Peripheral Brain - Bugs and Drugs

8/6/2019 Peripheral Brain - Bugs and Drugs

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DRUG Class Strep Staph Entero E. coli Proteus Klebsiella H. influ M. cat Ps

Penicillin Pen + - + - - - - -

Ampicillin aminopenicillin + - +++ + + - + -

Amox aminopenicillin + - +++ + + - + -Naficillin pen-ase res pen + + - - - - - -

Oxacillin pen-ase res pen + + - - - - - -

dicloxacillin pen-ase res pen + + - - - - - -

ticarcillin Antipseudo-Carboxy + - - + + + + +

piperacillin Antipseudo-Ureido + - Static + + + + +

Aztreonam Monobactam - - - + + + + +

Ertapenem Carbipenem + + - + + + + +

Mero/Doripe Carbipenem + + - + + + + +

Imipenem Carbipenem + + + + + + + +1st gen Cephs + +++ - +/- +/- +/- - -

2nd gen Cephs + ++ - + + + + +

3rd gen Cephs + - - + + + + +

4th gen Cephs + +++ - + + + + +

5th gen Cephs + +++ - + + + + +

Tobramycin Aminoglycoside +~ +~ +~ + + + +~ +~

Gentimicin Aminoglycoside +~ +~ +~ + + + +~ +~

Amikacin Aminoglycoside +~ +~ +~ + + + +~ +~

StreptomycinAminoglycoside +~ +~ +~ + + + +~ +~Neomycin Aminoglycoside +~ +~ +~ + + + +~ +~

Kanamycin Aminoglycoside +~ +~ +~ + + + +~ +~

ParomomycinAminoglycoside +~ +~ +~ + + + +~ +~

DRUG Class Strep Staph Entero E. coli Proteus Klebsiella H. influ M. cat Ps

Norfloxacin Fluoroquinolone NO! urine only + + + + +

Ciprofloxacin Fluoroquinolone - NO! urine only + + + + +

ofloxacin Fluoroquinolone NO! urine only + + + + +

Levofloxacin Fluoroquinolone + NO! urine only + + + + +Gemifloxacin Fluoroquinolone NO! urine only + + + + +

Moxifloxacin Fluoroquinolone +~ NO! NO! + + + + +

SMX/TMP Sulfonamide otA,B + - + + + + -

sulfisoxazole Sulfonamide - + - + + + + -

Sulfadiazine Sulfonamide - + - + + + + -

ErythromycinMacrolide ++ ++ - - - - +/- +

ClarithrymyciMacrolide +++ +++ - - - - ++ +

AzithromycinMacrolide + + - - - - +++ +

TelithromycinMacrolide-ketolide++++++++ - - - - +++ +



DRUG gen Strep Staph Entero E. coli Proteus KlebsH. influ M. cat Pseudo MRSA A

Cefadroxil 1 fad + +++ - +/- +/- +/- - - - -

Cefazoline 1 faz + +++ - +/- +/- +/- - - - -

Cephalexin 1 alex + +++ - +/- +/- +/- - - - -

Cefaclor 2 fac + + - + + + + + - -Cefuroxime 2 fur + + - + + + + + - -

Cefprozil 2 pro + + - + + + + + - -

Cefotetan 2 fot + + - + + + + + - -

Cefoxitin 2 fox + + - + + + + + - -

Cefixime 3 fix + +/- - + + + + + - -

Cefotaxime 3 tax + +/- - + + + + + - -

Cefpodocime proxetil 3 pod + +/- - + + + + + - -

Ceftazidime 3 taz + +/- - + + + + + + -

Ceftriaxone 3 tri + +/- - + + + + + - -

Ceftibuten 3 tib + +/- - + + + + + - -Cefdinir 3 dinir + +/- - + + + + + - -

Cefditoren pivoxil 3 dito + +/- - + + + + + - -

Cefepime 4 fep + + - + + + + + + -

Ceftaroline fosamil 5 caroline + + - + + + + + - +



Class MOA

Penicillin Cell wall synth cid

Aminopenicillin Cell wall synth cid

Cell wall synth cid

Cell wall synth cid

monobactam Cell wall synth cid

Carbapenem Cell wall synth cid

Cell wall synth cid

Aminoglycoside Cid

DNA gyrase cid

Sulfonamides Folic acid metab

Macrolide/Ketolide

C a

tat

Penicillinase

Res.

Antipseudomon

al

Cephalosporins

…

Protein synth 30S

inhibitor

fluoroquinolone

s

Cid

(w

TM

Protein synth 50Sinhibitor



Peak serum concentrations of Gent/tobramycin

Lower UTI

Synergy w/ entero and staph 3-5mcg/ml

intra-abd, sepsis or mod-sev infections 5-8mcg/ml

pneumonia 8-10mcg/ml

Amikacin will be 4-5x above values

Trough serum concentrations

Gent/tobra <1-2mcg/ml

Amikacin <4mcg/ml

Lung - only 20% gets in lung, so use in combo only

Empiric dosing:

IBW

CrCl

Ke

T1/2Vd

Tau

Infusion rate

Dose

Check

< 3mcg/ml



Gram + Gram - Pseudomon Anaerobes Atypical

Staph E. coli Bacteroids Mycoplasma

Strep Klebsiella Chlamydia

Entero Proteus Legionella

H. influenza

M. catarrhalis



Bug 1ST CHOICE MAY ALSO USE OPTION

Pen and Clinda (binds to toxin)

Entero Aminopenicillins

VRE Linezolid

MSSA Amox, Cephalexin

Incision and drainage if possible

Vanco 15-20mg/kg/dose Q8-12h

VRSA depends on susceptibility data

ESBLs

Pseudo

Folliculitis

Furuncles S.aureus Moist heat, incision and drainage

Strep(Group A)

Amp + Gent = amp has highconcentrations in urine so may still beused in setting of a high MIC

Tigecycline - butpoor urinepenetration

MRSA (CA)Outpatient: Clindamycin, TMP-SMX, Doxycycline, mincycline,linezolid

Inpatient: Vanco 1gQ12h (trough 15),

linezolid, dapto,clinda, telavancin

MRSA (HA)TMP-SMX, Linezolid, daptomycin,telavancin, quinpristin/dalfoprisin

Dapto, linezolid,

quinpristin/dafpristin, tigecycline& rifampin, bactrim(last 2 not formonotherapy)

Carbapenems ONLY - even though they

appear susceptible in vitro

Klebsiellapneumoniacarbapente

mase (KPC)

Tigecycline or polymixinsare the onlyoptions

possibly send in bacterial strain toCenter for Disease Control (CDC)to see what combo of drugs may

work.

Antipseudo, cipro, levofloxacin,carbapenems (not ertapenem)aminoglycosides, Cefazidime, Cefepime,Aztreonam, Polymixin/colistin

S.aureus,Pseudomonas,

Candida

Warm compress, topical Mupiocin orother antibiotics, clotrimazole.

For recurrences: tx nares w/muprocin



Carbuncles S.arureus, strep

Erysipelas Pen, Clinda

Impetigo

S.pyogenes Clindamycin

Cellulitis

Multiple

Cat/Dog bite

Human Bite Multiple Amp-Sul, Cephoxitin

S.arureus, strep Quinolones - if sucseptable

Warm compress. Topical: Clinda,

erythro, muirocin, benzoyl peroxideBIDx7days

PO: Diclocacillin, clinda,Cephalexin, TMP-SMX

Group A or G

StrepS.aureus,S.pyogenes(glomerulonephri

tis)

Bullous (S.aureus):Dicloxacillin, 1st genceph.

Non-Bullous (S.pyogenes): Pen,Dicloxacillin, Cefalexin

Lymphangitis

Pen IV x2-3days then PO PenVKx10days

S.pyogenes,S.aureus, Manyothers, Gram (-),Fugi

Empiric: PO: Cephalexin, DicloxacillinIV: Oxacillin/Nafcillin, (MRSA or PCN

allergy: Vanco, dapto, Linezolid

Pen allergy: Clinda, Cephalexin,vanco

Necrotizingfasciitis

Broad spectrum: Amp-Sul + Clinda +Cipro

Decubitusulcer

Cx usuallyuseless. Needdeep tissue orblood culture

Topical Abx x 2wks: Silver sulfadiazine,

combo abx ointments, propylene glycol"skin renu"

Pateurella, Staph, strep,

anaerobes

Augmentin, Doxycycline, PenVK,(Quinolones, TMP-SMX or Cefuroxime) +

(metronidazole or Clinda)

Avoid: 1st gen, dicloxacillin,Macrolides, clinda

IV: Amp-Sul,Zosyn, cafoxitin,carbapenems,anarobe coverage

Prophylactic Abx for everyone:Dicloxacillin + Pen x3-5days

Avoid: 1s Gens,Macrolides, clinda,aminoglycosides

DiabeticFoot

Infection(Acute)

1st Gens, Clinda, Augmentin, TMP-SMX,dicloxacillin

DiabeticFootInfection(Chronic)

Multiple, Gram+, Gram -,

anaerobic

Broad spectrum. Empiric is unknown.Save combo tx for resistant or severe.



antistaphylococci abx

Osteomylitis Abx x6wks!

UTI E.coli

Ptrostatitis Quinolones, TMP-SMX Ampicillin + Gent, Doxy

Pharyngitis

Jointinfection

Staph but need

cutlure and gramstain

1st occurance (tx 3 days): TMP-SMX,Cipro, Amocicillin. Pregnant: Amox,Cephs x7 days

Reocurrences (tx 7 Days): TMP-SMX, Cipro, B-lactams

Nitrofurantoin,Augmentin(entero)Cephs, Doxycycline,

Fosfomycin

UTI(prophylaxis)

TMP-SMX 80/400 1/2 tab daily or

3x/week, TMP 100mg QD, Nitrifurantoin50-100mg QD

Postcoital: TMP-SMX 80/400 1/2-

1 tab, Nitrofurantoin 50-100mg,Cipro 250mg, Levo 250mg

Pyelonephritis

PO: TMX-SMX, Quinolones (Not Moxy),Augmentin

IV: Quinolones (not Moxy),Amp+Gent,Cephs+aminoglycoside, Amp-Sulbactam + Aminoglycoside

AcuteSinusitis

Virus,

S.pneumoniae,H.influ

Symptomatic Tx: Decongestants, nasalsaline, nasal steroids

Amoxicillin, Doxy, TMP-SMX,Azithro, 2nd/3rd gen cephs

Drug resistant: Higdose Amox or

augmentin,Levo/Moxy,Ceftiraxone

Virus, Strep-A(+stomachache= rhumatic

fever -->damaged Hvalve)

1.Pen VK 2.Amox 3.Benzathine PCN

4.Cephalexin/Cefadroxil 5.Clinda 6.Azith 7.Clarith

CAP

(Outpatient)

S.pneumoniae,Mycoplasmapneumoniae,

H.influ,Chlamydlopilia,virus

Empiric Tx w/ no risk factors for DRSP:

Macrolide, Doxy

Risk factors for DRSP: Moxy orLevo, B-lactam (Amox 1g TID,

Augm 2g BID, 2nd or 3rd) +Macrolide or Doxy



B-Lactam + (Azith or Quinolone)

CAP Macrolide, Quinolone

CAP Macrolide, Quinolone

CAP MRSA Clinda 900mg, Linezolid, Vanco

CAP

(Inpatient)

S.pneumoniae,

Mycoplasmapneumoniae,H.influ,

Chlamydlopilia,legionella,anaerobes, virus

Moxy or Levo, B-lactam + Macrolide

(usually Ceftriaxone 1g QD + Z pack

CAP (ICU)

S.pneumoniae,S.aureus,H.influ,

legionella, Gramneg bacilli(entero andpseudo), virus

Pseudo: (Pip/tazo, cefepime,

imi/mero) + Cipro, Levo,aminoglycoside, Z-pack

Sdd Oseltamivir or

Zanamivir if influenza and <48 H

Legionella-Severepresentation.Urinary antigen

test forconfirmation

M.pneumoniae (Walkingpneumonia)

RASH, flu-like

Sx. No good Dxtest.

HAP (1st 4days - noMDR riskfoactors)

S.pneumo,H.influ, MSSA,Gram (-)

Ceftriazone, Levo or Moxy or Cipro,Amp/Sulbactam, Ertapenem



C. diff C.diff Metronidazole 250mg PO QID Vanco 125mg PO QID Bacitracin

E.coli

HAP (Late

onset - MDRrisk)

Pseudo, ESBLklebs,Acinetobacter,MRSA, Legionella

Pseudo coverage + more pseudocoverage+MRSA coverage. Streamilnetx when cultures come back. Tx 10-21days

Tuberculosis (Latent)

Isoniazid 300mg QD (x 6-9 mo.) + B625-50mg QD to prevent periphralneuropath

Isoniazid + Rifampin 600mgQD (Both Hepatotoxic)

Tuberculosis

(Active)

Culture Postitive: Isoniazid +Rifampin + Pyrazinamide +Ethambutol QD x 8wks. --> repeatXray. If (-) = tx x 4 more mo. If (+) =tx x 7 more mo. Culture Negative: samebut @ 2 mo. If Xray has no change -->

not TB. If no PZA --> 7 mo.

Ethambutol (no hepatotoxicity) isemperic only. Remove when susresults are good for INH and RIF.Pyrazinamide 15-30mg/kg/day(Hepatotoxicity, hyperuricemiaand myalgias), Fluoroquinolones -

Moxy or Levo

Sttreptomycin,Cycloserine, P-Aminosalicyclic acid,ethionamide,capreomycin,Corticosteroids usedas adjunctive w/

meningitis andpericardiis

PrimaryPeritonitis

(Cerrhosis)

Cefoxatin (+ metronidazole if anaerobessuspected)

other 3rd Gen Cephs, extendedspectrum pens, aztreonam,

imipenem, quinolones

PrimaryPeritonitis(Dialysis)

Skin flora:Staph, Strep.Gram +/-

Empirically: Cefazolin +Ceftaz orCefepime. Cover Gram+/- and pseudox2-3wks

Cefazolin + Aminoglycoside.Avoid prolonged aminoglycosideuse to preserve residual renalfunction

Imipenem/Cilastinor Cefepime orQuinolones

SecondaryPeritonitis



Enterococcal

CatheterRelatedInfections

Staph (coagneg), S.aureus,Aerobic gramneg bacilli,

Candida, Pseudo

MSSA: Naf/Oxacillin, 1st Gens, vanco,TMP-SMX. MRSA: Vanco, VRSA:Dapto,Pseudo: Cefepime, Carbapenem, Zosy,Aminogycoside. Femoral catheter:

Vanco + broad spectrum + fungal

Postive blood culture: Always

treat S.aureus x2wks IV

CatheterRelatedInfections(Entero)

Amp or PCN +/- Gent x7-14days.Alternative: Vanco

Amp resistant: Vanco+/-Gent.VRE:Linezolid, Dapto orQuin/Dalfopristin

Endocarditis(STREP)

On followingpage



MIC

Amp or PCN + Gent x 4-6wks

Staph MRSA: Vanco

Enterococcal

NOT FINISHED!!!

Endocarditi

s (STREP)

S.viridan,

S.bovis

< 0.12mcg/ml

(LOW)

Penicillin (high dose) x 4weeks or Ceftriaxone X 4

weeks

High dose Pen G orCeftriaxone + Gentamycin x

2 weeks - Gent pk-3-4, tr<1

Endocarditi

s (STREP)

S.viridan,

S.bovis

>0.12-0.5mcg/ml

(MODERATE)

Penicillin (high dose) x 4weeks or Ceftriaxone X 4

weeks + Gent for 2 wks

Endocarditis (STREP)

S.viridan,S.bovis

>0.5mcg/ml(HIGH)

Endocarditis (STAPH)

MSSA: Nafcillin or Oxacillin x4-

6 wks + Short course of

Gentamycin.

Endocarditis (Prosthetic

valve)

MSSA: Nafcillin or Oxacillin x 6weeks + aminoglycoside for

1st 2 weeks.

MRSA: Vanco + rifampin x 6weeks + aminoglycoside for

1st 2 weeks.Endocarditis

(ENTEROCO

CCAL)

High dose Pen G or Amp +

Gent x 6 weeks

Vanco or Amp/sulbactam +

Gent x 6 weeks



Pen allergy: Vancomycin.Resistant organisms: vanco

+ Pen or Ceftriaxone for 1st 2 weeks.

Mild Pen alergy: 1st genceph. True Pen allergy:Vanco - slow and lesseffective - candidate for pendesensitization



DRUG Class Strep Staph Entero E. coli Proteus Kleb H. influ M. cat Pseudo MRSA Anaerob Atypicals

Penicillin

Ampicillin

Amox

Naficillin

Oxacillin

dicloxacillin

ticarcillin

piperacillin

Aztreonam

Ertapenem

Mero/Doripenem

Imipenem

1st gen Cephs2nd gen Cephs

3rd gen Cephs

4th gen Cephs

5th gen Cephs

Tobramycin

Gentimicin

Amikacin

Streptomycin

Neomycin

Kanamycin

Paromomycin

Norfloxacin

Ciprofloxacin

ofloxacin

Levofloxacin

Gemifloxacin

Moxifloxacin

SMX/TMP

sulfisoxazole

Sulfadiazine



DRUG Class Strep Staph Entero E. coli Proteus KlebsH. influ M. cat Pseudo MRSA Anaerob Atypicals

Erythromycin

Clarithrymycin

Azithromycin

Telithromycin

Clindamycin

Metronidazole

Tetracycline

Demeclocycline

Doxycycline

minocycline

Tigecyclin

Polymixin

VancomycinTelavancin

Quin/Dafopristine

Linezolid

Daptomycin

Nitrofurantoin

Peripheral Brain - Bugs and Drugs

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