• Gram-Positive 🡪 purPle

• If postive then use coagulase test, if coagulase positive it is Staph aureus

• Atypicals 🡪 no color

• MSSA

• MRSA

• Normal Skin Flora

• Saprophyticus → coagulase (-)

• Pyogenes (Group A Strep → GAS)

• 1 Cause of Neonatal Meningitis

• Pneumoniae (Pneumococcus) → Strep pneumoniae

• Normal Flora

• Facium M = More resistant

• Facealis

• Listeria

• Anthrax

• Diphtheriae

Gram (+) Anaerobes

• Peptostreptococcus

• Tetani

• Difficile

• Botulism

• Perfringens (gangrene)

Gram (-) Cocci:

• Gonorrhea

• Meningitidis

• Catarrhalis

Gram (-) Rods: → usually GI

• Proteus

• E. Coli

• Klebsiella

• Haemophilus Influenzae

• Pseudomonas → gram (-) and lactose (-)

Curved/Spiral GNR

• H. Pylori

• Salmonella

• Shigella

• Campylobacter

Gram (-) Anearobe

B. Fragilis

*

Gram (+) Cocci:

• Tx: PCN family

• Strep Throat

• Cellulitis

• 1 Cause of Neonatal Meningitis

• Screening during pregnancy at 35-37 weeks

• Tx: Ampicillin or Penicillin G during contractions to prevent baby sepsis

• Mild PCN Allergy: IV Cefazolin

• Severe PCN Allergy: IV Clindamycin

• 1 Cause of many infections above the diaphragm → CAP, Otitis Media (middle ear infection), Bacterial Sinusitis, Meningitis

• 1 Cause of Meningitis

• Normal Flora, can cause effective endocarditis and dental procedures

• Tx: Dicloxacillin PO, Nafcillin IM/IV, Oxacillin IM/IV

• Others: Linezolid (Zyvox), Tedizolid (Sivextro), Delafloxacin (Baxdela)

• IV: Vancomycin (1st Line), Clindamycin, Linezolid, Tedizolid, Delafloxacin, Daptomycin (Cubicin), Ceftaroline (Teflaro), Vancins (Telavancin)

• MRSA Pneumonia Tx: Vancomycin, Linezolid, Televancin

• Also used in MRSA Colonization Eradication

• Normal Skin Flora

• UTI

• Facium

• Facealis

• Normal GI flora → large intestine

• Traditional: Ampicillin + Gentamicin

• Newer: Ampicillin + Ceftriaxone

• Ampicillin Resistant: Vancomycin + Gentamicin

• VRE: Daptomycin, Linezolid, Televancin, Ortivancin

Gram (+) Rods:

• Airborne droplets, contact, tissue damage from toxin

• Toxin → Pseudomembrane back to tonsils

• PCN or Erythromycin

• Close contact prophylaxis

• Contaminated dairy or vegetables

• Infection spreads to blood and causes Sepsis or Meningitis (Neonatal Meningitis)

• PCN Allergy: Bactrim, Vancomycin, Quinolones

• Vaccine for high risk and military

• Tx: Antitoxin + Ciprofloxacin, Doxycycline, Clindamycin, Meopenem, Linezolid

• Give Tetanus Toxoid Vaccine (Td or Tdap 3 doses 2 weeks apart)

• Soil, enters in wounds and produces toxin

• Alternative: PCNG IV

• Fecal Oral Transmission

• Spore forming → clean with soap and water

• Contact Precautions → Wash (soap), Gown, Gloves

• All antibiotics can cause C.Diff

OR

• Alternative: Metronidazole 500 mg PO TID 10d

• If C. Diff recurs in <6 months give Bezlotuxamib (Zinplava)

• Botulism

• Injury or Open Wound: Pip/Tazo + Clindamycin

• Directed Treatment: PCN + Clindamycin or Tetracycline

Gram (-) Cocci: → Diplococci

• Signs: HA, Neck Rigidity, Fever, N/V, light sensitivity, altered mental status

• Prophylaxis: Vaccine

• Adults: Ceftriaxone + Vancomycin (D/C Vanc after 48 hrs)

• If >50 yo + Ampicillin (covers Listeria)

• (+/-) Dexamethasone (decreases inflammation around brain)

• If Chlamydia is not excluded + Doxycycline 100 mg PO BID 7d

• Cephalosporin Allergy: Azithromycin 2 g + Gentamicin (240 mg IM) (320 mg PO)

• Neonatal Blindness Tx: Erythromycin Ophthalmic Ointment

• Otitis Media, Sinusitis

Gram (-) Rods: → usually GI

• Bladder → Acute Cystitis

• Kidney → Pyelonephritis

• Urosepsis (from kidneys into the bloodstream) → Septic Shock

• E. Coli Diarrhea, most abundant in colon and feces

• Causes Neonatal Meningitis

• Bladder → Acute Cystitis

• Kidney → Pyelonephritis

• Cystic Fibrosis Pneumonia, Swimmers ear

• Wounds, Burns

• Antipseudomonal PCN: Pip/Tazo (Zosyn)

• Ceftazidime + Avibactam → Avycaz

• Ceftolozane + Tazobactam → Zebrax

• Carbapenems: Doripenem, Meropenem, Imipenem

• Fluoroquinolones: Ciprofloxacin, Levofloxacin

• Monobactam: Aztreonam

• Klebsiella

• Diagnosis → Urea Breath Test

• Tx:

• Triple Therapy: Clarithromycin + Amoxicillin (PCN Allergy: Metronidazole) + PPI-BID (Lansoprazole, Omeprazole, Pantoprazole) → Prevpac

• Bismuth Quadruple Therapy: Metronidazole + Tetracycline + Bismuth + PPI-BID → Pylera

• Contamination Therapy: Clarithromycin + Amoxicillin + Metronidazole + PPI-BID

• Salmonella

• Shigella Campylobacter

• Most common below diaphragm, important colon bug

• Other: Carbapenems, B-Lactamase Inhibitor Combos → Amp/Sulbactam, Meropenem, Cefoxitin

• Otitis Media, Meningitis, Pneumonia

• HIB Vaccine

• Tx: Ceftriaxone or Cefotaxime

Other Bacteria:

• Intracellular Gram (-) Bacterium. Less discharge than gonorrhea

OR

Levofloxacin 500 mg PO qd 7d

• Prevention of Neonatal Blindness: Erythromycin Ophthalmic Ointment

• No cell wall, can't use a gram stain

• Can cause CAP

• Alternative: 3rd/4th Generation Quinolones

• Spirochete Bacteria

• Testing: Rapid Plasma Reign (RPR), VDRL

• Primary: Painless genital ulcer (early)

• Secondary: Rash on palms and soles

• Early → <1 year

• Latent → >1 year

• Tertiary: Heart or CNS effects (neurosyphilis)

• Parental PCN G → Benzathine (Bicillin-LA) IM once 2.4 mill/units

• Desensitize to PCN: if pregnant or HIV+ with poor compliance

• Heart: Bicillin-LA IM weekly for 3 weeks

• CNS (neurosyphilis): Penicillin G IV q4hrs for 10-14d

• Spirochete Bacteria

• Deer ticks → north west and north eastern areas

• Prophylaxis: Doxycycline 200 mg PO once

• Early localized → 10-14d

• Lyme Carditis → 14-21d

• Lyme Arthritis → 28d

• Neurological → Doxycycline PO or Ceftriaxone IV 14-21d

CAP:

• Bacterial: Strep. Pneumo (Pneumococcus → #1 CAUSE), H. Influenza, Moraxella, E.Coli, Klebsiella, Mycoplasma, Chlamydia

• Viral: Influenza, RSV, Rhinovirus

• Outpatient PO, Inpatient IV

• High Dose Amoxicillin 1g

• HIVES: Cephalosporin 3rd generation + Doxycycline + Macrolide

• PCN Allergy (not hives): Levofloxacin + Doxycycline + Macrolide

• If Macrolide Allergy: Augmentin + Doxycycline

• If Macrolide Allergy: Cephalosporin 3rd generation + Doxycycline

HAP:

• Pseudomonas and MSSA

• Pip/Tazo (Zosyn) 4.5 g IV q6h

• Ceftazidime (Fortaz)

• Cefepime

• Levofloxacin (Levaquin)

• Imipenem or Meropenem

• Aztreonam → only covers Gram (-) and pseudomonas

• If MRSA risk then ADD → Vancomycin, Linezolid, Tedizolid

1 drug for pseudomonas if little resistance risk

1 drug for pseudomonas plus 1 drug for MRSA if MRSA risk (like positive for MRSA of the nares)

2 drugs for pseudomonas plus 1 drug for MRSA if MDR (IV abx use in the last 90 days)

Do not use two beta lactams together

Endocarditis:

• Causes: Staph. Aureus, Strep. Viridians, Enterococcus, Candida, Pseudomonas

• Vegetations are shown by echocardiogram, 3 sets of blood cultures

• MSSA: Nafacillin

• MRSA: Vancomycin

• Strep → PCN Family

• PCN Allergy → Cephalexin 2 g or Azithromycin 500 mg or Clarithromycin 500 mg or Doxycycline 100 mg

Cellulitis:

• Skin infections

• Tx: Cephalexin

• Tx: Topical → Bactrim, Doxycycline, Clindamycin

• Erysipelas → red border is very sharp

Diverticulitis:

• Tx: High fiber diet

• Ciproflocacin or Levofloxacin + Metronidazole

• Bactrim + Metronidazole

• Amoxicillin + Clavulanate (Augmentin)

Bacterial Causes of Otitis Media: (in order)

1. Pneumococcus

2. Haemophilus

3. Moraxella

Tx: Amoxicillin or Amoxicillin + Clavulanate

Alternative: Ceftriaxone

Bacterial Causes of Neonatal Meningitis: (in order)

1. Strep Agalactiae (Group B Strep → GBS)

2. Listeria

Tx: Ampicillin + Gentamicin + Cefotaxime

Bacterial Causes of Meningitis: (in order)

1. Pneumococcus → Strep Pneumo

2. Neisseria Meningitidis

Tx: Ceftriaxone + Vancomycin

Close Contacts: Vaccine + Antibiotic prophylaxis

UTI:

1. (+) Leukocytes

2. (+) nitrates

1. Pseudomonas

2. E. Coli → most common cause

3. Klebsiella

4. Enterococcus

5. Proteus

6. Staph → Saprophyticus

1. Bactrim → Avoid in 1st trimester or at term and SULFA ALLERGY

2. Nitrofurantoin (Macrobid) → young healthy female, not pregnant, CrCl <60

1. okay in pregnancy

4. Ciprofloxacin

1. Cephalexin or amox DOC for pregnancy

1. Frequency

2. Urgency

3. Nocturia

4. Dysuria

5. Subapubic Pressure

1. Ciprofloxacin

2. Levofloxacin

2. Bactrim

3. Ceftriaxone

2. Symptoms: Fever, Chills, N/V, Flank Pain

Pregnancy:

BAD

PCN, Cephalosporins

Erythromycin, Azithromycin

Clindamycin

Nitrofurantoin

• 2nd trimester and most of 3rd

Tetracyclines (2nd/3rd trimester)

• Stains teeth

Fluroquinalones

Bactrim

• Birth defects in 1st trimester

Clarithromycin

Aminoglycosides

• Auditory dysfunction

Metronidazole (1st trimester)

• Avoid in 1st trimester due to birth defects

Nitrofurantoin

• Avoid Avoid in 1st trimester due to cardiac birth defect. Avoid during delivery

Storage:

DO NOT RF

Augmentin → RT 6 hrs

PCN VK

Clarithromycin (Biaxin)

Clindamycin (Cleocin)

Cefdinir (Omnicef)

Bactrim

Antibiotic Overview:

PCN, Cephalosporins, Carbapenems, Aztreonam, Vancomycin, Televancin, Oritavancin, Dalbavancin

Cell Wall Integrity

Beta-Lactamase

DNA Synthesis

Metronidazole

DNA Gyrase

Fluoroquinolones

Folate Synthesis

Bactrim

Protein Synthesis 30S

Aminoglycosides, Tetracyclines

Protein Synthesis 50S

Erythromycin, Clindamycin, Linezolid, Tedizolid, Telithromycin

Drugs

Penicillins PCN ALLERGY

• MOA: Inhibit cell wall synthesis, renally eliminated

• ADR: Bronchospasm, Seizure, Diarrhea, HIVES, Renal

• CrCl < 30 → AVOID

• Good in Pregnancy

• Bicillin C-R and Bicillin L-A CAN NOT BE SWITCHED

• Spectrum: Strep, Treponema Pallidum (Syphilis), dental prophylaxis/infection

• Also used in gout

• Used for Staphylococcus Aureus MSSA

• IV → ON

• PO → D

• Dicloxacillin PO EMPTY STOMACH

• Oxacillin IV

• Hepatic elimination, No renal dose adjustment needed

• IM

• Not used in Neurosyphilis

• Only drug used in patients with Syphilis and Pregnant

• IM

• Not used in syphilis

• IV

• Indication: Pneumococcal, Meningitis, Neurosyphilis, Anthrax

• PO → EMPTY STOMACH

Aminopenicillins: PCN ALLERGY

• Spectrum: Strep, Enterococci, Listeria

• Good in renal patients

• PO, IV

• EMPTY STOMACH

• DOC for Enterococci

• PO: 500 mg q8hr empty stomach

• IV: 1-2 g q4-6h RT 14d

• DOC for Otitis Media

• Otitis Media → 90 mg/kg/d

• Strep Throat → Montag ER 775 mg PO qd

• Dental Prophylaxis → 2 g PO (50 mg/kg) 1 hr before

Beta-Lactamase Inhibitors: PCN ALLERGY

• Used in combo to broaden coverage.

• IV

• Covers everything Pseudomonas

• IM, IV → NS

• PO, Chewable, Suspension → RF 10d, RT 6 hrs

• WITH FOOD

• DO NOT take 2 of the lower doses to make a higher dose → Calvulanate Acid will accumulate causing severe Diarrhea

Penicillin IV

PCN VK

• 1st Line for Strep throat

Amoxicillin

• 1st Line for Otitis Media

• DOC for infective endocarditis

• H. Pylori

Amoxicillin + Clavulanate (Augmentin)

• 1st Line for Otitis Media

• Sinus infections

Dicloxacillin

PCN G (Bicillin L-A)

• DOC for Syphilis and Pregnant

Naffcillin, Oxacillin

Piperacillin + Tazobactam (Zosyn)

• Only PCN for Pseudomonas

Cephalosporins: PCN ALLERGY

• Close structurally to PCN, B-lactam antibiotic

• ADR: Seizures, GI upset, Diarrhea

• Mostly Gram (+) and MSSA

• PEK → Proteus, E. Coli (UTI), Klebsiella

• Good for UTI and pregnancy 500 mg BID

• DOC for surgical prophylaxis

• Greater activity for Gram (-)

• HENPEKS → H. Influenzae, Enterobacter, Neisseria, Proteus, E. Coli, Klebsiella, Strep. Pneumonia

• 2nd Line for Otitis media (1st line is Amoxicillin)

• Cefuroxime (Ceftin) PO/IM/IV

• Anaerobic coverage → B. Fragilis

• NMTT Side Chain

• Anaerobic coverage → B. Fragilis

• Cefprozil (Cefzil) PO

• Enhanced Gram (-) activity

• RT → do not RF the suspension

• Seperate antacids/multivitamins/iron by >2 hrs

• Cefixime (Suprax)

• Cefpodoxime (Vantin)

• Antipseudomonal (Pseudomonas), intraabdominal, and HAP, UTI

• Ceftazidime + Avibactam (B-lactamase) → Avycaz IV

• Cefotaxime (Claforan)

• Meningitis/Endocarditis → 2 g IV q12h

• IM in glutes → with lidocaine to decrease pain

• Do not reconstitute with Ca products → like lactated ringers

• Give lidocaine for pain

• Hospital use only

• Only cephalosporin that covers MRSA Skin infection

• Used in CAP → MSSA

• Ceftolozane + Tazobactam (Zerbaxa) IV

• Ceftazidime (Fortaz, Tazicef) → 3rd gen IM/IV

• Cefepime → 4th gen IM/IV

• Ceftolozane + Tazobactam (Zerbaxa) → 5th gen → given with Metronidazole

Cephalosporins IV

Cephalexin (Keflex)

• 1st generation

• MSSA, Strep throat

Cefuroxime

• 2nd generation

• Otitis media, CAP, sinus infections

Cefdinir

• 3rd generation

Cefazolin

• 1st generation

• Surgical prophylaxis

Cefotetan and Cefoxitin

• 2nd generation

• B. Fragilis

• Surgical Prophylaxis

Ceftriaxone and Cefotaxime

• 3rd generation

• CAP, Meningitis, Pyelonephritis

Ceftazidime

• 3rd generation

• Pseudomonas

Cefepime

• 4th generation

• Pseudomonas

Ceftaroline

• 5th generation

• Only one for MRSA

Carbapenems: PCN ALLERGY

• Hospital use only → All IV

• Extended Spectrum B-lactamase (ESBL)

• Gram (+) → NO MRSA

• Gram (-)

• Anaerobes

• Good in Intra-abdominal infections, DOC for infectious pancreatitis

• AVOID with SEIZURES → can decrease Valproic Acid levels (seizure med)

• Imipenem causes most seizures

• Mixed in NS

• Cilastin prevents renal metabolism of Imipenem

• Least amount of Seizures

• Mixed in NS or D5W

• Only qd dosing

• Mixed in NS

• No activity against Pseudomonas or Enterococcus

• Mixed in NS or D5W

• Meropenem + Vaborbactam (Vabomere)

Monobactam: Good in PCN Allergy

• MOA: Inhibits cell wall synthesis

• Spectrum: Aerobic Gram (-) only including Pseudomonas

• Use if nephrotoxicity to aminoglycosides

Vancomycin: Ototoxicity and Nephrotoxicity

• PO, IV

• MOA: inhibits synthesis of cell wall phospholipids

• Good to use in PCN Allergy

• Bacteremia

• Pneumonia

• Osteomyelitis

• Endocarditis

• Meningitis

• AUC/MIC >400-600

• Peak: 20-30 mcg/mL

• Trough is drawn at steady state 30 min before 4th dose

• If a patient has Bacteremia, endocarditis, osteomyelitis, meningitis, HAP (from Staph. Aureus) trough levels should be 15-20 mcg/mL

• Red Man Syndrome → histamine release due to rapid infusion. Treat with Diphenhydramine. Do not discontinue due to Red Man Syndrome.

• 2nd Line for C. Diff

• 125 mg PO QID 10d

• LD: 25-30 mg/kg

• MD: 15-20 mg/kg over 1hr q8-12h

• CrCl 20-49 → 15-20 mg/kg qd

• CrCl <20 Serum concentration

Aminoglycosides:

• Concentration dependent killing → peaks are more important

• Avoid in patients (kids) that have tubes in their ears due to Ototoxicity

• Spectrum: Gram (-)

• Trough → drawn 30 min before 4th dose

• Peak → drawn 30 in after 4th dose ends → peaks are more important for these drugs

• Peak (highest amount in body): 5-10

• Trough (lowest amount in body): <2

• Peak: 20-30

• Trough: <5

• AVOID in PREGNANCY

• Peak: 5-10

• Trough: <2

Daptomycin (Cubicin):

• RT 12 hr or RF 48 hr → NS or LR

• Each vial is single use only

• MOA: Binds to cell membrane and causes rapid depolarization. Inhibition of Protein, DNR, RNA, without cell lysis.

• Stop Statin while using Daptomycin → restart Statin upon discharge due to myopathy

• Cant be used in lungs, binds to surfactant in lungs→ not for MRSA Pneumonia

• Can be used in MRSA Skin infections

• Linezolid (Zyvox) PO/IV

• Synercid

Fluoroquinolones:

• MOA: Inhibits Bacterial DNA gyrase

• Indications: CAP, UTI, STD

• Spectrum: Gram (-), Atypicals (mycoplasma, legionella, chlamydia)

• BOX: Tendon Rupture (especially if on a corticosteroid)

• CI: Pregnancy, Children <18 yo, patients with myasthenia gravis

• 6 hrs after antacids

• 2hrs before antacids

• NEVER in CAP

• NG Tube → Crush IR for use

• PO → 250-500 mg q12h → XR qd dosing

• IV → 200-400 mg q12h

• IV = 80% of PO Dose

• CrCl 30-50 → q12hr

• CrCl <30 → 200-500 mg q18-24h

• Can increase levels of Theophylline and Warfarin

• Respiratory quinalone → good for pneumonia

• Respiratory tract (CAP), SSTI, UTI

• IV→ PO 1:1 (Same dose)

• BOX: TENDON RUPTURE

• Aerobic Bacteria

• Ophthalmic solution (Eyes)

• PO

• Discontinue if patient gets RASH

• PO, IV

• Causes most QTc

• NOT FOR UTI

• Vigamox → ophthalmic solution TID

• Ophthalmic suspension (SHAKE)

• PO, IV

• Covers MRSA, Strep, E. Coli, Klebsiella, Pseudomonas, Enterobacter, CAP

Macrolides:

• MOA: Binds to ribosomal subunit 50S

• CYP3A4 Inhibitor

• ADR: ↑QTc

• Erythromycin

• GAS, Sinusitis, CAP, MAC

• Dose: 250-500 BID or 1000 mg qd (XL → WITH FOOD)

• CYP3A4

• ↑Levels of Carbamazepine, Digoxin, Lovastatin, Simvastatin, Theophylline

• Z-Pak → 500 mg on day 1, then 250 mg on days 2-5 → 6 pills for 5 days

• ZMAX → RT use within 12hrs, must be mixed at pharmacy

• Chlamydia and Gonorrhea → 1 g once

• MAC Prophylaxis (CD4 <50)→ 1200 mg qweek

• ADR: Hearing loss, ↑QTc

• C. Diff ONLY

• 200 mg PO BID 10d

Tetracyclines:

• MOA: Inhibits protein synthesis, Binds to 30S

• Spectrum: Gram (+) and (-) Aerobes, Mycoplasma, Chlamydia, Syphilis (in PCN ALLERGY)

• Caution: photosensitivity, ↑INR with warfarin, ↓PO contraceptives effects

• <8yo → tooth discoloration

• WITH FOOD and 8 oz water, sit up for 30 min

• Great in renal impairment

• Used in CAP and Lyme Disease (14d for lyme disease)

• Lyme Disease → 10-14d

• CAP → 100 mg PO/IV BID

• PO, IV

• 200 mg once, then 100 mg BID WITH FOOD and 8 oz water

• ADR: Hepatotoxicity, Lupus

• EMPTY STOMACH

• ADR: Photosensitivity, avoid Ca products and antacids

• AVOID: PREGNANCY (teeth staining), Children <8 yo (temporary stunting of growth)

Clindamycin (Ceocin):

• MOA: Inhibits protein synthesis, binds to 50S

• Suspension → RT and Shake

• Gram (+) and all Anaerobes

• Avoid Erythromycin, and decrease dose in renal

• BOX: #1 cause of C. Diff

Metronidazole (Flagyl):

• MOA: Disruption of bacterial DNA Synthesis

• Spectrum: C. Diff, B. Fragilis, Giardia

• CI: 1st trimester

• ADR: Disulfiram reaction, dark urine, metallic taste, Seizures, furry tongue, neuropathy

• IV → RF, if crystals re-disolve at RT, NS, Protect from light

• PO → EMPTY STOMACH

Nitrofurantoin (Macrobid):

• Uncomplicated UTI (Cystitis only)

• Qd dosing is for prophylaxis

• ADR: Brown urine, hepatotoxicity, pulmonary toxicity, peripheral neuropathy

• AVOID CrCl <60

• Pregnancy >38 weeks

• Infants

Fosfomycin (Monurol):

• Simple uncomplicated UTI in women

• 3 g single dose packet in ½ Cup (4 oz) water

• Bactrim → SULFA ALLERGY

• Nitrofurantoin → CrCl <60

• Uncomplicated UTI (Cystitis only)

Oxazolidinones:

• MOA: Binds to 50S

• Only Gram (+)

• IV → Isotonic, D5W

• Suspension → RT 21d

• Used in VRE, MRSA, and other Gram (+)

• ADR: Thrombocytopenia (↓Platelets), Peripheral neuropathy, optic neuropathy

• Dose: 600 mg PO/IV q12h

• Drug-Drug: MAO-I

• Pro-Drug

• PO, IV

Synercid (Quinupristine + Dalfopristin)

• MOA: inhibits protein synthesis

• Covers VRE, MRSA, and other Gram (+)

• D5W

• ADR: Myalgia, Arthralgia, Venous irritation

• Covers E. Faecium ONLY → saved usually for VRE UTI of this sort only due to ADRs

Glycines:

• MOA: Binds to 30S

• IV → RF 45 hr, reconstitute at RT 24 hr

• Pregnancy

• <8 yo → tooth discoloration

• Monitor INR (↑INR) → warfarin

• BOX: Death

Rifaximin (Xifaxan):

• Travelers Diarrhea

• IBS-D (Irritable bowel syndrome with diarrhea)

• Prevention of hepatic encephalopathy

Rifamycin (Aemcolo): used for colon

• Travelers diarrhea

• Non-invasive E. Coli

Lipoglycopeptides:

• MOA: inhibits cell wall synthesis

• Gram (+), MRSA and MSSA

• IV qd over 60 min (to reduce Red Man Syndrome → increased histamine release Tx with Benadryl)

• ADR: fetal risk, nephrotoxicity, N/V, ↑QTc

• D5W

• D5W

Trimethoprim + Sulfamethoxazole (Bactrim, Septra DS): → SULFA ALLERGY

• D5W (5 mL added to 125 mL D5W)

• NEVER RF

• Cloudy or crystals → TRASH

• Multi-dose vials are good for 48 hrs

• MOA: Inhibits bacterial dihydrofolate reductase, sulfonamide for synergism, inhibition of folic acid pathway

• If SULFA Allergy give Dapsone or Atovaquone

• Bone Marrow → Anemia, Leukopenia, Thrombocytopenia

• ↑K

• SJS (Rash), Photosensitivity

• G6PD deficiency

• PREGNANCY

• Crystal formation → drink water

• CrCl 15-30 → 50% dose

• CrCl <15 AVOID

• Warfarin → ↑INR (decrease warfarin dose 25-50%)

• Rifampin → ↓Bactrim levels

• 5:1 Ratio (SMX:TMP)

• Dosing is based on TMP

• IV → PO = 1:1

• Uncomplicated 3-5d

• Complicated 7-10d

• Pyelonephritis 14-21d

• Tx: 15-20 mg/kg/d TMP q6h 14-21d

• Prophylaxis (CD4 <200): 1 DS BID

Antifungals

Molds

Dimorphics

Dermatophytes

Unicellular

Multicellular

Can be unicellular yeasts or multicellular molds

Tineas

Candida

Aspergillus

Histoplasma

Blastomyces

Tinea Capitis → Scalp

Tinea Corporis → Ringworm

Tinea Versicolor

Tinea Cruris → Jock itch

Tinea Pedis → Athlete's foot

Tinea Unguium (onychomycosis) → toe nails

Candida Albicans: Yeast

• Esophageal, oral, vaginal thrush, skin infections (Diaper Rash)

• Nystatin “swish and swallow” or Fluconazole

• Azole Fungal creams or Fluconazole (diflucan) 150 mg PO once

• Vision → 0.25% miconazole + Zn Oxide

Cryptococcus: Yeast

• Bird droppings (bats and pigeons), Decaying wood

• Fluconazole or Itraconazole

• Amp B + Flucytosine

Aspergillosis: Mold

• Airborne transmission

• DOC: Voriconazole (VFend)

MOA

Drugs

Polyenes

Binds to ergosterol

Amphotericin B

Azoles

Inhibits ergosterol synthesis

Fluconazole (Diflucan)

Itraconazole

Echinocandins

Caspofungin

Anidulafungin

Inhibits DNA synthesis

Flucytosine (5-FC)

Amphotericin B:

• MOA: Binds to ergosterol (cell membrane)

• ADR: Chills, HoTN, Nephrotoxicity, Shaking, ↓K, ↓Mg

• IV → D5W, Protect from light, RF 1 week, RT 24h

• Lipid → Amphotec, Abelcet, AmBisome

• Premedicate → Acetaminophen, Diphenhydramine, Hydrocortisone, Meperidine

Azoles:

• MOA: CYP3A4 Inhibitor, Cell membrane

• ADR: Hepatotoxicity

• PO, Solution

• Inj, Suspension

• DOC for aspergillosis

• PO, Cream

• Vaginal Candidiasis

• Oral and esophageal candidiasis

• PO, Cream, Shampoo

• Dandruff, Tinea Versicolor → Shampoo

• BOX: Hepatotoxicity

Terbinafine:

• Lamisil Cream 1% OTC qd/BID 1-4 weeks

• MOA: Cell membrane

• Finger Nails → 250 mg PO qd for 6 weeks

• Toe Nails → 250 mg PO qd for 12 weeks

Antivirals

Herpes:

• HSV-1 → Cold sores

• HSV-2 → Genital warts

• Varicella (Zoster) → Chickenpox and Shingles

• Renal → drink fluids

• 1st episode: 200 mg 5x a day for 10d

• Recurrence: 200 mg 5x a day for 5d

• Prophylaxis: 400 mg BID

• Zoster: 800 mg 5x a day for 7d

• Varicella: 800 mg QID for 5d

• Valacyclovir (Valtrex)

Influenza:

• Seasonal Allergies, Cold

• PO

• Caution in asthma/COPD and Milk protein allergy

• IV

• PO

Hepatitis:

• Fecal oral transmission from contaminated food or water (international travel)

• Hep A Vaccine → Vaqta, Havrix, Twinrix (Hep A + Hep B)

• Blood transmission (vertical, sexual)

• Hep B Vaccine → Engerix-B, Recombivax HB, Twinrix (Hep A + Hep B)

• Blood Transmission (IV drug users)

• No vaccine

Herpes:

• HSV-1 → cold sores

• HSV-2 → genital herpes

• Varicella → Chickenpox

• Zoster → Shingles

• Tx: Acyclovir (Zorivax), Valacyclovir (Valtrex), Famicyclovir

Criteria

Treatment

PCP

CD4<200

Bactrim (DOC)

Atovaquone (Mepron)

Toxoplasmosis

CD4<100

Treat only if (+)

Bactrim

Dapsone

MAC

CD4<50

Azithromycin 1 g weekly

Candidiasis (thrush)

Fluconazole

CMV (Cytomegalovirus)

Valganciclovir

Ganciclovir

Antibiotics

Antibiotics

Gram Stains:

• Gram-Positive 🡪 purPle

• If postive then use coagulase test, if coagulase positive it is Staph aureus

• Gram-Negative 🡪 piNk

• Atypicals 🡪 no color

Gram (+) Cocci:

• MSSA

• MRSA

• Normal Skin Flora

• Saprophyticus → coagulase (-)

• Pyogenes (Group A Strep → GAS)

• 1 Cause of Neonatal Meningitis

• Pneumoniae (Pneumococcus) → Strep pneumoniae

• Normal Flora

• Facium M = More resistant

• Facealis

Gram (+) Rods (Bacilli) :

• Listeria

• Anthrax

• Diphtheriae

Gram (+) Anaerobes

• Peptostreptococcus

• Tetani

• Difficile

• Botulism

• Perfringens (gangrene)

Gram (-) Cocci:

• Gonorrhea

• Meningitidis

• Catarrhalis

Gram (-) Rods: → usually GI

• Proteus

• E. Coli

• Klebsiella

• Haemophilus Influenzae

• Pseudomonas → gram (-) and lactose (-)

Curved/Spiral GNR

• H. Pylori

• Salmonella

• Shigella

• Campylobacter

Gram (-) Anearobe

B. Fragilis

*

Gram (+) Cocci:

• Tx: PCN family

• Strep Throat

• Cellulitis

• 1 Cause of Neonatal Meningitis

• Screening during pregnancy at 35-37 weeks

• Tx: Ampicillin or Penicillin G during contractions to prevent baby sepsis

• Mild PCN Allergy: IV Cefazolin

• Severe PCN Allergy: IV Clindamycin

• 1 Cause of many infections above the diaphragm → CAP, Otitis Media (middle ear infection), Bacterial Sinusitis, Meningitis

• 1 Cause of Meningitis

• Normal Flora, can cause effective endocarditis and dental procedures

• Tx: Dicloxacillin PO, Nafcillin IM/IV, Oxacillin IM/IV

• Others: Linezolid (Zyvox), Tedizolid (Sivextro), Delafloxacin (Baxdela)

• IV: Vancomycin (1st Line), Clindamycin, Linezolid, Tedizolid, Delafloxacin, Daptomycin (Cubicin), Ceftaroline (Teflaro), Vancins (Telavancin)

• MRSA Pneumonia Tx: Vancomycin, Linezolid, Televancin

• Also used in MRSA Colonization Eradication

• Normal Skin Flora

• UTI

• Facium

• Facealis

• Normal GI flora → large intestine

• Traditional: Ampicillin + Gentamicin

• Newer: Ampicillin + Ceftriaxone

• Ampicillin Resistant: Vancomycin + Gentamicin

• VRE: Daptomycin, Linezolid, Televancin, Ortivancin

Gram (+) Rods:

• Airborne droplets, contact, tissue damage from toxin

• Toxin → Pseudomembrane back to tonsils

• PCN or Erythromycin

• Close contact prophylaxis

• Contaminated dairy or vegetables

• Infection spreads to blood and causes Sepsis or Meningitis (Neonatal Meningitis)

• PCN Allergy: Bactrim, Vancomycin, Quinolones

• Vaccine for high risk and military

• Tx: Antitoxin + Ciprofloxacin, Doxycycline, Clindamycin, Meopenem, Linezolid

• Give Tetanus Toxoid Vaccine (Td or Tdap 3 doses 2 weeks apart)

• Soil, enters in wounds and produces toxin

• Alternative: PCNG IV

• Fecal Oral Transmission

• Spore forming → clean with soap and water

• Contact Precautions → Wash (soap), Gown, Gloves

• All antibiotics can cause C.Diff

OR

• Alternative: Metronidazole 500 mg PO TID 10d

• If C. Diff recurs in <6 months give Bezlotuxamib (Zinplava)

• Botulism

• Injury or Open Wound: Pip/Tazo + Clindamycin

• Directed Treatment: PCN + Clindamycin or Tetracycline

Gram (-) Cocci: → Diplococci

• Signs: HA, Neck Rigidity, Fever, N/V, light sensitivity, altered mental status

• Prophylaxis: Vaccine

• Adults: Ceftriaxone + Vancomycin (D/C Vanc after 48 hrs)

• If >50 yo + Ampicillin (covers Listeria)

• (+/-) Dexamethasone (decreases inflammation around brain)

• If Chlamydia is not excluded + Doxycycline 100 mg PO BID 7d

• Cephalosporin Allergy: Azithromycin 2 g + Gentamicin (240 mg IM) (320 mg PO)

• Neonatal Blindness Tx: Erythromycin Ophthalmic Ointment

• Otitis Media, Sinusitis

Gram (-) Rods: → usually GI

• Bladder → Acute Cystitis

• Kidney → Pyelonephritis

• Urosepsis (from kidneys into the bloodstream) → Septic Shock

• E. Coli Diarrhea, most abundant in colon and feces

• Causes Neonatal Meningitis

• Bladder → Acute Cystitis

• Kidney → Pyelonephritis

• Cystic Fibrosis Pneumonia, Swimmers ear

• Wounds, Burns

• Antipseudomonal PCN: Pip/Tazo (Zosyn)

• Ceftazidime + Avibactam → Avycaz

• Ceftolozane + Tazobactam → Zebrax

• Carbapenems: Doripenem, Meropenem, Imipenem

• Fluoroquinolones: Ciprofloxacin, Levofloxacin

• Monobactam: Aztreonam

• Klebsiella

• Diagnosis → Urea Breath Test

• Tx:

• Triple Therapy: Clarithromycin + Amoxicillin (PCN Allergy: Metronidazole) + PPI-BID (Lansoprazole, Omeprazole, Pantoprazole) → Prevpac

• Bismuth Quadruple Therapy: Metronidazole + Tetracycline + Bismuth + PPI-BID → Pylera

• Contamination Therapy: Clarithromycin + Amoxicillin + Metronidazole + PPI-BID

• Salmonella

• Shigella Campylobacter

• Most common below diaphragm, important colon bug

• Other: Carbapenems, B-Lactamase Inhibitor Combos → Amp/Sulbactam, Meropenem, Cefoxitin

• Otitis Media, Meningitis, Pneumonia

• HIB Vaccine

• Tx: Ceftriaxone or Cefotaxime

Other Bacteria:

• Intracellular Gram (-) Bacterium. Less discharge than gonorrhea

OR

Levofloxacin 500 mg PO qd 7d

• Prevention of Neonatal Blindness: Erythromycin Ophthalmic Ointment

• No cell wall, can't use a gram stain

• Can cause CAP

• Alternative: 3rd/4th Generation Quinolones

• Spirochete Bacteria

• Testing: Rapid Plasma Reign (RPR), VDRL

• Primary: Painless genital ulcer (early)

• Secondary: Rash on palms and soles

• Early → <1 year

• Latent → >1 year

• Tertiary: Heart or CNS effects (neurosyphilis)

• Parental PCN G → Benzathine (Bicillin-LA) IM once 2.4 mill/units

• Desensitize to PCN: if pregnant or HIV+ with poor compliance

• Heart: Bicillin-LA IM weekly for 3 weeks

• CNS (neurosyphilis): Penicillin G IV q4hrs for 10-14d

• Spirochete Bacteria

• Deer ticks → north west and north eastern areas

• Prophylaxis: Doxycycline 200 mg PO once

• Early localized → 10-14d

• Lyme Carditis → 14-21d

• Lyme Arthritis → 28d

• Neurological → Doxycycline PO or Ceftriaxone IV 14-21d

CAP:

• Bacterial: Strep. Pneumo (Pneumococcus → #1 CAUSE), H. Influenza, Moraxella, E.Coli, Klebsiella, Mycoplasma, Chlamydia

• Viral: Influenza, RSV, Rhinovirus

• Outpatient PO, Inpatient IV

• High Dose Amoxicillin 1g

• HIVES: Cephalosporin 3rd generation + Doxycycline + Macrolide

• PCN Allergy (not hives): Levofloxacin + Doxycycline + Macrolide

• If Macrolide Allergy: Augmentin + Doxycycline

• If Macrolide Allergy: Cephalosporin 3rd generation + Doxycycline

HAP:

• Pseudomonas and MSSA

• Pip/Tazo (Zosyn) 4.5 g IV q6h

• Ceftazidime (Fortaz)

• Cefepime

• Levofloxacin (Levaquin)

• Imipenem or Meropenem

• Aztreonam → only covers Gram (-) and pseudomonas

• If MRSA risk then ADD → Vancomycin, Linezolid, Tedizolid

1 drug for pseudomonas if little resistance risk

1 drug for pseudomonas plus 1 drug for MRSA if MRSA risk (like positive for MRSA of the nares)

2 drugs for pseudomonas plus 1 drug for MRSA if MDR (IV abx use in the last 90 days)

Do not use two beta lactams together

Endocarditis:

• Causes: Staph. Aureus, Strep. Viridians, Enterococcus, Candida, Pseudomonas

• Vegetations are shown by echocardiogram, 3 sets of blood cultures

• MSSA: Nafacillin

• MRSA: Vancomycin

• Strep → PCN Family

• PCN Allergy → Cephalexin 2 g or Azithromycin 500 mg or Clarithromycin 500 mg or Doxycycline 100 mg

Cellulitis:

• Skin infections

• Tx: Cephalexin

• Tx: Topical → Bactrim, Doxycycline, Clindamycin

• Erysipelas → red border is very sharp

Diverticulitis:

• Tx: High fiber diet

• Ciproflocacin or Levofloxacin + Metronidazole

• Bactrim + Metronidazole

• Amoxicillin + Clavulanate (Augmentin)

Bacterial Causes of Otitis Media: (in order)

1. Pneumococcus

2. Haemophilus

3. Moraxella

Tx: Amoxicillin or Amoxicillin + Clavulanate

Alternative: Ceftriaxone

Bacterial Causes of Neonatal Meningitis: (in order)

1. Strep Agalactiae (Group B Strep → GBS)

2. Listeria

Tx: Ampicillin + Gentamicin + Cefotaxime

Bacterial Causes of Meningitis: (in order)

1. Pneumococcus → Strep Pneumo

2. Neisseria Meningitidis

Tx: Ceftriaxone + Vancomycin

Close Contacts: Vaccine + Antibiotic prophylaxis

UTI:

1. (+) Leukocytes

2. (+) nitrates