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Naplex
Infectious Diseases I - Clinical pearl
| Question | Answer |
|---|---|
| Anti-staphylococcal penicillins (ASPs) | Nafcillin, oxacillin, cloxacillin, and dicloxacillin. |
| Natural penicillins | penicillin G (IV) and penicillin V (oral) |
| Additional coverage for Aminopenicillin + beta-lactamase inhibitor vs Aminopenicillin | Anaerobes, MSSA |
| Which penicilline cover MSSA | - Anti-staphylococcal penicillins - Aminopenicillin + beta-lactamase inhibitor - Extended spectrum penicillins |
| What penicillines cover Atypicals | NON of them |
| What penicillines cover Anaerobes | - Aminopenicillin + beta-lactamase inhibitor - Extended spectrum penicillins |
| Amoxicillin: common indications and doses | • Acute otitis media: 80-90 mg/kg/day (pick 90 for calculation) • Infective endocarditis prophylaxis: 2 grams PO x1 • H. pylori regimens |
| Penicillin VK: common indications and doses | • Strep throat, mild nonpurulent skin infections |
| Amoxicillin/Clavulanate (Augmentin): common indications and doses | • Acute otitis media: 90 mg/kg/day • Use lowest dose of clavulanate possible |
| Penicillines Class effects | Beta-lactam allergy, risk of seizures (with accumulation) - Renal dose adj --> oki for seizures |
| Penicillin G Benzathine (Bicillin L-A): common indications and doses | • Syphilis: 2.4 million units IM x 1 |
| Pennicilline w/o renal dose adjustments | Nafcillin and Oxacillin (inj) Dicloxacillin (PO) |
| What cephalosporines cover Atypicals | NON of them |
| What cephalosporins cover MRSA | 5th generation (ceftaroline) |
| What cephalosporins cover Anaerobes | Cefoxitin / cefotetan |
| Cepha vs peni coverage | • Most of peni: Enterococcus (not VRE) |
| 1st Generation PO: Cephalexin - common indications and doses | • Strep throat, MSSA skin infections |
| 2d Generation PO: Cefuroxime - common indications and doses | • Acute otitis media, CAP |
| 3rd Generation PO: Cefdinir - common indications and doses | • Acute otitis media |
| 1st Generation (Parenteral): Cefazolin - common indications and doses | • Surgical prophylaxis |
| 2d Generation: Cefotetan, Cefoxitin - common indications and doses | • Surgical prophylaxis (GI procedures) • Cefotetan: disulfiram-like reaction |
| 3" Generation: Ceftriaxone and Cefotaxime - common indications and doses | • CAP, meningitis, SBP, pyelonephritis • Ceftriaxone: no renal dose adjustment, do not use in neonates |
| Cepha Pseudomonas coverage | • 3rd Generation (Ceftazidime) • 4th Generation (Cefepime) |
| • Meropenem/vaborbactam • Imipenem/cilastatin/relebactam | Additional activity against some carbapenemase-producing gram-negatives |
| Ertapenem vs other Carbapenems | Lack of PAE: • Pseudomonas • Acinobacter • Enterococcus (not VRE) |
| Aztreonam vs Carbapenems | Lack of: • Gram positive (Enterococcus - not VRE, MSSA, Streptococcus) • Anaerobes |
| Ertapenem must be diluted in normal saline. | YES |
| penicillin allergy | Do not use carbapenem, instead use Aztreonam |
| Seizure risk | Carbapenem • Risk increase with higher doses, failure to dose adjust in renal dysfunction, or use of imipenem/cilastatin Penicillines risk w accumulation w/o renal dose adj --> If adjust renal dose: oki for seizures |
| Aminoglycosides spectrum | • Gram-negative bacteria (including Pseudomonas) • Synergy for gram-positive infections • Toxicities: Nephrotoxicity (watch for additive effects), Ototoxicity |
| Aminoglycosides dose | • Traditional: 1.5-2.5 mg/kg Q8H. Monitor: Peaks/troughs • Extended Interval: 4-7 mg/kg Q24H. Monitoring: Mid-interval (10-14H post dose) • Use adjusted body weight if obese |
| Respiratory Quinolones | Levofloxacin, moxifloxacin w reliable S. pneumoniae activity (in pneumonia) |
| Antipseudomonal Quinolones | • Ciprofloxacin, levofloxacin • Used for Pseudomonas infections (including pneumonia) |
| Quinolones - Common Uses | • Can vary by agent: pneumonias, UTIs, IAIs, travelers' diarrhea |
| Atypical pathogen activity | • Quinolones • Macrolides |
| Quinolone - not use for UTIs | • Moxifloxacin • Only quinolone that is not renally adjusted |
| Quinolone - IV to PO Ratio 1:1 | Levofloxacin and moxifloxacin |
| Quinolone - Counseling | • Avoid sun exposure, separate from polyvalent cations, monitor blood glucose (in diabetes) • Watch for tendon rupture, neuropathy, CNS or psychiatric side effects |
| Quinolone - Profile Review Tips | • Caution with CVD, reduce K/Mg and with other QT-prolonging drugs (e.g., azole antifungals, antipsychotics, methadone, macrolides) • Avoid in patients with a seizure history or if using seizure drugs • Avoid in children |
| Macrolides coverage | • Atypicals, Bordetella pertussis |
| clarithromycin & erythromycin contraindicated with | lovastatin and simvastatin |
| Macrolides Drug interactions (clarithromycin & erythromycin) | CYP INHIBITORS |
| Tetracyclines | • Atypicals, gram-positives (MRSA), some gram-negatives, unique pathogens • Does not prolong QT • Avoid in pregnancy and children < 8 years of age • Photosensitivity, chelation |
| Sulfamethoxazole/trimethoprim | • MRSA, PEK, opportunistic pathogens (Stenotrophomonas, Pneumocystis, Toxoplasma) • SMX:TMP 5:1, dose TMP • SEs (photosensitivity, hemolytic anemia: + Coombs test) • Warfarin interaction • Hyperkalemia: particularly with IV therapy and/or high doses |
| Vancomycin Dosing for MRSA | • IV, weight-based (renal adjustments) • Cause infusion reaction (it is infused too quickly) |
| Vancomycin Dosing for C. difficile | PO, fixed dose |
| Monitoring | • Serious MRSA infections: AUC/MIC ratio 400-600 or goal trough 15-20 mcg/mL • Other infections: goal trough 10-15 mcg/mL |
| Daptomycin | • CPK elevations/muscle-related ADRs • Inactivated by pulmonary surfactant (will not treat pneumonia) •Compatibility with NS |
| Linezolid (Zyvox) | • IV:PO ratio is 1:1 • "Serotonergic" / drug interactions • Thrombocytopenia |
| Clindamycin (Cleocin) | • Anaerobic and gram-positive activity • D-test: Positive result indicates inducible clindamycin resistance • High risk of C. diff |
| Metronidazole (Flagyl) | • Anaerobic activity only • Patient counseling: Disulfiram reaction, Metallic taste, Drug interactions (warfarin) |
| Nitrofurantoin (Macrodantin, Macrobid) | • Cystitis only • CrCl < 60 ml/min: not recommended • Gl upset (take with food) • Urine discoloration |
| Methicillin-susceptible Staphylococcus aureus (MSSA) | • Dicloxacillin, nafcillin, oxacillin • Cefazolin, cephalexin (and other 1st and 2nd generation cephalosporins) • Amoxicillin/clavulanate, ampicillin/sulbactam |
| Methicillin-resistant Staphylococcus aureus (MRSA) | • Vancomycin (consider using alternative if MIC ≥ 2) • Linezolid • Daptomycin (not in pneumonia) • Ceftaroline • SMX/TMP (CA-MRSA SSTIs) • Doxycycline, minocycline (CA-MRSA SSTIs) • Clindamycin* (CA-MRSA SSTIs) |
| Vancomycin-resistant Enterococcus (VRE) | • Pen G or ampicillin (E. faecalis only) • Linezolid • Daptomycin |
| HNPEK | • Beta-lactam/beta-lactamase inhibitor • Cephalosporins (except 1" generation) • Carbapenems • Aminoglycosides • Quinolones • SMX/TMP |
| ESBL producing gram-negative rods (E. coli, K. pneumoniae, P. mirabilis) | • Carbapenems • Ceftazidime/avibactam • Ceftolozane/tazobactam |
| Carbapenem-resistant gram-negative rods (CRE) | • Ceftazidime/avibactam • Colistimethate, polymyxin B • Meropenem/vaborbactam • Imipenem/cilastatin/relebactam |
| Gram-negative anaerobes (Bacteroides fragilis) | • Metronidazole • Beta-lactam/beta-lactamase inhibitor • Cefotetan, cefoxitin • Carbapenems • Moxifloxacin (reduced activity) |
| Pseudomonas aeruginosa | • Piperacillin/tazobactam • Cefepime • Ceftazidime • Ceftazidime/avibactam • Ceftolozane/tazobactam • Carbapenems (except ertapenem) • Ciprofloxacin, levofloxacin • Aztreonam • Tobramycin • Colistimethate, polymyxin B |
| Abx work on Cell wall synthesis - Plasma membrane integrity | • Daptomycin • Polymyxins |
| Abx work on Cell wall synthesis - Peptidoglycan synthesis | Vancomycin |
| Abx work on Cell wall synthesis - Peptidoglycan cross-linking | • Penicillins • Cephalosporins • Monobactam • Carbapenems |
| Abx work on Ribosome/protein synthesis - 30S subunit (A T) | • Aminoglycosides • Tetracyclines |
| Abx work on Ribosome/protein synthesis - 50S subunit (M C L) | • Macrolides • Clindamycin • Linezolid |
| Abx work on RNA synthesis | • Rifampin |
| Abx work on DNA synthesis (F Me) | • Fluoroquinolones • Metronidazole |
| What Abx should be avoided due to musculoskeletal toxicity during pregnancy, when breastfeeding & in children | Fluoroquinolones (eg, levofloxacin) should be avoided during pregnancy due to the risk of musculoskeletal toxicity in the developing fetus. |
| Enterobacter cloacae | Gram egative, more drug-resistant (AmpC beta-lactamase) (1st, 2nd, 3rd cepha: avoid). Pip/tazo, cefepime (4th), and carbapenems have activity against E. cloacae. |
| What Abx has the highest risk for seizure? | Imipenem (a carbapenem) carries the highest risk of seizures among all beta-lactam antibiotics. |
| What Abx cause Hemolytic anemia (identified with a positive Coombs test)? | • Cephalosporins • Penicillins • Bactrim (G6PD deficiency) |
| Macrolides coverage | • Atypicals (Legionella spp., Mycoplasma pneumoniae, Chlamydophila pneumoniae) • MAC • Bordetella pertussis, Haemophilus spp., Moraxella catarrhalis • Streptococcus pneumoniae • Chlamydia trachomatis |
| Minocycline SEs | Drug-induced lupus erythematosus (minocycline only, not other tetracycline) |
| Factors should be considered when recommending an empiric antibiotic regimen | • Drugs (route, spectrum, PK/PD, SEs) • Pt (Age, weight, allergy, renal / liver function, resistant risk, pregnancy, immune status) • Diseases (Site of infection, severity) |
| Prior initiate Nitrofurantoin, what lab to be assessed | • Nitrofurantoin: reduced efficacy and increased risk of AEs (pulmonary toxicity, hepatotoxicity, peripheral neuropathy) in renal impairment. • Contraindicated with a CrCI ≤ 60 mL/min. |
| Bactrim coverage | • (+): Streptococcus spp., MSSA, MRSA • (-): Proteus spp., Escherichia coli, Klebsiella spp. • Opportunistic pathogens (eg, Pneumocystis jirovecii, Stenotrophomonas maltophilia, Toxoplasma gondii) |
| Daptomycin monitoring | • SCr (for renal dose adjustments) • CPK at baseline and weekly • Signs/symptoms of myopathy (muscle pain or weakness) |
| Gentamicin or tobramycin traditional dose: goal of peak / trough | For 4th dose: • Peak (goal 5-10 mcg/mL): 30 min after the end of infusion • Trough (goal < 2 mcg/mL): before infusion (< 30 min) |
| Abx cover Atypical bacteria • Legionella spp. • Mycoplasma pneumoniae • Chlamydophila pneumoniae | • Fluoroquinolones (eg, levofloxacin, ciprofloxacin) • Macrolides (eg, azithromycin, clarithromycin) • Tetracyclines (eg, doxycycline, minocycline) |
| Select type of body weight for gentamicin & tobramycin dosing | • TBW if TBW < IBW • IBW • Adj BW if TBW > 120% IBW |
| 1st cephalosporin | • PO: cephalexin & cefadroxil • IV: cefazolin |
| 2nd cephalosporin | • PO: cefaclor & cefprozil • IV/PO: cefuroxime • IV: cefotetan & cefoxitin |
| 3rd cephalosporin | • PO: cefdinir, cefpodoxime & cefixime • IV: ceftazidime • IV/IM: ceftriaxone |
| 4th cephalosporin | • IV: cefepime |
| 5th cephalosporin | • IV: ceftaroline fosamil (Teflaro) & ceftobiprole |
| Cephalosporin/beta-lactamase inhibitor combination | • IV: ceftolozane/tazobactam (Zerbaxa) • IV ceftazidime/avibactam (Avycaz) |
| Counsel Fluoroquinolones | • Pain or tenderness at the back of your ankle: contact MD • Monitor your BG more frequently while taking this medication. • Protect your skin from sunlight • Psychiatric effects (eg, agitation, delirium) • Musculoskeletal toxic • (QT prolongation) |
| Aminoglycosides toxicities | • Nephrotoxicity • Ototoxicity. Regular monitoring creatinine, urine output and auditory function (ie, audiometric testing) are essential to minimize risks. |
| VCM infusion rate | • Not to exceed 1 gram/hr (INCREASE risk of infusion reaction if infused more quickly) |
| What effect does clavulanate have on amoxicillin in amoxicillin/clavulanate | • Expands spectrum of activity • Inhibits degradation |
| Lipoglycopeptides | • Telavancin (Vibativ) • Oritavancin (Orbactiv, Kimyrsa) • Dalbavancin (Dalvance) (Vancomycin - glycopeptides) |
| Cyclic lipopeptide | • Daptomycine |
| Liquid oral antibiotics - Refrigerate | • Peni V • Augmentin (optional for Amox) • All Cepha, except Cefdinir • Fidaxomicin • Vancomycin |
| Which antibiotic requires a D-test to verify that its reported susceptibility is reliable prior to use? | • Clindamycin D-testing is used to detect inducible resistance in clindamycin-susceptible Staphylococcus aureus isolates. A positive test indicates that resistance to clindamycin can develop during treatment and that clindamycin should be avoided. |
| Glycylcycline | Tigecycline |
| Lincosamide | Clindamycin |
| Oxazolidinone | Linezolid |
| Dificid (fidaxomicin) | • Target C. difficile. • Large, complex structure and poor water solubility limit systemic absorption, achieve high concentrations in the colon where C. difficile resides. • Minimizing systemic adverse effects. |
| Zyvox (linezolid) DDI | Concurrent use of linezolid (a monoamine oxidase inhibitor) with other serotonergic medications (eg, St.John's wort, tramadol) increases the risk of serotonin syndrome. |
| Storage, handling of select IV antimicrobials | • NOT refrigerate: Acyclovir, Metronidazole, Moxifloxacin, Bactrim • Protect from light: Doxycycline, Micafungin, Pentamidine |
| Compatibility of select IV antimicrobials | • Dextrose: Amphotericin B, Pentamidine, Bactrim • Saline: Ampicillin, Unasyn, Ertapenem • Saline or lactated Ringer: Caspofungin, Daptomycin |
| Zyvox (linezolid) safety issues | • Myelosuppression (thrombocytopenia, anemia, leukopenia): increase risk when used > 14 days • Neuropathy (optic, peripheral): increase risk when used > 28 days • Hypoglycemia |
Created by:
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