINGOCOCCI
• --PNEUMOCOCCI (PCN-R STREP PNEUMO)
• --STAPH (MRSA)
• ----------------------------------

• TOX
• --SKIN, URINE, TEARS, SWEAT, SALIVA TURN ORANGE
• --INDUCE CYP450

TB -- "RIPE"

MOA -- UNKNOWN

50% OF INH-R & RIF-R ALSO PYRAZ-R

• TOX
• --N/V
• --HEPATO 1-5%

TB -- "RIPE"

• MOA
• --INH CELL WALL SYNTH:
• --INH ARABINOSYL TRANSFERASE FOR ATABINOGLYCAN

80% INH-RIF-R ARE ETHAM-R

• TOX
• --OCULAR DAMAGE!
• --VISION TEST BEFORE ADMIN AND q4-6 wks

SOMETIMES "RIPS"

S - STREPTOMYCIN

P.O. DOXYCYCLINE

PLUS

I.V. GENTAMICIN

LINCOSAMIDE

IV & PO

INH PROT SYNTH BY BINDING TO 50S RIBO SU -- STATIC

F=0.9

• GREAT G+, NO G-
• --SSTI (MRSA, B-HEMO STREP)
• --PCN ALLERGY

NO VRE

G+ ANAEROBES (ASPIR PNEUMO)

GOOD PENETRATION expt CNS

HIGH BONE/SERUM CONC (OSTEOMYLITIS IN KIDS)

HEP MET

CAUSES RASH

C.DIFF!!! - Tx METRONIDAZOLE OR ORAL VANC

ONCE DOC FOR BACEROIDES, BUT NOW R

STATIC

• erythromycin
• clarithro
• azithro

telithro -- lethal hep damage

MOD G+ ACTIVITY, inc STREP PNEUMO

MIN G- IF USED w CLARITHROMYCIN AND AZITHROMYCIN

EXCELLENT FOR INTRACELLULAR BUGS. NOT TB, BUT MYCOBAC AVUM, CHAMYDIA, MYCOPLASMA

GOLD STANDARD FOR LEGIONELLA

STREP PNEUMO FOR Pt w PCN ALLERGY

NOT GOOD SSTI

NO KIDS OTITIS MEDIA

• --------------------------------------------------
• ERYTHROMYCIN - iv and po (severe n/v). stims motilin receptors. inh cyp450. adj for renal fcn

CLARITHROMYCIN - po only

• AZITHROMYCIN - iv and po
• ----------------------------

• NO ACTIVITY AGAINST
• --ENTEROCOCCUS
• --MRSA
• --VRE

R BY MOD BINDING SITE ON 50S RIBO SUBUNIT

P.O. OR I.V. MACROLIDE

PLUS

ETHAMBUTOL

P.O. MINOCYCLINE,

OR

TOPICAL CLINDAMYCIN,

OR

TOPICAL ERYTHROMYCIN

DAPSONE

ALL SSTIS SHOULD BE CONSIDER TO BE CAUSED BY STAPH OR STREP UNLESS PROVED OTHERWISE BY CULTURE, SO EMPIRIC DRUG THERAPY SHOULD INCLUDE A DRUG(S) WHICH COVER MSSA, MRSA AND GROUPS A AND B STREP. DRUGS FOR EMPIRIC THERAPY:

MALARIA

• FALCIPARUM AND MALARIAE
• --ONLY 1 CELL CYCLE IN LIVER, CLEAR >4wks
• --Tx OF RBC STAGE CURES INFECTION

• OVALE AND VIVAX
• --HEP INF PERSISTANT = RELAPSE

PLASMODIUM

MALARIA Tx

KILLS ERYTH STAGE OF VIVAX, OVALE, MALARIAE, SOME FALC

CHECK CDC FOR REGIONS OF CHLORO-R MALARIA

MALARIA Tx

KILLS ALL PLASMODIUM spp

KILLS HEP FORM OF OVALE & VIVAX

GIVEN AFTER RBC Tx w CHLOROQUINE

• HEMOLYTIC ANEMIA IN Pt WITH G-6-P GENETIC DEFICIENCY
• --TEST BEFORE GIVING
• --MEDITERANIAN OR ASIAN
• --FAVAISM
• --PREVENTS NADPH FORMATION WHICH PROTECTS CELL MEM FROM OX
• --AVOID PREGOs

PLASMODIUM MALARIA Tx

CONTROVERSIAL DRUG

• 1 OF ONLY DRUGS THAT SUPP/CURE MDR FALCIPARUM
• --ATOVAQUONE & PROGUANIL ALSO

• S/E
• --N/V
• --HALLUCINATIONS (exacerbate psych probs)

• CHLOROQUINE
• --SAFE FOR KIDS

• CHLORO-R AREAS
• --ATOVAQUONE + PROGUANIL
• --MEFLOQUINE
• --DOXY
• --PRIMAQUINE

• MDR AREAS
• --MEFLOQUINE

BEGIN Tx 2 WEEKS PRIOR TO TRAVEL