Professional Documents
Culture Documents
TREATMENT OF INFECTIONS
Improvement of patient outcomes by selecting the
MOST APPROPRIATE ANTIMICROBIAL (OR
ANTIBIOTIC), which depends on the following:
o Recognized and identified site of infection
o Patients underlying illness(es) and other risk
factors
o Likely pathogens involved
o Drug resistance
Example:
Most common etiologic agent for SSTI Gram (+) cocci
Most appropriate antibiotic: -lactams (oxacillin, cloxacillin
aka Anti-Staphylococcal -lactams)
Penicillin: will not work against Staphylococcus aureus
Vancomycin: reserved for MRSA alone (to prevent drug
resistance)
If infectious agent is known: give narrow spectrum antibiotics
DM, COPD, and CKD may expand the list of suspected
microbes
[2013B]
ANTIBIOTICS
o
o
Cycloserine
Glycopeptides bind to the terminal D-alanine-Dalanine component of stem peptide inhibits addition
of subunits to peptidoglycan backbone [Harrisons]
ANTIMICROBIAL UTILIZATION
ANCHORES-ANDAL-ANDRADE (editor)
Vancomycin
Teicoplanin
Penicillins
Penicillin G
Methicillin-Like
Methicillin
Cloxacillin
Dicloxacillin
Flucloxacillin
Penicillin V
Cephalosporins
Broad spectrum
Cefotaxime
Ceftriaxone
Anti-pseudomonal
Ceftazidime
Cefepime
Cefpirome
Anti-haemophilus
Ceflaclor
Cefuroxime
Cefamandole
Moderate spectrum
Cephalexin
Cephazolin
Cephalothin
Anti-anaerobic
Cefoxitin
Cefotetan
Others
Monobactams
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Aztreonem
Carbapenems
Imipinem
-lactamase Inhibitors
Clavulanic acid
Sulbactam
Cell-Membrane Inhibitors
o Polymixins disrupt the permeability of both the
o
o
Polymixin B
Polymixin E
DNA Inhibitors
o Transcription
Rifamycins
Rifampicin
Rifabutin
o Replication
5-nitroimidazoles
Metronidazole
Tinidazole
Quinolones
Nalidixic Acid
Norfloxacin
Ciprofloxacin
Ofloxacin
Protein Synthesis Inhibitors
o Fusidic Acid
o Muprocin
o Chloramphenicol binds reversibly to the 50S
Neomycin
Streptomycin
Kanamycin
Kanamycin
Gentamicin
Tobramycin
Amikacin
Tetracyclines interact reversibly with the
Tetracycline
Minocycline
Doxycycline
Metabolic Analogues interfere with bacterial
synthesis of folic acid, cessation of bacterial cell
growth [Harrisons 18th ed]
o
o
o
Dapsone
Sulfonamides
Trimethoprim
Lincomycin
Clindamycin
MASK
Azalides
Ketolides
Macrolides bind specifically to 50S portion of
the bacterial ribosome and inhibit protein chain
elongation [Harrisons 18th ed]
Erythromycin
Azithromycin
Clarithromycin
Roxithromycin
Aminoglycosides exert bactericidal effect by
ANCHORES-ANDAL-ANDRADE (editor)
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o
o
[2013B]
Superinfection
Unwanted adverse reactions
Waste of efforts and resources
Increase in total cost of therapy
Emergence of antimicrobial resistance
COLLATERAL DAMAGE
Ecological adverse effects of antibiotic
therapy
o Selection of drug-resistant organisms
o Unwanted development of colonization or
infection with multi-drug resistant organisms
elimination of non-resistant forms results in
increased prevalence of resistant forms [2013B]
ANCHORES-ANDAL-ANDRADE (editor)
Site of infection
Local antibiogram
Every attempt should be made to narrow the
antibiotic spectrum
Advanced age
Comorbidity
Severity of illness
Inter-institutional transfer of patients (especially
from nursing homes)
Prolonged hospitalization
Gastrointestinal or transplant surgery
The presence of any invasive device (especially
central venous catheters)
Exposure to antibiotics (especially cephalosporins)
Goals
o To optimize clinical outcomes while
minimizing unintended consequences of
antimicrobial use, including toxicity, selection
of pathogenic organisms, and emergence of
resistance
o To reduce healthcare costs without adversely
impacting quality of care
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BOTTOM LINE
Antimicrobial resistance is a critical patient safety
issue
Antimicrobial resistance is a public health threat
Antibiotics should be viewed as a limited resource
Physicians play the role of stewards
o Judicious prescription of quality antibiotics
Goals
o To maximize therapeutic efficacy
o To minimize toxicity and the risk of developing
antimicrobial resistance
ANTIBIOTIC CHECKLIST
Q1: Is an antibiotic indicated on the basis of
clinical and laboratory findings?
ANCHORES-ANDAL-ANDRADE (editor)
Septic
Elderly
Possible IE
WARNING: Unnecessary treatment of viral
infections is a major source of excess
antibiotic use. Most fevers are caused by viral
o
o
o
PRESUMPTIVE THERAPY
Severe sepsis
Immunocompromised states
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Febrile neutropenia
Possible acute endocarditis
Known or suspected meningitis
Acute necrotizing cellulitis
ANTIMICROBIAL MISUSE
Common Misuses of Antibiotics
o Prolonged empiric treatment without clear
evidence of infection
o Treatment of positive culture in absence of
disease
o Failure to narrow antimicrobial therapy when
a causative organism is identified
o Prolonged prophylaxis
o Excessive use of certain antimicrobials
Prescribers
o Not all prescribing practices are judicious
Pressures providers
Incomplete course
ACTIONS:
Epidemiologic factors
o Nosocomial or healthcare-related infections
o Prior antibiotic use
o Staphylococcal infections (possibility of ORSA
Oxacillin-resistant Staphylococcus aureus)
o
o
ANCHORES-ANDAL-ANDRADE (editor)
Page 5 of 9
Meropenem
Fluoroquinolones
IV Ciprofloxacin
IV Levofloxacin
Benzylpenicllin
o
High Risk CAP Risk for Pseudomonas
aeruginosa infection
o History of chronic or prolonged (>7 days
within the past month)
o Use of broad spectrum antibiotic therapy
o Malnutrition
o Chronic Use of steroid therapy: >7.5mg/day
o Sever underlying bronchopulmonary disease
(COPD, bronchiectasis)
Antipneumococcal Antipseudomonal lactam
o IV antipneumococcal antipseudomonal
Cephalosporin
Cefoperazone-sulbactam
Ticarcillin-Clavulanic acid
Piperacillin-tazobactam
o IV antipneumococcal antipseudomonal
Carbapenem
Imipinem-cilastatin
ANCHORES-ANDAL-ANDRADE (editor)
Cotrimoxazole (green)
Chloramphenicol (purple)
Ampicillin (blue)
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Penicillins,
cephalosporins,
aminoglycosides,
vancomycin,
aztreonam,
carbapenems,
fluoroquinolones,
metronidazole
Erythromycin,
clindamycin,
tetracycline,
sulfonamides,
chloramphenicol
o Frequency of administration
o Number of antibiotics
o Administration costs: IV>IM>PO
o Narrow vs. Broad spectrum
Bactericidal vs. Bacteriostatic
BACTERICIDAL
Inhibit bacterial
replication; kill the bacteria
BACTERIOSTATIC
Inhibit bacterial growth
ANCHORES-ANDAL-ANDRADE (editor)
o
o
-lactam + -lactam
Higher costs
False sense of security
Page 7 of 9
EXCRETED BY THE
KIDNEYS
Aminoglycosides
EXCRETED BY THE
LIVER
Cefoperazone only
cephalosporin excreted by
the liver [2013B]
Aztreonam
Chloramphenicol
Cephalosporins
Clindamycin
Carbapenems
Doxycycline
Quinolones
Erythromycin
Penicillin
Metronidazole
Trimethoprim
Nafcillin
Vancomycin
Rifampicin
Tetracycline
Sulfamethoxazole
Presence or indwelling device
Humoral and cellular host defense mechanisms
Previous antibiotic use and response to such
Underlying illnesses
o DM
o COPD/Bronchiectasis
Amphotericin B
Vancomycin
Aminoglycosides
o Good bioavailability:
Fluoroquinolones
Metronidazole
Clindamycin
Chloramphenicol
Fluconazole
Linezolid
ANCHORES-ANDAL-ANDRADE (editor)
DETERMINED BY:
Availability and affordability
Nature and site of infection
Probable organism
o Antimicrobial resistance in the local setting
(hospital/specific unit)
Pk/Pd
o Patient tolerability and side effects
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[2013B]
TREATMENT FAILURE
SUMMARY
ANCHORES-ANDAL-ANDRADE (editor)
Page 9 of 9