NR I566 IMidterm IStudy IGuide
Week I1
-Things Ito Iknow Iabout Ieach Iof Ithe Imajor Iantibiotic Idrug Iclasses
Bactericidal Ivs. IBacteriostatic
• Bactericidal Iantibiotics Idirectly Ikill Ibacteria
o preferred Ifor Iimmunocompromised Ipatients Isuch Ias Ithose Iwith Idiabetes, IHIV, Ior Icancer I& Ifor Ithose
who Ihave Ioverwhelming Iinfections.
o Agents: Iaminoglycosides, Ibeta-lactams, Ifluoroquinolones, Imetronidazole, Imost Iantimycobacterial
Iagents, Istreptogramins, I& Ivancomycin.
• Bacteriostatic Iagents Iinhibit Ibacterial Iproliferation Iwhile Ithe Ihost's Iimmune Isystem Idoes Ithe Ikilling.
o Agents: Iclindamycin, Imacrolides, Isulfonamides, I& Itetracyclines
o Bactericidal Iagents: I“BANG IQ IR.I.P” I- IBeta-lactams, IAminoglicosides, INitroimidazoles I(Metronidazole),
IGlycopeptides I(Vancomycin), I Quinolones, IRifampicin, IPolymyxins I(Colistin)
o Bacteriostatic Iagents: I“Ms. IColt” I- IMacrolides, ISulfonamides, IChloramphenicol, IOxazolidinones,
ILincosamides I(Clindamycin), I Tetracyclines
*Bactericidal Iantibiotics Ikill Ibacteria Idirectly, I& Ibacteriostatic Iantibiotics Istop/weaken Ibacteria IfromIgrowing
Ito Ienable Ithe Iimmune Isystem Ito Itake Ihold Iof Iinfection*
Aminoglycosides I(narrow-spectrum Iantibiotics Iused Iprimarily Iagainst Iaerobic Igram-negative Ibacilli; Idisrupt IproteinIsynthesis
Iby Ibinding Ito Ithe I30S Iribosomal Isubunit, Iresulting Iin Irapid Ibacterial Ideath) I(p. I683)
• Examples: IGentamicin, ITobramycin, IAmikacin, INeomycin, IKanamycin, IStreptomycin, IParomycin, IPlazomicin I(p.
I687)
• Indications Ifor Iuse: ITreatment Iof Iserious Iinfections Icaused Iby Igram-negative Iaerobic Ibacilli I(Pseudomonas
Iaeruginosa, Ienterobacteriaceae, Itopical Iinfection, Iocular Ibacterial Iinfections, Iintestinal Iamebiasis, Icomplicated
IUTI) I(p. I687)
, • Contraindications I& Ihigh-risk Ipatients: IAminoglycosides Ishould Ibe Iused Iwith Icaution Iin Ipatients Iwith Irenal
Iimpairment, Ipreexisting Ihearing Iimpairment, I& Ithose Ireceiving Iototoxic I& Inephrotoxic Idrugs. I(pp. I685-687)
• Monitoring Ineeds: IAminoglycoside Ilevels I(peaks I& Itroughs) I& Irenal Ifunction Imust Ibe Imonitored. IMonitor Ifor
Ineurotoxicity, Iototoxicity, I& Inephrotoxicity.
• Which Iones Irequire Irenal Idosing Iadjustments Iand Ihow Imuch I(i.e., I25%, I50%, Ietc.): ITo Iavoid Iserious Itoxicity, Iwe
Imust Ireduce Idosage Isize Ior Iincrease Ithe Idosing Iinterval Iin Ipatients Iwith Ikidney Idisease. I(p. I685) I *Clarithromycin
• Patient Ieducation: I*Patients Ishould Ibe Iinformed Iabout Ithe Isymptoms Iof Ivestibular I& Icochlear Idamage I&
Iinstructed Ito Ireport Ithem.
• Lifespan Iconsiderations: I(p. I685)
Infants: IAminoglycosides Iare Iapproved Ito Itreat Ibacterial Iinfections Iin Iinfants Iyounger Ithan I8 Idays. IDosing Iis
Ibased Ion Iweight I& Ilength Iof Igestation.
Children/adolescents: IAminoglycosides Iare Isafe Ifor Iuse Iagainst Ibacterial Iinfections Iin Ichildren I& Iadolescents.
Pregnant Iwomen: IThere Iis Ievidence Ithat Iuse Iof Iaminoglycosides Iin Ipregnancy Ican Iharm Ithe Ifetus.
IBreastfeeding Iwomen: IGentamicin Iis Iprobably Isafe Ito Iuse Iduring Ilactation. IThere Iis Ilimited Iinformation
Iregarding Iits Iuse Iin Ithis Iway.
Older Iadults: ICaution Imust Ibe Iused Iregarding Idecreased Irenal Ifunction Iin Ithe Iolder Iadult.
Cephalosporins I(Beta-lactam Iantibiotics Isimilar Iin Istructure I& Iactions Ito Ithe Ipenicillins; Ibactericidal; Ioften Iresistant Ito
Ibeta-lactamases, I& Iactive Iagainst Ia Ibroad Ispectrum Iof Ipathogens; Imost Iwidely Iused Igroup Iof Iantibiotics) I(p. I669)
• Examples: I1st Igeneration: ICephalexin I(Keflex); I2nd Igeneration: ICefoxitin, ICefaclor I(Ceclor); I3rd Igeneration:
th th
ICefotaxime, ICefdinir, ICeftriaxone I(Rocephin); I4 Igeneration: ICefepime, I5 Igeneration: ICeftaroline
• Indications Ifor Iuse:
1st Igeneration: IStaphylococci Ior Istreptococci I(Use Iin Ipatients Iwith Imild IPCN Iallergy, Istrep Ipharyngitis, IskinIinfections,
I& Isurgical Iprophylaxis)
2nd Igeneration: IHaemophilus Iinfluenzae, IKlebsiella, Ipneumococci, I& Istaphylococci I(Otitis, Isinusitis, I& Irespiratory
Itract Iinfections)
3rd Igeneration: IPseudomonas Iaeruginosa, INeisseria Igonorrhoeae, I& IKlebsiella, ISerratia I(Meningitis, Igram-
Inegative Inosocomial Iinfections)
4th Igeneration: IPseudomonas Iaeruginosa I(Hospital-acquired Ipneumonia I& Icomplicated Iintra-abdominal I& IUTIs
Idue Ito Iresistant Ipseudomonas)
5th Igeneration: IMethicillin-resistant IStaphylococcus Iaureus I(MRSA-associated Iinfections). I(p. I671)
• Contraindications I& Ihigh-risk Ipatients: ICephalosporins Iare Icontraindicated Ifor Ipatients Iwith Ia Ihistory Iof Iallergic
Ireactions Ito Icephalosporins Ior Isevere Ireactions Ito Ipenicillin. IPatients Iusing Icefazolin I& Icefotetan Imust Inot
Iconsume Ialcohol. IUse Icefotetan, Icefazolin, I& Iceftriaxone Icautiously Iin Ipatients Itaking Iother Iagents Ithat Ialso
Ipromote Ibleeding I(anticoagulants, Ithrombolytics, INSAIDS, Ietc). I(pp. I670-671)
• Monitoring Ineeds: IMonitor Ifor Isigns Iof IC. Idif Iinfection I& Irenal Ifunction Iin Ipatients Iwith Irenal Iimpairment
Iand/or Iprolonged Iuse.
• Which Iones Irequire Irenal Idosing Iadjustments Iand Ihow Imuch I(i.e., I25%, I50%, Ietc.): IIn Ipatients Iwith Irenal
Iinsufficiency, Idosages Iof Imost Icephalosporins Imust Ibe Ireduced Ito Iprevent Iaccumulation Ito Itoxic Ilevels.
rd
I(EXCEPTION: ICeftriaxone I(3 Igeneration) Iis Ieliminated Ilargely Iby Ithe Iliver, Iso Idosage Ireduction Iis Iunnecessary Iin
Ipatients Iwith Irenal Iimpairment) I(p. I669)
• Patient Ieducation: I*All Icephalosporins Ican Ipromote IC. Idif Iinfection, Iso Ipatients Ishould Ibe Iinstructed Ito Ireport
Ian Iincrease Iin Istool Ifrequency.
• Lifespan Iconsiderations:
Infants: I3rd Igeneration Icephalosporins Iare Iused Ito Itreat Ibacterial Iinfections Iin Ineonates Ias Iwell Ias Iinfants.
IChildren/adolescents: ICephalosporins Iare Icommonly Iused Ito Itreat Ibacterial Iinfections Iin Ichildren, Iincluding
Iotitis Imedia I& Igonococcal I& Ipneumococcal Iinfections.
Pregnant Iwomen: IAll Icephalosporins Iappear Isafe Ifor Iuse Iin Ipregnancy.
Breastfeeding Iwomen: ICephalosporins Iare Igenerally Inot Iexpected Ito Icause Iadverse Ieffects Iin Ibreastfed Iinfants.
Older Iadults: IDoses Ishould Ibe Iadjusted Iin Iolder Iadults Iwith Idecreased Irenal Ifunction.
Tetracyclines I(broad-spectrum Iantibiotics Iactive Iagainst Ia Iwide Ivariety Iof Igram-positive I& Igram-negative Ibacteria;
Isuppress Ibacterial Igrowth Iby Ibinding Ito Ithe I30S Iribosomal Isubunit I& Iinhibiting Iprotein Isynthesis, Iextensive Iuse Ihas
,resulted Iin Iincreasing Ibacterial Iresistance—because Iof Ithis I& Ithe Iavailability Iof Iother Iantibiotics Iwith Igreater IselectivityI&
st
Iless Itoxicity, Itheir Iuse Ihas Ideclined I& Ithey Iare Irarely Idrugs Iof I1 Ichoice) I(p. I676)
• Examples: ITetracycline, IDemeclocycline, IDoxycycline, IEravacycline, IMinocycline, IOmadacycline, ISarecycline
• Indications Ifor Iuse: ITreatment Iof Itetracycline-sensitive Iinfections, Iacne, I& Iperiodontal Idisease. I1st Iline Idrugs Ifor
rickettsial Idiseases I(Rocky IMountain Ispotted Ifever, Ityphus Ifever, IQ Ifever); Iinfections Icaused Iby IChlamydia
Itrachomatis I(trachoma, Ilymphogranuloma Ivenereum, Iurethritis, Icervicitis); Ibrucellosis; Icholera; Ipneumonia
Icaused Iby IMycoplasma Ipneumoniae; ILyme Idisease; Ianthrax; I& Igastric Iinfection Iwith I H. Ipylori.
• Contraindications I& Ihigh-risk Ipatients: IContraindicated Iin Ipregnant Iwomen I& Iin Ichildren Iyounger Ithan I8 Iyears.
• Monitoring Ineeds: INone Irecommended.
• Which Iones Irequire Irenal Idosing Iadjustments Iand Ihow Imuch I(i.e., I25%, I50%, Ietc.): ITetracyclines Imay
exacerbate Irenal Iimpairment Iin Ipatients Iwith Ipreexisting Ikidney Idisease. IBecause Itetracycline I& Idemeclocycline
Iare Ieliminated Iby Ithe Ikidneys, Ithese Iagents Ishould Inot Ibe Igiven Ito Ipatients Iwith Irenal Iimpairment. IIf Ia Ipatient
Iwith Irenal Iimpairment Irequires Ia Itetracycline, Ieither Idoxycycline Ior Iminocycline Ishould Ibe Iused Ibecause Ithese
Idrugs Iare Ieliminated Iprimarily Iby Ithe Iliver. I(p. I677)
• Patient Ieducation: I*Should Inot Ibe Itaken Iwith Icalcium Isupplements, Imilk Iproducts, Iiron Isupplements,
Imagnesium-containing Ilaxatives, Ior Imost Iantacids Ibecause Ithey Ican Idecrease Itetracycline Iabsorption. I*GI
Idistress Ican Ibe Ireduced Iby Itaking Itetracycline Iwith Imeals. I*Advise Ipatients Ito Iavoid Iprolonged Iexposure Ito
Isunlight, Iwear Iprotective Iclothing, I& Iapply Ia Isunscreen Ito Iexposed Iskin. I*Patients Ishould Inotify Iprovider Iif
Isignificant Idiarrhea Ioccurs Iso Ithat Ithe Ipossibility Iof Ibacterial Isuperinfection Ican Ibe Ievaluated. I(pp. I676-678)
• Lifespan Iconsiderations: I(p. I678)
Children/adolescents: ITetracyclines Ishould Inot Ibe Iused Iin Ichildren Iyounger Ithan I8 Iyears Ibecause Ithey Imay Icause
Ipermanent Idiscoloration Iof Ithe Iteeth.
Pregnant Iwomen: IAnimal Istudies Ireveal Ithat Itetracyclines Ican Icause Ifetal Iharm Iin Ipregnancy. IThus, Ithis Iclass Iof
Idrugs Ishould Ibe Iavoided Iin Ipregnant Iwomen.
Breastfeeding Iwomen: IUse Iof Itetracyclines Iduring Itooth Idevelopment Ican Icause Ipermanent Istaining.
ITetracyclines Ishould Ibe Iavoided Iby Ibreastfeeding Iwomen.
Older Iadults: ITetracyclines Ican Iinteract Iwith Idrugs, Iincluding Idigoxin. IIn Ithe Iolder Iadult Iwho Itakes Imany
Imedications, Icheck Ifor Iinteractions.
Penicillins I(Beta-lactam Iantibiotics; Iactive Iagainst Ia Ivariety Iof Igram-negative I& Igram-positive Ibacteria, Ilow Itoxicity,
Ibactericidal Iby Idisrupting Ithe Isynthesis Iof Ithe Icell Iwall Ithrough Iinhibition Ior Itranspeptidases I& Ipromoting Icell Iwall
Idestruction Ithrough Iactivating Iautolysins) I(p. I662)
• Examples:
Narrow-spectrum Ipenicillins/penicillinase Isensitive: IPenicillin IG, IPenicillin IV
Narrow-spectrum Ipenicillins/penicillinase Iresistant I(antistaphylococcal Ipenicillins): INafcillin, IOxacillin,
IDicloxacillin
Broad-spectrum Ipenicillins I(aminopenicillins): IAmpicillin, IAmoxicillin
Extended-spectrum Ipenicillin I(antipseudomonal Ipenicillin): IPiperacillin.
Penicillin/Beta-Lactamase Icombinations: IAmpicillin/sulbactam I(Unasyn), IAmoxicillin/clavulanate I(Augmentin),
IPiperacillin/tazobactam I(Zosyn)
• Indications Ifor Iuse: ITreatment Iof Iinfections Icaused Iby Isensitive Ibacteria.
Narrow-spectrum Ipenicillins/penicillinase Isensitive: IStreptococcus, INeisseria, Imany Ianaerobes, Ispirochetes, I&Iothers
Narrow-spectrum Ipenicillins/penicillinase Iresistant I(antistaphylococcal Ipenicillins): IStaphylococcus Iaureus
IBroad-spectrum Ipenicillins I(aminopenicillins): IHaemophilus Iinfluenzae, IEscherichia Icoli, IProteus Imirabilis,
Ienterococci, I& INeisseria Igonorrhoeae
Extended-spectrum Ipenicillin I(antipseudomonal Ipenicillin): ISame Ias Ibroad-spectrum Ipenicillins I+ IPseudomonas
Iaeruginosa, IEnterobacter, IProteus, IBacteroides Ifragilis, I & Imany IKlebsiella
• Contraindications I& Ihigh-risk Ipatients: IPenicillins Ishould Ibe Iused Iwith Iextreme Icaution Iin Ipatients Iwith Ia Ihistory
Iof Isevere Iallergic Ireactions Ito Ipenicillins, Icephalosporins, Ior Icarbapenems.
• Monitoring Ineeds: IRenal Iimpairment Ican Icause Ipenicillins Ito Iaccumulate Ito Itoxic Ilevels. IMonitor Ifunction Iin
Ipatients Iwith Irenal Idisease.
, • Which Iones Irequire Irenal Idosing Iadjustments Iand Ihow Imuch I(i.e., I25%, I50%, Ietc.): I*Amoxicillin, IAugmentin,
IPenicillin
• Patient Ieducation:
• Lifespan Iconsiderations: I(p. I666)
Infants: IPenicillins Iare Iused Isafely Iin Iinfants Iwith Ibacterial Iinfections, Iincluding Isyphilis, Imeningitis, I& Igroup IA
Istreptococcus.
Children/adolescents: IPenicillins Iare Ia Icommon Idrug Iused Ito Itreat Ibacterial Iinfections Iin Ichildren.
IPregnant Iwomen: IAlthough Ithere Iare Ino Iwell-controlled Istudies Iin Ipregnant Iwomen, Ievidence Iwe Ido Ihave
nd rd
Isuggests Ithere Iis Ino I2 Ior I3 Itrimester Ifetal Irisk.
Breastfeeding Iwomen: IAmoxicillin Iis Isafe Ifor Iuse Iin Ibreastfeeding Imothers. IData Iare Ilacking Iregarding
Itransmission Iof Isome Iother Ipenicillins Ifrom Imother Ito Iinfant Ithrough Ibreast Imilk.
Older Iadults: IDoses Ishould Ibe Iadjusted Iin Iolder Iadults Iwith Irenal Idysfunction.
Sulfonamides I(usually Ibacteriostatic; Isuppress Ibacterial Igrowth Iby Iinhibiting Ithe Isynthesis Iof Itetrahydrofolate, Ia Ifolate
Iderivative; Ibroad-spectrum Iantimicrobials) I(p. I689)
• Examples: ISulfadiazine, ISulfamethoxazole, ISulfacetamide Iophthalmic I(Trimethoprim Iis INOT Ia Isulfonamide, Ibut IitIis
Iincluded Ihere Idue Ito Iits Isame Imechanism Iof Iaction=suppressing Ithe Isynthesis Iof Itetrahydrofolate IAND Iis
Icombined Iwith Isulfamethoxazole Ito Iform Ithe Imedication IBactrim.)
• Indications Ifor Iuse: IPrimarily Iused Ito Itreat IUTIs. IOther Imajor Iuses Iare Itopical Ito Itreat Isuperficial Iinfections Iof Ithe
Ieyes I& Ito Isuppress Ibacterial Icolonization Iin Iburns. IAlso Iuseful Ifor Inocardiosis, IListeria Ispecies Iinfection, I&
Iinfection Iwith IP. Ijirovecii. IUsed Ias Ialternatives Ito Idoxycycline I& Ierythromycin Ifor Iinfections Icaused Iby IC.
Itrachomatis. IUsed Iin Iconjunction Iwith Ipyrimethamine Ito Itreat I2 Iprotozoal Iinfections: Itoxoplasmosis I& Imalaria
Icaused Iby Ichloroquine-resistant IPlasmodium Ifalciparum. ISulfasalazine Iis Iused Ito Itreat Iulcerative Icolitis.
• Contraindications I& Ihigh-risk Ipatients: ISulfonamides Iare Icontraindicated Ifor Inursing Imothers, Ipregnant Iwomen
st
Iin Ithe I1 Itrimester I& Ialso Ithose Inear Iterm, I& Iinfants Iyounger Ithan I2 Imonths. IAn Ialternative Iantibiotic Imust Ibe
chosen Ifor Ipatients Iwith IG6PD Ideficiency I(can Icause Ihemolytic Ianemia). IExercise Icaution Iin Ipatients Iwith Irenal
Iimpairment—may Irequire Ia Ireduced Idosage. ITrimethoprim Iis Icontraindicated Iin Ipatients Iwith Ifolate Ideficiency
I(manifested Ias Imegaloblastic Ianemia) I& Ishould Ibe Iavoided Iwhen Ifolate Ideficiency Iis Ilikely I(patients Iwith
Ialcoholism I& Ipregnant Iwomen).
• Monitoring Ineeds: I*CBC Ishould Ibe Imonitored Iif Ithe Ipatient Idevelops Isigns Ior Isymptoms Iof Iblood Idisorders, Ias
Ishould ICD4+ Icount Ifor Ipatients Iwith IHIV. I*Signs I& Isymptoms Iof Ihypersensitivity Ireactions I& Iof Iresolution Iof
infection Ishould Ialso Ibe Iassessed. I*If Ihyperkalemia Iis Isuspected Idue Ito Iuse Iof Itrimethoprim, Ipotassium Imust Ibe
Ichecked I4 Idays Iafter Istarting Itreatment. I(p. I694)
• Which Iones Irequire Irenal Idosing Iadjustments Iand Ihow Imuch I(i.e., I25%, I50%, Ietc.): IFor Ipatients Iwith Ia
Icreatinine Iclearance I(CrCl) Iof I15-30 ImL/min, Iproviders Ishould Iprescribe I50% Iof Ithe Itypical Irecommended Idose. IIf
ICrCl Ifalls Ibelow I15 ImL/min, Idrug Imust Ibe Idiscontinued I (p. I694) I*Bactrim
• Patient Ieducation: I*Instruct Ipatients Ito Icomplete Ithe Iprescribed Icourse Iof Itreatment Ieven Ithough Isymptoms
Imay Iabate Ibefore Ithe Ifull Icourse Iis Iover. I*Patients Itaking Ioral Isulfonamides Ishould Idrink Iat Ileast I8 Ito I10 Iglasses
Iof Iwater Ior Iother Inoncaffeinated Ifluids Iper Iday Ito Idecrease Ithe Irisk Ifor Icrystalluria. I(Caffeine Imay Ibe Itaken Iin
Iaddition Ito Ithe Iother Ifluids). I*To Iprevent Iphotosensitivity Ireactions, Iadvise Ipatients Ito Iavoid Iprolonged Iexposure
Ito Isunlight, Iwear Iprotective Iclothing, I& Iapply Isunscreen Ito Iexposed Iskin. ITanning Ibeds Ishould Ibe Iavoided.
*Patients Ishould Ibe Iinstructed Ito Iobserve Ifor Ialterations Ithat Imay Iindicate Ihypersensitivity I& Ireport ItheseIpromptly
Iif Ithey Ioccur.
• Lifespan Iconsiderations:
Infants: IUse Iof Isulfonamides Iin Iinfants Iyounger Ithan I2 Imonths Ican Icause Ikernicterus I(deposition Iof Ibilirubin IinIthe
Ibrain—neurotoxic I& Ican Icause Isevere Ineurologic Ideficits I& Ieven Ideath).
Pregnant Iwomen: ISystemic Isulfonamides Imay Icause Ibirth Idefects, Iespecially Iif Itaken Iduring Ithe I1st Itrimester. IIf
Itaken Inear Iterm, Ithe Iinfant Imay Idevelop Ikernicterus.
Breastfeeding Iwomen: ISulfonamides Iare Isecreted Iin Ibreast Imilk. IBreastfeeding Iwomen Ion Isulfonamides Ishould
Ibe Iwarned Ithat Ibreastfeeding Ian Iinfant Iyounger Ithan I2 Imonths Ican Icause Ikernicterus.
Older Iadults: IOlder Ipatients Iare Imore Ilikely Ito Iexperience Iadverse Ieffects, I& Iwhen Iexperienced, Ithe Ieffects IareImore
Ilikely Ito Ibe Isevere. ILife-threatening Ieffects—including Ineutropenia, IStevens-Johnson Isyndrome, I& Itoxic
Iepidermal Inecrolysis—occur Imore Ifrequently Iin Iolder Iadults.
Week I1
-Things Ito Iknow Iabout Ieach Iof Ithe Imajor Iantibiotic Idrug Iclasses
Bactericidal Ivs. IBacteriostatic
• Bactericidal Iantibiotics Idirectly Ikill Ibacteria
o preferred Ifor Iimmunocompromised Ipatients Isuch Ias Ithose Iwith Idiabetes, IHIV, Ior Icancer I& Ifor Ithose
who Ihave Ioverwhelming Iinfections.
o Agents: Iaminoglycosides, Ibeta-lactams, Ifluoroquinolones, Imetronidazole, Imost Iantimycobacterial
Iagents, Istreptogramins, I& Ivancomycin.
• Bacteriostatic Iagents Iinhibit Ibacterial Iproliferation Iwhile Ithe Ihost's Iimmune Isystem Idoes Ithe Ikilling.
o Agents: Iclindamycin, Imacrolides, Isulfonamides, I& Itetracyclines
o Bactericidal Iagents: I“BANG IQ IR.I.P” I- IBeta-lactams, IAminoglicosides, INitroimidazoles I(Metronidazole),
IGlycopeptides I(Vancomycin), I Quinolones, IRifampicin, IPolymyxins I(Colistin)
o Bacteriostatic Iagents: I“Ms. IColt” I- IMacrolides, ISulfonamides, IChloramphenicol, IOxazolidinones,
ILincosamides I(Clindamycin), I Tetracyclines
*Bactericidal Iantibiotics Ikill Ibacteria Idirectly, I& Ibacteriostatic Iantibiotics Istop/weaken Ibacteria IfromIgrowing
Ito Ienable Ithe Iimmune Isystem Ito Itake Ihold Iof Iinfection*
Aminoglycosides I(narrow-spectrum Iantibiotics Iused Iprimarily Iagainst Iaerobic Igram-negative Ibacilli; Idisrupt IproteinIsynthesis
Iby Ibinding Ito Ithe I30S Iribosomal Isubunit, Iresulting Iin Irapid Ibacterial Ideath) I(p. I683)
• Examples: IGentamicin, ITobramycin, IAmikacin, INeomycin, IKanamycin, IStreptomycin, IParomycin, IPlazomicin I(p.
I687)
• Indications Ifor Iuse: ITreatment Iof Iserious Iinfections Icaused Iby Igram-negative Iaerobic Ibacilli I(Pseudomonas
Iaeruginosa, Ienterobacteriaceae, Itopical Iinfection, Iocular Ibacterial Iinfections, Iintestinal Iamebiasis, Icomplicated
IUTI) I(p. I687)
, • Contraindications I& Ihigh-risk Ipatients: IAminoglycosides Ishould Ibe Iused Iwith Icaution Iin Ipatients Iwith Irenal
Iimpairment, Ipreexisting Ihearing Iimpairment, I& Ithose Ireceiving Iototoxic I& Inephrotoxic Idrugs. I(pp. I685-687)
• Monitoring Ineeds: IAminoglycoside Ilevels I(peaks I& Itroughs) I& Irenal Ifunction Imust Ibe Imonitored. IMonitor Ifor
Ineurotoxicity, Iototoxicity, I& Inephrotoxicity.
• Which Iones Irequire Irenal Idosing Iadjustments Iand Ihow Imuch I(i.e., I25%, I50%, Ietc.): ITo Iavoid Iserious Itoxicity, Iwe
Imust Ireduce Idosage Isize Ior Iincrease Ithe Idosing Iinterval Iin Ipatients Iwith Ikidney Idisease. I(p. I685) I *Clarithromycin
• Patient Ieducation: I*Patients Ishould Ibe Iinformed Iabout Ithe Isymptoms Iof Ivestibular I& Icochlear Idamage I&
Iinstructed Ito Ireport Ithem.
• Lifespan Iconsiderations: I(p. I685)
Infants: IAminoglycosides Iare Iapproved Ito Itreat Ibacterial Iinfections Iin Iinfants Iyounger Ithan I8 Idays. IDosing Iis
Ibased Ion Iweight I& Ilength Iof Igestation.
Children/adolescents: IAminoglycosides Iare Isafe Ifor Iuse Iagainst Ibacterial Iinfections Iin Ichildren I& Iadolescents.
Pregnant Iwomen: IThere Iis Ievidence Ithat Iuse Iof Iaminoglycosides Iin Ipregnancy Ican Iharm Ithe Ifetus.
IBreastfeeding Iwomen: IGentamicin Iis Iprobably Isafe Ito Iuse Iduring Ilactation. IThere Iis Ilimited Iinformation
Iregarding Iits Iuse Iin Ithis Iway.
Older Iadults: ICaution Imust Ibe Iused Iregarding Idecreased Irenal Ifunction Iin Ithe Iolder Iadult.
Cephalosporins I(Beta-lactam Iantibiotics Isimilar Iin Istructure I& Iactions Ito Ithe Ipenicillins; Ibactericidal; Ioften Iresistant Ito
Ibeta-lactamases, I& Iactive Iagainst Ia Ibroad Ispectrum Iof Ipathogens; Imost Iwidely Iused Igroup Iof Iantibiotics) I(p. I669)
• Examples: I1st Igeneration: ICephalexin I(Keflex); I2nd Igeneration: ICefoxitin, ICefaclor I(Ceclor); I3rd Igeneration:
th th
ICefotaxime, ICefdinir, ICeftriaxone I(Rocephin); I4 Igeneration: ICefepime, I5 Igeneration: ICeftaroline
• Indications Ifor Iuse:
1st Igeneration: IStaphylococci Ior Istreptococci I(Use Iin Ipatients Iwith Imild IPCN Iallergy, Istrep Ipharyngitis, IskinIinfections,
I& Isurgical Iprophylaxis)
2nd Igeneration: IHaemophilus Iinfluenzae, IKlebsiella, Ipneumococci, I& Istaphylococci I(Otitis, Isinusitis, I& Irespiratory
Itract Iinfections)
3rd Igeneration: IPseudomonas Iaeruginosa, INeisseria Igonorrhoeae, I& IKlebsiella, ISerratia I(Meningitis, Igram-
Inegative Inosocomial Iinfections)
4th Igeneration: IPseudomonas Iaeruginosa I(Hospital-acquired Ipneumonia I& Icomplicated Iintra-abdominal I& IUTIs
Idue Ito Iresistant Ipseudomonas)
5th Igeneration: IMethicillin-resistant IStaphylococcus Iaureus I(MRSA-associated Iinfections). I(p. I671)
• Contraindications I& Ihigh-risk Ipatients: ICephalosporins Iare Icontraindicated Ifor Ipatients Iwith Ia Ihistory Iof Iallergic
Ireactions Ito Icephalosporins Ior Isevere Ireactions Ito Ipenicillin. IPatients Iusing Icefazolin I& Icefotetan Imust Inot
Iconsume Ialcohol. IUse Icefotetan, Icefazolin, I& Iceftriaxone Icautiously Iin Ipatients Itaking Iother Iagents Ithat Ialso
Ipromote Ibleeding I(anticoagulants, Ithrombolytics, INSAIDS, Ietc). I(pp. I670-671)
• Monitoring Ineeds: IMonitor Ifor Isigns Iof IC. Idif Iinfection I& Irenal Ifunction Iin Ipatients Iwith Irenal Iimpairment
Iand/or Iprolonged Iuse.
• Which Iones Irequire Irenal Idosing Iadjustments Iand Ihow Imuch I(i.e., I25%, I50%, Ietc.): IIn Ipatients Iwith Irenal
Iinsufficiency, Idosages Iof Imost Icephalosporins Imust Ibe Ireduced Ito Iprevent Iaccumulation Ito Itoxic Ilevels.
rd
I(EXCEPTION: ICeftriaxone I(3 Igeneration) Iis Ieliminated Ilargely Iby Ithe Iliver, Iso Idosage Ireduction Iis Iunnecessary Iin
Ipatients Iwith Irenal Iimpairment) I(p. I669)
• Patient Ieducation: I*All Icephalosporins Ican Ipromote IC. Idif Iinfection, Iso Ipatients Ishould Ibe Iinstructed Ito Ireport
Ian Iincrease Iin Istool Ifrequency.
• Lifespan Iconsiderations:
Infants: I3rd Igeneration Icephalosporins Iare Iused Ito Itreat Ibacterial Iinfections Iin Ineonates Ias Iwell Ias Iinfants.
IChildren/adolescents: ICephalosporins Iare Icommonly Iused Ito Itreat Ibacterial Iinfections Iin Ichildren, Iincluding
Iotitis Imedia I& Igonococcal I& Ipneumococcal Iinfections.
Pregnant Iwomen: IAll Icephalosporins Iappear Isafe Ifor Iuse Iin Ipregnancy.
Breastfeeding Iwomen: ICephalosporins Iare Igenerally Inot Iexpected Ito Icause Iadverse Ieffects Iin Ibreastfed Iinfants.
Older Iadults: IDoses Ishould Ibe Iadjusted Iin Iolder Iadults Iwith Idecreased Irenal Ifunction.
Tetracyclines I(broad-spectrum Iantibiotics Iactive Iagainst Ia Iwide Ivariety Iof Igram-positive I& Igram-negative Ibacteria;
Isuppress Ibacterial Igrowth Iby Ibinding Ito Ithe I30S Iribosomal Isubunit I& Iinhibiting Iprotein Isynthesis, Iextensive Iuse Ihas
,resulted Iin Iincreasing Ibacterial Iresistance—because Iof Ithis I& Ithe Iavailability Iof Iother Iantibiotics Iwith Igreater IselectivityI&
st
Iless Itoxicity, Itheir Iuse Ihas Ideclined I& Ithey Iare Irarely Idrugs Iof I1 Ichoice) I(p. I676)
• Examples: ITetracycline, IDemeclocycline, IDoxycycline, IEravacycline, IMinocycline, IOmadacycline, ISarecycline
• Indications Ifor Iuse: ITreatment Iof Itetracycline-sensitive Iinfections, Iacne, I& Iperiodontal Idisease. I1st Iline Idrugs Ifor
rickettsial Idiseases I(Rocky IMountain Ispotted Ifever, Ityphus Ifever, IQ Ifever); Iinfections Icaused Iby IChlamydia
Itrachomatis I(trachoma, Ilymphogranuloma Ivenereum, Iurethritis, Icervicitis); Ibrucellosis; Icholera; Ipneumonia
Icaused Iby IMycoplasma Ipneumoniae; ILyme Idisease; Ianthrax; I& Igastric Iinfection Iwith I H. Ipylori.
• Contraindications I& Ihigh-risk Ipatients: IContraindicated Iin Ipregnant Iwomen I& Iin Ichildren Iyounger Ithan I8 Iyears.
• Monitoring Ineeds: INone Irecommended.
• Which Iones Irequire Irenal Idosing Iadjustments Iand Ihow Imuch I(i.e., I25%, I50%, Ietc.): ITetracyclines Imay
exacerbate Irenal Iimpairment Iin Ipatients Iwith Ipreexisting Ikidney Idisease. IBecause Itetracycline I& Idemeclocycline
Iare Ieliminated Iby Ithe Ikidneys, Ithese Iagents Ishould Inot Ibe Igiven Ito Ipatients Iwith Irenal Iimpairment. IIf Ia Ipatient
Iwith Irenal Iimpairment Irequires Ia Itetracycline, Ieither Idoxycycline Ior Iminocycline Ishould Ibe Iused Ibecause Ithese
Idrugs Iare Ieliminated Iprimarily Iby Ithe Iliver. I(p. I677)
• Patient Ieducation: I*Should Inot Ibe Itaken Iwith Icalcium Isupplements, Imilk Iproducts, Iiron Isupplements,
Imagnesium-containing Ilaxatives, Ior Imost Iantacids Ibecause Ithey Ican Idecrease Itetracycline Iabsorption. I*GI
Idistress Ican Ibe Ireduced Iby Itaking Itetracycline Iwith Imeals. I*Advise Ipatients Ito Iavoid Iprolonged Iexposure Ito
Isunlight, Iwear Iprotective Iclothing, I& Iapply Ia Isunscreen Ito Iexposed Iskin. I*Patients Ishould Inotify Iprovider Iif
Isignificant Idiarrhea Ioccurs Iso Ithat Ithe Ipossibility Iof Ibacterial Isuperinfection Ican Ibe Ievaluated. I(pp. I676-678)
• Lifespan Iconsiderations: I(p. I678)
Children/adolescents: ITetracyclines Ishould Inot Ibe Iused Iin Ichildren Iyounger Ithan I8 Iyears Ibecause Ithey Imay Icause
Ipermanent Idiscoloration Iof Ithe Iteeth.
Pregnant Iwomen: IAnimal Istudies Ireveal Ithat Itetracyclines Ican Icause Ifetal Iharm Iin Ipregnancy. IThus, Ithis Iclass Iof
Idrugs Ishould Ibe Iavoided Iin Ipregnant Iwomen.
Breastfeeding Iwomen: IUse Iof Itetracyclines Iduring Itooth Idevelopment Ican Icause Ipermanent Istaining.
ITetracyclines Ishould Ibe Iavoided Iby Ibreastfeeding Iwomen.
Older Iadults: ITetracyclines Ican Iinteract Iwith Idrugs, Iincluding Idigoxin. IIn Ithe Iolder Iadult Iwho Itakes Imany
Imedications, Icheck Ifor Iinteractions.
Penicillins I(Beta-lactam Iantibiotics; Iactive Iagainst Ia Ivariety Iof Igram-negative I& Igram-positive Ibacteria, Ilow Itoxicity,
Ibactericidal Iby Idisrupting Ithe Isynthesis Iof Ithe Icell Iwall Ithrough Iinhibition Ior Itranspeptidases I& Ipromoting Icell Iwall
Idestruction Ithrough Iactivating Iautolysins) I(p. I662)
• Examples:
Narrow-spectrum Ipenicillins/penicillinase Isensitive: IPenicillin IG, IPenicillin IV
Narrow-spectrum Ipenicillins/penicillinase Iresistant I(antistaphylococcal Ipenicillins): INafcillin, IOxacillin,
IDicloxacillin
Broad-spectrum Ipenicillins I(aminopenicillins): IAmpicillin, IAmoxicillin
Extended-spectrum Ipenicillin I(antipseudomonal Ipenicillin): IPiperacillin.
Penicillin/Beta-Lactamase Icombinations: IAmpicillin/sulbactam I(Unasyn), IAmoxicillin/clavulanate I(Augmentin),
IPiperacillin/tazobactam I(Zosyn)
• Indications Ifor Iuse: ITreatment Iof Iinfections Icaused Iby Isensitive Ibacteria.
Narrow-spectrum Ipenicillins/penicillinase Isensitive: IStreptococcus, INeisseria, Imany Ianaerobes, Ispirochetes, I&Iothers
Narrow-spectrum Ipenicillins/penicillinase Iresistant I(antistaphylococcal Ipenicillins): IStaphylococcus Iaureus
IBroad-spectrum Ipenicillins I(aminopenicillins): IHaemophilus Iinfluenzae, IEscherichia Icoli, IProteus Imirabilis,
Ienterococci, I& INeisseria Igonorrhoeae
Extended-spectrum Ipenicillin I(antipseudomonal Ipenicillin): ISame Ias Ibroad-spectrum Ipenicillins I+ IPseudomonas
Iaeruginosa, IEnterobacter, IProteus, IBacteroides Ifragilis, I & Imany IKlebsiella
• Contraindications I& Ihigh-risk Ipatients: IPenicillins Ishould Ibe Iused Iwith Iextreme Icaution Iin Ipatients Iwith Ia Ihistory
Iof Isevere Iallergic Ireactions Ito Ipenicillins, Icephalosporins, Ior Icarbapenems.
• Monitoring Ineeds: IRenal Iimpairment Ican Icause Ipenicillins Ito Iaccumulate Ito Itoxic Ilevels. IMonitor Ifunction Iin
Ipatients Iwith Irenal Idisease.
, • Which Iones Irequire Irenal Idosing Iadjustments Iand Ihow Imuch I(i.e., I25%, I50%, Ietc.): I*Amoxicillin, IAugmentin,
IPenicillin
• Patient Ieducation:
• Lifespan Iconsiderations: I(p. I666)
Infants: IPenicillins Iare Iused Isafely Iin Iinfants Iwith Ibacterial Iinfections, Iincluding Isyphilis, Imeningitis, I& Igroup IA
Istreptococcus.
Children/adolescents: IPenicillins Iare Ia Icommon Idrug Iused Ito Itreat Ibacterial Iinfections Iin Ichildren.
IPregnant Iwomen: IAlthough Ithere Iare Ino Iwell-controlled Istudies Iin Ipregnant Iwomen, Ievidence Iwe Ido Ihave
nd rd
Isuggests Ithere Iis Ino I2 Ior I3 Itrimester Ifetal Irisk.
Breastfeeding Iwomen: IAmoxicillin Iis Isafe Ifor Iuse Iin Ibreastfeeding Imothers. IData Iare Ilacking Iregarding
Itransmission Iof Isome Iother Ipenicillins Ifrom Imother Ito Iinfant Ithrough Ibreast Imilk.
Older Iadults: IDoses Ishould Ibe Iadjusted Iin Iolder Iadults Iwith Irenal Idysfunction.
Sulfonamides I(usually Ibacteriostatic; Isuppress Ibacterial Igrowth Iby Iinhibiting Ithe Isynthesis Iof Itetrahydrofolate, Ia Ifolate
Iderivative; Ibroad-spectrum Iantimicrobials) I(p. I689)
• Examples: ISulfadiazine, ISulfamethoxazole, ISulfacetamide Iophthalmic I(Trimethoprim Iis INOT Ia Isulfonamide, Ibut IitIis
Iincluded Ihere Idue Ito Iits Isame Imechanism Iof Iaction=suppressing Ithe Isynthesis Iof Itetrahydrofolate IAND Iis
Icombined Iwith Isulfamethoxazole Ito Iform Ithe Imedication IBactrim.)
• Indications Ifor Iuse: IPrimarily Iused Ito Itreat IUTIs. IOther Imajor Iuses Iare Itopical Ito Itreat Isuperficial Iinfections Iof Ithe
Ieyes I& Ito Isuppress Ibacterial Icolonization Iin Iburns. IAlso Iuseful Ifor Inocardiosis, IListeria Ispecies Iinfection, I&
Iinfection Iwith IP. Ijirovecii. IUsed Ias Ialternatives Ito Idoxycycline I& Ierythromycin Ifor Iinfections Icaused Iby IC.
Itrachomatis. IUsed Iin Iconjunction Iwith Ipyrimethamine Ito Itreat I2 Iprotozoal Iinfections: Itoxoplasmosis I& Imalaria
Icaused Iby Ichloroquine-resistant IPlasmodium Ifalciparum. ISulfasalazine Iis Iused Ito Itreat Iulcerative Icolitis.
• Contraindications I& Ihigh-risk Ipatients: ISulfonamides Iare Icontraindicated Ifor Inursing Imothers, Ipregnant Iwomen
st
Iin Ithe I1 Itrimester I& Ialso Ithose Inear Iterm, I& Iinfants Iyounger Ithan I2 Imonths. IAn Ialternative Iantibiotic Imust Ibe
chosen Ifor Ipatients Iwith IG6PD Ideficiency I(can Icause Ihemolytic Ianemia). IExercise Icaution Iin Ipatients Iwith Irenal
Iimpairment—may Irequire Ia Ireduced Idosage. ITrimethoprim Iis Icontraindicated Iin Ipatients Iwith Ifolate Ideficiency
I(manifested Ias Imegaloblastic Ianemia) I& Ishould Ibe Iavoided Iwhen Ifolate Ideficiency Iis Ilikely I(patients Iwith
Ialcoholism I& Ipregnant Iwomen).
• Monitoring Ineeds: I*CBC Ishould Ibe Imonitored Iif Ithe Ipatient Idevelops Isigns Ior Isymptoms Iof Iblood Idisorders, Ias
Ishould ICD4+ Icount Ifor Ipatients Iwith IHIV. I*Signs I& Isymptoms Iof Ihypersensitivity Ireactions I& Iof Iresolution Iof
infection Ishould Ialso Ibe Iassessed. I*If Ihyperkalemia Iis Isuspected Idue Ito Iuse Iof Itrimethoprim, Ipotassium Imust Ibe
Ichecked I4 Idays Iafter Istarting Itreatment. I(p. I694)
• Which Iones Irequire Irenal Idosing Iadjustments Iand Ihow Imuch I(i.e., I25%, I50%, Ietc.): IFor Ipatients Iwith Ia
Icreatinine Iclearance I(CrCl) Iof I15-30 ImL/min, Iproviders Ishould Iprescribe I50% Iof Ithe Itypical Irecommended Idose. IIf
ICrCl Ifalls Ibelow I15 ImL/min, Idrug Imust Ibe Idiscontinued I (p. I694) I*Bactrim
• Patient Ieducation: I*Instruct Ipatients Ito Icomplete Ithe Iprescribed Icourse Iof Itreatment Ieven Ithough Isymptoms
Imay Iabate Ibefore Ithe Ifull Icourse Iis Iover. I*Patients Itaking Ioral Isulfonamides Ishould Idrink Iat Ileast I8 Ito I10 Iglasses
Iof Iwater Ior Iother Inoncaffeinated Ifluids Iper Iday Ito Idecrease Ithe Irisk Ifor Icrystalluria. I(Caffeine Imay Ibe Itaken Iin
Iaddition Ito Ithe Iother Ifluids). I*To Iprevent Iphotosensitivity Ireactions, Iadvise Ipatients Ito Iavoid Iprolonged Iexposure
Ito Isunlight, Iwear Iprotective Iclothing, I& Iapply Isunscreen Ito Iexposed Iskin. ITanning Ibeds Ishould Ibe Iavoided.
*Patients Ishould Ibe Iinstructed Ito Iobserve Ifor Ialterations Ithat Imay Iindicate Ihypersensitivity I& Ireport ItheseIpromptly
Iif Ithey Ioccur.
• Lifespan Iconsiderations:
Infants: IUse Iof Isulfonamides Iin Iinfants Iyounger Ithan I2 Imonths Ican Icause Ikernicterus I(deposition Iof Ibilirubin IinIthe
Ibrain—neurotoxic I& Ican Icause Isevere Ineurologic Ideficits I& Ieven Ideath).
Pregnant Iwomen: ISystemic Isulfonamides Imay Icause Ibirth Idefects, Iespecially Iif Itaken Iduring Ithe I1st Itrimester. IIf
Itaken Inear Iterm, Ithe Iinfant Imay Idevelop Ikernicterus.
Breastfeeding Iwomen: ISulfonamides Iare Isecreted Iin Ibreast Imilk. IBreastfeeding Iwomen Ion Isulfonamides Ishould
Ibe Iwarned Ithat Ibreastfeeding Ian Iinfant Iyounger Ithan I2 Imonths Ican Icause Ikernicterus.
Older Iadults: IOlder Ipatients Iare Imore Ilikely Ito Iexperience Iadverse Ieffects, I& Iwhen Iexperienced, Ithe Ieffects IareImore
Ilikely Ito Ibe Isevere. ILife-threatening Ieffects—including Ineutropenia, IStevens-Johnson Isyndrome, I& Itoxic
Iepidermal Inecrolysis—occur Imore Ifrequently Iin Iolder Iadults.
