antibiotic conference

8/14/2019 Antibiotic Conference

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Drug List (Sulfonamides)

ProtypeProtype/Important/Important sulfisoxazolesulfisoxazole

sulfamethoxazolesulfamethoxazole

sulfadiazinesulfadiazine

trimethoprimtrimethoprim--sulfamethoxazolesulfamethoxazole

OthersOthers SulfasalazineSulfasalazine

silver sulfadiazinesilver sulfadiazine

sulfacetamidesulfacetamide

sulfadoxinesulfadoxine--pyrimethaminepyrimethamine

tripletriple--sulfonamidessulfonamides


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Drug List (Penicillins)

Prototype/ImportantPrototype/Important

Pen GPen G (natural pen)(natural pen)

NafcillinNafcillin ((PenasePenase resisresis.).)

AmpicillinAmpicillin ((aminopenaminopen.).)

PiperacillinPiperacillin ((antipseudantipseud.).)

Related DrugsRelated Drugs

OthersOthers

Pen G procainePen G procaine

Pen GPen G benzathinebenzathine

Pen VPen V MethacillinMethacillin,, oxacillinoxacillin

AmoxacillinAmoxacillin

TicarcillinTicarcillin

ClavulanicClavulanic acid,acid,sulbactamsulbactam (beta(beta

lactamaselactamase inhibitors)inhibitors)


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Drug List (Cephalosporins)


CefazolinCefazolin (1st gen.)(1st gen.)

CefuroximeCefuroxime (2nd gen.)(2nd gen.)

CefotaximeCefotaxime (3rd gen.)(3rd gen.) CefepineCefepine (4th gen.)(4th gen.)

OthersOthers

CephalexinCephalexin (oral, 1st gen.)(oral, 1st gen.)

CefaclorCefaclor (oral, 2nd gen.)(oral, 2nd gen.)

CefiximeCefixime (oral, 3rd gen.)(oral, 3rd gen.) CeftriaxoneCeftriaxone (long duration,(long duration,

3rd gen.)3rd gen.)


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Cephalosporins (half-life)

CefazolinCefazolin (1.5(1.5--2hr)2hr) CefuroximeCefuroxime (1.3 hr)(1.3 hr)

CefotaximeCefotaxime (1 hr)(1 hr)

CefepineCefepine (1 hr)(1 hr)

CephalexinCephalexin (1 hr)(1 hr) CefaclorCefaclor (0.75 hr)(0.75 hr)

CefiximeCefixime (3(3--4 hr)4 hr)

CeftriaxoneCeftriaxone (6(6--8 hr)8 hr)


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Drug List (other beta lactams)

PrototypePrototype IImipenemmipenem

OthersOthers ImipenemImipenem--cilistatincilistatin


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Drug List (aminoglycosides)

PrototypePrototype GentamicinGentamicin

OthersOthers AmikacinAmikacin

StreptomycinStreptomycin

NeomycinNeomycin


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Drug List (antitubercular)

ImportantImportant IsoniazidIsoniazid

RifampinRifampin

OthersOthers StreptomycinStreptomycin

EthambutolEthambutol

PyrazinamidePyrazinamide


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Drug Listtetracyclines/chloramphen.

PrototypePrototype TetracyclineTetracycline

ChloramphenicolChloramphenicol

OthersOthers DoxycyclineDoxycycline

MinocyclineMinocycline


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Drug List (agents for UTI)


MethenamineMethenamine

CiprofloxacinCiprofloxacin

Related agentsRelated agents

PhenazopyridinePhenazopyridine

OthersOthers

NitrofurantoinNitrofurantoin

NorfloxacinNorfloxacin (only UTI)(only UTI)

OfloxacinOfloxacin,, LevofloxacinLevofloxacin MoxifloxacinMoxifloxacin,,

SparfloxacinSparfloxacin,,

TrovofloxacinTrovofloxacin (newer(newerexpanded spectrum)expanded spectrum)


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Drug List (miscellaneous)

PrototypePrototype ErythromycinErythromycin

ClindamycinClindamycin

VancomycinVancomycin

MetronidazoleMetronidazole

OthersOthers AzithromycinAzithromycin


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Penicillin SubclassesPen G Nafcillin Ampicillin

Amoxacillin

Ticarcillin

Piperacillin

Resistant to

betalactamases

No Yes(gram pos.) No No

Clinical

status

Spectrum Strep.N.men.

Staph.(penicillinase-producing)

same aspen G plusH.flu.,

E.coli

Pseud.aerug., someenteric gram neg.bacilli

Combined

with betalactamase

inhibitors

No No Yes Yes


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Clinical Status of Penicillins

Pen G & VPen G & V: Group A: Group A StrepStrep., most., most StrepStrep..pneumoniaepneumoniae, N., N. meningitidismeningitidis, T., T. pallidumpallidum(syphilis)(syphilis)

NafcillinNafcillin:: penicillinasepenicillinase--producingproducing StaphStaph.. Ampicillin/AmoxacillinAmpicillin/Amoxacillin :: H.fluH.flu. (. (otitisotitis media,media,

URTI),URTI), E.coliE.coli (UTI),(UTI), ShigellaShigella, Salmonella, Salmonella

PiperacillinPiperacillin:: PseudPseud.. aerugaerug. (UTI), some gram. (UTI), some gramneg. bacillineg. bacilli


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Cephalosporin SubclassesFirst Gen.(Cefazolin)

Second Gen.(Cefuroxime)

Third Gen.(Cefotaxime)

Spectrum same as Pen Gplus Staph.more gram neg.Klebsiella

Expanded gramneg. and H. flu.

Good gram neg.bacilli (hospital-acquired)

Resistanceto betalactamases

Relativelyresistant togram pos.

Increased vs.gram neg.

More resistant togram neg.

Clinicalstatus

CNSpenetranc

e

inadequate inadequate formost

adequate


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Clinical Status ofCephalosporins

CefazolinCefazolin: serious: serious KlebsiellaKlebsiella pneumoniaepneumoniae, alternate, alternate

toto penicillinspenicillins forfor strepstrep. &. & staphstaph.; prophylaxis in.; prophylaxis insurgery vs.surgery vs. staphstaph & enteric gram neg.& enteric gram neg.

CefuroximeCefuroxime: gram neg. hosp. infections resistant to: gram neg. hosp. infections resistant to

1st gen.1st gen. cephceph., including beta., including beta lactamaselactamase--producingproducingstrains,strains, H.fluH.flu. (. (CefaclorCefaclor used orally for some H. flu.)used orally for some H. flu.)

CefotaximeCefotaxime: serious gram neg. bacilli esp. if: serious gram neg. bacilli esp. if

meningitis, betameningitis, beta lactamaselactamase--producing gonococciproducing gonococci((ceftriaxoneceftriaxone preferred); may be combined with AG;preferred); may be combined with AG;some other 3rd gen.some other 3rd gen. cephceph. useful vs.. useful vs. Pseud.aerugPseud.aerug..

((ceftazidimeceftazidime))


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What are the major differences between

imipenem, penicillins and cephalosporins ?

SpectrumSpectrum

DistributionDistribution

Why is it combined withWhy is it combined with cilistatincilistatin?? ToxicityToxicity

Clinical StatusClinical Status


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Major Differences inImipenem, Penicillins, Ceph.

SpectrumSpectrum

ImipenemImipenem broadestbroadest covers most gram neg. bacillicovers most gram neg. bacilli(very resistant to beta(very resistant to beta lactamaseslactamases)) StaphStaph., plus., plusanaerobes (B.anaerobes (B. fragilisfragilis))

PharmacokineticsPharmacokinetics

ImipenemImipenem metabolized by renalmetabolized by renal

dehydropeptidasesdehydropeptidases (need(need cilistatincilistatin)) Toxicity (Toxicity (ImipenemImipenem))

allergic responses,allergic responses, superinfectionssuperinfections,,

thrombophlebitisthrombophlebitis, seizures (rare), seizures (rare)


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Major features of Penicillins

SpectrumSpectrum

Pen GPen G best forbest for strepstrep. but not cover. but not cover staphstaph..

AmpicillinAmpicillin forfor strepstrep., H. flu., salmonella/., H. flu., salmonella/shigellashigella,,E. coliE. coli


eliminated by renal secretioneliminated by renal secretion

ToxicityToxicity allergicallergic rxsrxs, seizures in high doses, seizures in high doses

AmpicillinAmpicillin: rash, diarrhea (: rash, diarrhea (superinfectionssuperinfections))

Pi eracillinPi eracillin: latelet d sfunction,: latelet d sfunction, thromo hlebitisthromo hlebitis


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Major Features ofCephalosporins

SpectrumSpectrum

1st gen1st gen.:.: strepstrep.,., staphstaph., more gram., more gram neg.bacillineg.bacilli

2nd gen2nd gen.: more gram neg. in hospital, H. flu..: more gram neg. in hospital, H. flu.

3rd gen3rd gen

.: best vs. gram neg. bacilli (very resistant

.: best vs. gram neg. bacilli (very resistantto betato beta lactamaseslactamases))


eliminated by renal secretion (some metabolized)eliminated by renal secretion (some metabolized) ToxicityToxicity

allergicallergic rxsrxs,, superinfectionssuperinfections, low potential renal, low potential renal

toxicitytoxicity


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What are the unique featuresof aztreonam?

Compared withCompared with penicillinspenicillins andandcephalosporinscephalosporins

SpectrumSpectrum


Adverse effectsAdverse effects

Is there crossIs there cross--sensitivity withsensitivity with penicillinspenicillins??


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Unique Features ofAztreonam

MonobactamMonobactam with only gram neg. spectrumwith only gram neg. spectrum

no crossno cross allergenicityallergenicity with pen orwith pen or cephceph

used alone only for UTIused alone only for UTI

potential gram pos.potential gram pos. superinfectionssuperinfections must be givenmust be given parenterallyparenterally


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What are the important characteristics that

all aminoglycosides have in common?

SpectrumSpectrum PharmacokineticsPharmacokinetics



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Features of Aminoglycosides excellent vs.excellent vs. aerobic gram neg. bacilliaerobic gram neg. bacilli

limited distributionlimited distribution toto extracellularextracellular fluidsfluids

eliminated almost entirely byeliminated almost entirely by glomerularglomerular

filtration (filtration (monitor renal functionmonitor renal function)) serious toxicitiesserious toxicities

irreversibleirreversible ototoxicityototoxicity

vestibular toxicityvestibular toxicity

nephrotoxicitynephrotoxicity

neuromuscular blockadeneuromuscular blockade


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Summarize the status of aminoglycosidesand third generation cephalosporins

Clinical status ofClinical status of aminoglycosidesaminoglycosides

Clinical status of third generationClinical status of third generation

cephalosporinscephalosporins Clinical status ofClinical status of imipenemimipenem


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Aminoglycosides vs 3rd Gen.Cephalosporins/Imipenem

3rd3rd gengen cephceph.: preferred vs. gram neg. sepsis.: preferred vs. gram neg. sepsis

to avoid serious toxicities of AGto avoid serious toxicities of AG some 3rd gen.some 3rd gen. cephceph. better vs.. better vs. PseudPseud. while. while

other better vs. other gram neg. bacilliother better vs. other gram neg. bacilli

initial therapy of lifeinitial therapy of life--threatening sepsisthreatening sepsisinvolvesinvolves combination of AG pluscombination of AG plus either 3rdeither 3rd

gen.gen. cephceph. /. / antipseudomonalantipseudomonal pen/pen/ imipenemimipenem imipenemimipenem reservedreserved for mixed infections thatfor mixed infections that

my involvemy involve anerobesanerobes (B.(B. fragilisfragilis))


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Erythromycin

Clinical useClinical use Adverse reactionsAdverse reactions


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Erythromycin

Clinical UsesClinical Uses

Respiratory infections (Chlamydia,Respiratory infections (Chlamydia,MycoplasmaMycoplasma,, LegionellaLegionella,, BordetellaBordetella))

Alternate to pen in mildAlternate to pen in mild--moderatemoderateinfect.(strepinfect.(strep., H. flu.)., H. flu.)


frequent GI disturbancesfrequent GI disturbances

cholestaticcholestatic hepatitis withhepatitis with estolateestolate ester in adultsester in adults

inhibition of hepatic CYP3A (drug interactions)inhibition of hepatic CYP3A (drug interactions)


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Tetracyclines



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Tetracyclines Clinical useClinical use

some gram neg. infectionssome gram neg. infections RickettsiaRickettsia, Chlamydia,, Chlamydia, MycoplasmaMycoplasma

spirochetes,spirochetes, LymeLyme disease, acne, travelers diarrheadisease, acne, travelers diarrhea

Adverse reactions (numerous)Adverse reactions (numerous) discolor teeth in children,discolor teeth in children, phototoxicityphototoxicity, GI, GI

disturbances,disturbances, superinfectionssuperinfections

vestibular toxicity (vestibular toxicity (minocyclineminocycline))

renal toxicity (if renal insufficiency, outdatedrenal toxicity (if renal insufficiency, outdatedtetracyclinestetracyclines

hepatic toxicity (high doses in malnourished, pregnancy,hepatic toxicity (high doses in malnourished, pregnancy,

liver disease)liver disease)


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Ciprofloxacin



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Ciprofloxacin Clinical useClinical use

oral or IV for variety of gram neg. enteric bacillioral or IV for variety of gram neg. enteric bacilli

good for UTI; some used for genital infectionsgood for UTI; some used for genital infectionsdue todue to chlamydiachlamydia or gonococcior gonococci

some used for respiratory tract infections due tosome used for respiratory tract infections due toMycoplasmaMycoplasma,, LegionellaLegionella,, BrucellaBrucella,, MycobacteriaMycobacteria

newer analogs better vs.newer analogs better vs. StrepStrep.. PneumoniaePneumoniae


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Ciprofloxacin Adverse reactionsAdverse reactions

some GIsome GI rashrash

cartilage damage in children, tendon rupturescartilage damage in children, tendon ruptures

photosensitivityphotosensitivity CNS toxicity (dizziness, ataxia, insomnia)CNS toxicity (dizziness, ataxia, insomnia)

seizures (rare)seizures (rare)

Hepatotoxicity only withHepatotoxicity only with TrovafloxacinTrovafloxacin Photosensitivity most frequent withPhotosensitivity most frequent with

sparfloxacinsparfloxacin


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Chloramphenicol



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Chloramphenicol Clinical useClinical use

alternate for meningitis due toalternate for meningitis due to H.fluH.flu., N.., N.meningitidismeningitidis,, StrepStrep.. pneumoniaepneumoniae

severe anaerobic infections of CNSsevere anaerobic infections of CNS

alternate toalternate to tetracyclinestetracyclines forfor rickettsiarickettsia,, chlamydiachlamydia,,brucellosisbrucellosis

Adverse reactionsAdverse reactions aplasticaplastic anemiaanemia (rare), bone marrow suppression(rare), bone marrow suppression

(reversible),(reversible), superinfectionssuperinfections,, Gray Baby syndromeGray Baby syndrome


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Sulfamethoxazole-Trimethoprim



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Trimethoprim-Sulfamethoxazole Clinical useClinical use

UTI due to susceptible gram neg. bacilliUTI due to susceptible gram neg. bacilli

otitisotitis media or chronic bronchitis due to H. flu.,media or chronic bronchitis due to H. flu.,StrepStrep.. pneumoniaepneumoniae

PneumocystisPneumocystis cariniicarinii

Salmonella,Salmonella, ShigellaShigella,, toxigenictoxigenic E. coliE. coli


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Trimethoprim-Sulfamethoxazole Adverse reactionsAdverse reactions

HematopoieticHematopoietic disorders:disorders: anemiasanemias (give(give folinicfolinicacid)acid)

Hypersensitivity Reactions: frequent allergicHypersensitivity Reactions: frequent allergic

reactions to sulfonamides (rash photosensitivity),reactions to sulfonamides (rash photosensitivity),

CNS toxicity (headache, depression,CNS toxicity (headache, depression,hallucinations)hallucinations)

higher incidence side effects in AIDS (fever, rash,higher incidence side effects in AIDS (fever, rash,leukopenialeukopenia, diarrhea), diarrhea)


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What drugs are useful in treating anaerobic

infections caused by B. fragilis?

List five examplesList five examples


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Drugs are useful in treating anaerobic

infections caused by B. fragilis

ClindamycinClindamycin

ChloramphenicolChloramphenicol

MetronidazoleMetronidazole

ImipenemImipenem Some 2nd gen.Some 2nd gen. cephalosporinscephalosporins

cefoxitincefoxitin,, cefotetancefotetan

some 3rd gen.some 3rd gen. cephalosporinscephalosporins andandantipseudomonalantipseudomonal penicillinspenicillins have moderatehave moderateactivityactivity


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What advantages do these drugs have

compared to others within the same class?

AzithromycinAzithromycin ((ZithromaxZithromax)) CeftriaxoneCeftriaxone ((RocephinRocephin))

DoxycyclineDoxycycline ((VibramycinVibramycin))

LevofloxacinLevofloxacin ((LevequinLevequin))


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Advantages of Azithromycin Improved spectrum vs. erythromycinImproved spectrum vs. erythromycin

especially vs. Mycobacteriumespecially vs. Mycobacterium aviumavium complex, H.complex, H.influenzaeinfluenzae,, ChlamydiaeChlamydiae, some gram neg., some gram neg.

Long halfLong half--life due to accumulation inlife due to accumulation inmacrophages and fibroblasts (5 day regimenmacrophages and fibroblasts (5 day regimenfor respiratory tract infections)for respiratory tract infections)

Not inhibit liver CYP metabolism of otherNot inhibit liver CYP metabolism of otherdrugsdrugs


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Advantages of Ceftriaxone Increased activity vs. gramIncreased activity vs. gram--negneg. bacilli, esp.. bacilli, esp.

in treating meningitisin treating meningitis Highly resistant to betaHighly resistant to beta lactamaseslactamases esp.esp.

NeisseriaNeisseria

gonorrheaeagonorrheaea

and H.and H.

influenzaeinfluenzae

Long halfLong half--life, used as single dose regimenlife, used as single dose regimenfor gonorrheafor gonorrhea


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Advantages of Doxycycline Complete oral absorption, not affected byComplete oral absorption, not affected by

food or antacidsfood or antacids Not require dose reduction for patients withNot require dose reduction for patients with

reduced renal functionreduced renal function

Often used for travelers diarrhea since betterOften used for travelers diarrhea since betteroral absorption and less GI disturbancesoral absorption and less GI disturbances


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Advantages of Levofloxacin

(Moxifloxacin)

expanded spectrum vs. some gram pos.expanded spectrum vs. some gram pos.esp.esp. StrepStrep.. pneumoniaepneumoniae

also reliable vs. otheralso reliable vs. other respresp. tract. tract

pathogens such aspathogens such as chlamydiachlamydia,,mycoplasmamycoplasma ,, LegionellaLegionella, H., H. influenzaeinfluenzae

good vs. gram neg. causes ofgood vs. gram neg. causes of UTIsUTIs andandgastroenteritisgastroenteritis


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Case #1

Trauma accident with severe burnTrauma accident with severe burnpatientpatient

PseudPseud.. aerugaerug. pneumonia. pneumonia

start withstart with cefotaximecefotaxime (3rd gen.(3rd gen. cephceph.).)

infection worsenedinfection worsened

patient finally dies ofpatient finally dies of intracerebralintracerebralhemorrhagehemorrhage


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Case #1 Questions 1. Why may a third generation cephalosporin1. Why may a third generation cephalosporin

be a poor choice?be a poor choice? 2. What complications of some third2. What complications of some third

generationgeneration cephalosporinscephalosporins make them amake them aparticularly bad choice on the basis of theparticularly bad choice on the basis of thepatients risk factors?patients risk factors?

What classes of antimicrobial drugs areWhat classes of antimicrobial drugs arereasonable choices for treating infectionsreasonable choices for treating infectionscaused by Pseudomonascaused by Pseudomonas aeruginosaaeruginosa? List the? List the

notable limitations of each drug class.notable limitations of each drug class.


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Case # 1(Answers) 1.1. cefotaximecefotaxime not highly effective vs. Pseudomonasnot highly effective vs. Pseudomonas

esp. in burn unit as resistance with single drugesp. in burn unit as resistance with single drugtherapytherapy

(use(use antipsuedomonalantipsuedomonal pen plus AG)pen plus AG)

2. some third gen.2. some third gen. cephceph. cause bleeding. cause bleeding((hypoprothrombinemiahypoprothrombinemia) and impair) and impair phagocytosisphagocytosis(pneumonia can worsen, resist.)(pneumonia can worsen, resist.)

3. alternatives:3. alternatives: piperacillinpiperacillin (platelet dysfunction,(platelet dysfunction,hypersensitivity) plushypersensitivity) plus amikacinamikacin ((nephrotoxicitynephrotoxicity,,ototoxicityototoxicity), or 3rd gen.), or 3rd gen. ceph.(ceftazidimeceph.(ceftazidime), or), or

imipenemimipenem oror fluoroquinolonefluoroquinolone))


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Case #2 OtitisOtitis media initially thatmedia initially that developesdevelopes intointo

meningitis due tomeningitis due to StrepStrep.. pneumpneum.. GivenGiven CefaclorCefaclor (oral 2nd gen.(oral 2nd gen. cephceph.) as out.) as out

patientpatient

patient worsens to comatose state and givenpatient worsens to comatose state and givenmassive doses of penicillin and has statusmassive doses of penicillin and has status

epilepticusepilepticus regains consciousness upon decreasing doseregains consciousness upon decreasing dose

of penicillinof penicillin


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Case #2 Questions 1. Was an oral, second generation1. Was an oral, second generation

cephalosporin the best antimicrobialcephalosporin the best antimicrobialconsidering the most likelyconsidering the most likely organism(sorganism(s) to be) to becausing hiscausing his otitisotitis media?media?

2. What feature of penicillin makes it2. What feature of penicillin makes itdangerous in very high doses in patients withdangerous in very high doses in patients with

a more permeable blooda more permeable blood--brain barrier?brain barrier? 3. What alternative antimicrobials may be3. What alternative antimicrobials may be

recommended in the treatment of meningitisrecommended in the treatment of meningitis

caused by Streptococcuscaused by Streptococcus pneumoniaepneumoniae??


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Case #2 (answers)

1. 2nd gen.1. 2nd gen. cephceph. orally may be inadequate. orally may be inadequate

dose to prevent meningitis; parenteral dosedose to prevent meningitis; parenteral dosepreferred or high doses ofpreferred or high doses of amoxacillinamoxacillin ororpenicillin but pt compliance a concern; couldpenicillin but pt compliance a concern; coulduseuse amoxacillinamoxacillin--clavulanicclavulanic acid to cover betaacid to cover betalactamaselactamase producing strainsproducing strains

2. pen G in high doses causes convulsions2. pen G in high doses causes convulsionsesp. ifesp. if inflammedinflammed meningesmeninges

3. alternatives: IV pen G or3. alternatives: IV pen G or ampicillinampicillin,,

cefotaximecefotaxime, or, or chloram henicolchloramphenicol


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Case #3

CefuroximeCefuroxime (2nd gen.(2nd gen. cephceph.) induces.) inducesantibiotic associated colitis with severeantibiotic associated colitis with severediarrhea leading to deathdiarrhea leading to death


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Case #3 Questions 1. What disease entities are associated with the1. What disease entities are associated with the

administration of broadadministration of broad--spectrumspectrumantimicrobials?antimicrobials?

2. Are these complications of broad2. Are these complications of broad--spectrumspectrumantimicrobials ever lethal? If so, by whatantimicrobials ever lethal? If so, by whatmeans?means?

3. What antimicrobial, if any, is recommended3. What antimicrobial, if any, is recommendedto treat the probable cause of diarrhea in thisto treat the probable cause of diarrhea in thispatient?patient?


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Case #3 (answers)

1. overgrowth or1. overgrowth or superinfectionsuperinfection fromfromexotoxinexotoxin--producing Clostridiumproducing Clostridium

difficiledifficile

,,

staphstaph

. or

. orcandidacandida

2.2. exotoxinexotoxin--producing C.producing C. difficiledifficile maymayproduce fatalitiesproduce fatalities

3. oral3. oral vancomycinvancomycin oror metronidazolemetronidazole


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Case #4

UTI in 22 year old woman with gramUTI in 22 year old woman with gramneg. bacteria andneg. bacteria and PMNsPMNs in urinein urine


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Case #4 Questions 1. What is the most likely organism to be1. What is the most likely organism to be

causing her UTI?causing her UTI? 2. What organism must be excluded as a2. What organism must be excluded as a

possible cause of herpossible cause of her pyuriapyuria to avoid infectionto avoid infectionof the upper genital tract that might leave herof the upper genital tract that might leave herinfertile or with aninfertile or with an ectopicectopic pregnancy?pregnancy?

3. Assume that the gram3. Assume that the gram--negneg. bacteria are. bacteria arebacilli. On the basis of the most likelybacilli. On the basis of the most likelyorganism, what antimicrobials are candidatesorganism, what antimicrobials are candidates

for being the best to treat her UTI?for being the best to treat her UTI?


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Case #4 Questions (cont.) 4. If she were a patient in the Burn Unit who4. If she were a patient in the Burn Unit who

had developed a UTI, on the basis of the mosthad developed a UTI, on the basis of the mostlikely organism, what antimicrobials would belikely organism, what antimicrobials would belikely to be effective in her management?likely to be effective in her management?

5. How would your management of a UTI5. How would your management of a UTIdiffer if you knew she was just recovering fromdiffer if you knew she was just recovering from

profound renal failure associated with recentprofound renal failure associated with recenttrauma?trauma?

6. If she were pregnant, how would treat the6. If she were pregnant, how would treat the

UTI? Explain your selections/UTI? Explain your selections/nonselectionsnonselections..


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Case #4 (answers) 1.1. E.coliE.coli, other gram neg. bacilli, other gram neg. bacilli

2. exclude2. exclude gonococcalgonococcal urethritisurethritis 3.3. sulfisoxazolesulfisoxazole,, ampicillin/amoxacillinampicillin/amoxacillin, TMP/SMX,, TMP/SMX,

tetracycline,tetracycline, norfloxacinnorfloxacin

4. in burn unit cover resistant strains of gram neg.4. in burn unit cover resistant strains of gram neg.bacilli; use TMP/SMX orbacilli; use TMP/SMX or norfloxacinnorfloxacin/other/other fluoroqfluoroq..

5. avoid sulfonamide & AG if poor renal function;5. avoid sulfonamide & AG if poor renal function;

useuse amoxacillinamoxacillin,, doxycyclinedoxycycline, or, or fluoroquinolonefluoroquinolone

6. if pregnant avoid sulfonamides, tetracycline,6. if pregnant avoid sulfonamides, tetracycline,fluoroquinolonefluoroquinolone; consider; consider amoxacillinamoxacillin alone oralone or

withwith clavulanicclavulanic acidacid


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Case #5

Pneumonia due to PseudomonasPneumonia due to Pseudomonasaeruginosaaeruginosa after surgery for crushafter surgery for crushinjury to chest and arminjury to chest and arm

Therapy withTherapy with aminoglycosideaminoglycoside pluspluspiperacillinpiperacillin

serumserum creatininecreatinine becomes elevatedbecomes elevated


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Case #5 Questions 1. Outline the options available to the surgical1. Outline the options available to the surgical

management team and evaluate them.management team and evaluate them. 2. What types of patients tend to be2. What types of patients tend to be

predisposed topredisposed to aminoglycosideaminoglycoside toxicities?toxicities?


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Case # 5 ( answers) 1. order serum levels of AG; delay next dose1. order serum levels of AG; delay next dose

by 4by 4--8 hours; change from AG to8 hours; change from AG toantipseudomonalantipseudomonal 3rd gen.3rd gen. cephceph. (. (ceftazidimeceftazidime))oror fluoroquinolonefluoroquinolone oror aztreonamaztreonam

2. pts predisposed to AG toxicity: low GFR,2. pts predisposed to AG toxicity: low GFR,elderly, dehydration or volume depleted,elderly, dehydration or volume depleted,

prior AGprior AG rxrx, or other, or other nephrotoxicnephrotoxic drugsdrugs

antibiotic conference

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