Antibiotic, Antifungal, and Anti-helminthic Drug Indications (DOCs) Julia Jones (with fungal contributions from Wendy Chen)

Antibiotic, Antifungal, and Anti-helminthic Drug Indications (DOCs)

Julia Jones(with fungal contributions from Wendy Chen)

Primary SyphilisPenicillin G, IM x 1

What if patient is very allergic to Penicillins?

Doxycycline p.o. x 2wks

Staphylococci with plasmid-encoded β-lactamases

Dicloxacillin

Pseudomonas AeruginosaPiperacillin-Tazobactam

What if patient is a little bit allergic to Penicillins?

3rd gen ceph (ceftazadime)4th gen ceph (cefepime)

What if patient is a lot allergic to Penicillins, cephalosporins?

Aztreonam (monobactam)

What if I wanted to use a protein synthesis inhibitor?

Aminoglycosides

What if that drug was too nephrotoxic?

Aztreonam (monobactam)

The Big Gun?

Imipenem

Meningitis in patients >3 months old

Ceftriaxone (IV, 3rd GC) can add Vancomycin +/- Rifampin

Gonorrhea

3rd GC Ceftriaxone (IM) or Cefixime (p.o.)

What if very allergic to cephalosporins? ( 2 alternatives)

FQs

Azithromycin

Serratia

• Imapenem• Aztreonam

EHEC

• None. Supportive/symptomatic

Typhoid Fever

Ceftriaxone (serious G- infxn)Or?

FQ, 2nd line TMP/SMX

ETEC

• Severe G- infection: • cephalosporin• Severe G- rod aerobic infection: • AG• 2nd line: • TMP/SMX• G- GI tract Tx: • FQ

Shigella

• 1st line:• FQ• 2nd line:• TMP/SMX• Other?• Amino-penicillin

Community-acquired pneumonia

Azithromycin (ML)

Plus?

Ceftriaxone + AG

Nosocomial pneumonia

Ceftriaxone + Gentamicin (aminoglycoside)

Serious Gram (-) infections

Ceftriaxone

MRSA

Vancomycin (sometimes add Gentamicin +/- Rifampin)

Mycoplasma pneumonia

Doxycycline (tetracycline)Azithromycin

Enterobacter

• DOC?• Imapenem• Other choices?• 2nd/3rd/4th gen Cephalosporins• Pipercillins

ChlamydiaDoxycycline

(+macrolide – azithromycin or erythromycin) How do I pick?

depends on desired dosing regimenWhat other protein synthesis inhibitor?

TMP/SMX

Rickettsia (RMSF)

Doxycycline

Vibrio cholera

Doxycycline

Legionella

Doxycycline (+erythromycin)

Skin infections caused by community-acquired MRSA

TMP/SMXWhat if allergic to sulfonamides?

DoxycyclineOther drugs?

Clindamycin, FQs

Staph aureus drugs?

• Dicloxacillin• Other drugs in this group?• “I met a nasty ox:”• Methicillin, • Nafcillin, • Oxacillin

• Vancomycin• Clindamycin

Proteus

• Aminopenicillins• All cephalosporins

Acinetobacter

• This used to be a pseudomonas• Imepenem

Anthrax!!

• FQ• This is actually the prophylactic Tx. Not DOC.

Lyme disease

• Doxycycline• 3rd gen cephalosporin

MAC (Mycobacterium avium)

• Azithromycin• Ethambutol• (FQ)

Hemophilis

• Amino-penicillins• 2nd/3rd/4th gen Ceph• Aztreonam• Chloramphenicol• For prophylaxis?• Rifampin• Who gets it?• All close contacts

Klebsiella

• All cephalosporins• Aztreonam

Strep pneumo

• Penicillin• Aminopenicillin + B-lactamase inhibitor• Strep pneumo is notorious for what

resistance mechanism?• Altering PBP. Solution?• 3rd/4th gen cephalosporins

Dental prophylaxis for endocarditis

• Clindamycin• Aminopenicillins

• Rx for strep viridans/mutans?• Penicillin

Lupus

• INH• Ooh. Lupus is also a contraindication in

which drug?• Primaquine

Moraxella

• Amino-penicillin• Azithromycin

Corynebacterial Diphtheria

Macrolides (Azithromycin or Erythromycin)

What else?Pen G/V

Anaerobic Abscesses

Clindamycin or Metronidazole

Brain Abscesses

Metronidazole

B.Frag Rx

• Metronidazole• Imipenem (probably b/c this is a good Rx for

mixed infections)• What other drug is good for mixed

infections?• Clindamycin

Meningitis in a patient with a β-lactam allergy

Chloroamphenicol

Strep Pyogenes?

• Pharyngitis• Pen V• what if allergic?• Erythromycin

H.Pylori

• Amino penicillin + ML• Or• Doxycycline

Listeria meningitis

• Amino-penicillin

Adult sinusitis

TMP/SMXAminopenicillins

Nocardia

• TMP/SMX

Lower UTITMP/SMX

Upper + lower UTIFQ

UTI d/t #1 cause in womenE.Coli – AG

UTI d/t #2 cause in womenStaph saprophyticus--Dicloxaxillin

Chronic Bronchitis

TMP/SMX

Prostatitis

TMP/SMX

Pneumocystis PneumoniaTMP/SMX

Prevention/prophylaxis?Caspofungin

Prophylaxis in an AIDS patient?Dapsone

Pseudomembranous Colitis due to C. difficile

Metronidazole (1st choice)Vancomycin (2nd choice)

What caused it in the first place?Any antibiotic can cause.

In real life, FQ is apparently the #1. In our class, #1 is Clindamycin,

#2 is amino-penicillins

Prophylaxis for meningitis due to H. influenzae or N. meningitidis

Rifampin

Side effect: Orange Pee

DOC for TB (5 in order; adverse effects in parentheses)

IRPES (rhymes with “herpes”):INH (peripheral neuropathy – give Vitamin B6)Rifampin (orange bodily fluids; ramps up P450)PZA (gout)Ethambutol (visual disturbances; gout)Streptomycin (ototoxic; nephrotoxic)

Leprosy

Dapsone + Clofazimine + Rifampin

Systemic fungal infections (especially life-threatening)

Amphotericin B

Ringworm

Terbinafine (could also include itraconazole or ketoconazole)

Tinea capitis in kids

Griseofulvin

Prevention of cryptococcal meningitis in AIDS patients already

on Amphotericin B

Fluconazole

Cryptococcal meningitis

Amphotericin B + Flucytosine (then maybe add fluconazole)

Coccidiodal meningitis

Fluconazole (could also use intrathecal Amphotericin B)

Non-meningeal coccidiosis

Ketoconazole

Non-meningeal histoplasmosis

Itraconazole

Blastomycosis

Itraconazole

AIDS patients on amphotericin B-stabilized histoplasmosis

Itraconazole

Invasive aspergillosis (1st & 2nd line drugs)

Itraconazole (1st line)Caspofungin (2nd line)

Chromoblastomycosis

Flucytosine (alone)

Neutropenic patient with fever and unresponsive to antibiotics

Amphotericin B

Induction of AIDS therapy

Amphotericin B

Sporothrix schenkii

Itraconazole

Systemic Candidiasis

Amphotericin B(if this doesn’t work, then use

Caspofungin)(if that doesn’t work, then use

Fluconazole)

Localized candidiasis (oropharyngeal, esophageal,

vaginal)

•Amphotericin B (oral/topical; “swish and swallow” for oropharyngeal; topical use for vaginal; nystatin)•Itraconazole•Ketoconazole (for mucocutaneous candidiasis)•Fluconazole

Anti-fungal drugs eliminated by the kidney

FluconazoleFlucytosine

Anti-fungal drugs eliminated by the liver

KetoconazoleItraconazole

Fungicidal Drugs

Amphotericin BCaspofunginTerbinafine

Fungistatic Drugs

AzolesFlucytosineGriseofulvin

IV only (or main method)

Caspofungin(Amphotericin B is usually IV-

administered; Candida is the only indication for oral/topical use)

Immunocompetent patient suspected of having histoplasmosis

Do not prescribe anything(this was one of the questions in the

syllabus… tricky)

Pinworm

Mebedazole (1st choice)Pyrantel (2nd choice)

Hookworm

Mebedazole (1st choice)Pyrantel (2nd choice)

Cestodes

Praziquantel

Trematodes

Praziquantel

Cysticercosis

Albendazole

Cystic Hydatid Disease

Albendazole

Cutaneous larva migrans

Albendazole

Filiariasis

Ivermectin (1st choice)Diethylcabamazine (2nd choice)

Loiasis (worms in connective tissue)

Diethylcarbamazine

Tropical eosinophilia

Diethylcarbamazine

Onchocerciasis

Ivermectin

Strongyloidiasis

Ivermectin

Schistosomiasis

Praziquantel

Malaria (erythrocytic form)

ChloroquineMefloquineDoxycycline

Atovaquone-ProguanilArteminsinin

Malaria (P. vivax & P. ovale in liver)

Primaquine

Amebiasis

Metronidazole

Giardiasis

Metronidazole

Trichomoniasis

Metronidazole

Cyclospora Infections

TMP/SMX

Email me about any corrections or DOC additions!

- Julia ([email protected])