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ANTIBIOTIC SELECTION ANTIBIOTIC SELECTION
ByBy
Prof. ABDEL FATTAH ABDEL SATTARProf. ABDEL FATTAH ABDEL SATTAR
HEAD OF ANESTHESIA & PAIN RELIEFHEAD OF ANESTHESIA & PAIN RELIEF
DEPARTMENTDEPARTMENT
NATIONAL CANCER INSTITUTENATIONAL CANCER INSTITUTE
CAIRO UNIVERSTIYCAIRO UNIVERSTIY
20072007
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Topics:
Introduction.
Antibiotic Review.
Principles of Antibiotic choice.
Surgical Prophylaxis -- antimicrobial use
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ANTIBIOTICS REVIEW ANTIBIOTICS REVIEW
Since the development of Sulphonamides inSince the development of Sulphonamides in1930 and Penicillin in 1940, numerous effective1930 and Penicillin in 1940, numerous effective
antibacterial, antifungal and recently antiviralantibacterial, antifungal and recently antiviralagents have become available.agents have become available.
TheThe similaritiessimilarities of many of these antibiotics areof many of these antibiotics aremore striking than their differencesmore striking than their differences..
The newest antibiotic is often not the bestThe newest antibiotic is often not the best
choice.choice. Therefore obtaining culture in conjunction withTherefore obtaining culture in conjunction with
susceptibility testing is imperative.susceptibility testing is imperative.
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The empiric use of antibiotics is the normThe empiric use of antibiotics is the norm
rather than exception.rather than exception. The physician should be familiar with theThe physician should be familiar with the
suspected organismssuspected organisms for bothfor both communitycommunity
andand hospital acquired infectionhospital acquired infection..
Choice will consider Choice will consider ::
The nature of the infectionThe nature of the infection (What organisms(What organismsare most likely involved) .are most likely involved) .
Understanding of different antibioticsUnderstanding of different antibiotics(spectrum and limitations)(spectrum and limitations)
The patient factorsThe patient factors (renal or hepatic(renal or hepatic
dysfunction are common in ICU patient) .dysfunction are common in ICU patient) .
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The selection of specific antibioticsThe selection of specific antibiotics
depends on:depends on:1.1.
The presumed site of infectionThe presumed site of infection
(see table 1(see table 1below).below).
Table 1: Frequency of Source of InfectionTable 1: Frequency of Source of Infection
Respiratory TractRespiratory Tract
25%25%
Abdominal / Pelvic Abdominal / Pelvic
25%25%BacteremiaBacteremia
15%15%
Urinary TractUrinary Tract
10%10%
SkinSkin
5%5%IV Catheter IV Catheter
5%5%
Other sourceOther source
15%15%
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22--
Gram's stain results .Gram's stain results .
33--
Suspected or known organismsSuspected or known organisms
44--
Resistance patterns of the commonResistance patterns of the common
hospital microbial flora.hospital microbial flora.55--
PatientPatient’’s immune status (especiallys immune status (especially
neutropenia and immunosuppressiveneutropenia and immunosuppressivedrugs), allergies, renal dysfunction, anddrugs), allergies, renal dysfunction, and
hepatic dysfunction.hepatic dysfunction.
66--
Antibiotic availability, hospital resistance Antibiotic availability, hospital resistance
patterns, and clinical variables of patientpatterns, and clinical variables of patient
to be treatedto be treated
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CLASSIFICATION & PATHOGENICITY CLASSIFICATION & PATHOGENICITY
OF MICROBESOF MICROBES11--BACTERIABACTERIA::
* Gram* Gram--stained: positive, negative.stained: positive, negative.* Acid fast bacilli: Mycobacterium(TB,Leprae).* Acid fast bacilli: Mycobacterium(TB,Leprae).* Spirochetes: Treponema (Syphilis),* Spirochetes: Treponema (Syphilis),Leptospira, Borrelia(Relapsing Fever).Leptospira, Borrelia(Relapsing Fever).
22-- Viruses Viruses::
DNA & RNA containing viruses.DNA & RNA containing viruses.
33--FungiFungi::
* Filamentous: Tinea, Aspergillus.* Filamentous: Tinea, Aspergillus.** True Yeast: Cryptococcus neoformans.True Yeast: Cryptococcus neoformans.* Yeast like: Candida albicans.* Yeast like: Candida albicans.
44--
ProtozoaProtozoa
::Toxoplasmosis,Leishmaniasis,Toxoplasmosis,Leishmaniasis,Trichomonas.Trichomonas.
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GRAMGRAM--STAINED BACTERIAL PATHOGENSSTAINED BACTERIAL PATHOGENS
GramGram--
positive cocci (Aerobic):positive cocci (Aerobic):* Staphylococcus:S.aureus, albus(epidermis).* Staphylococcus:S.aureus, albus(epidermis).
* Streptococcus:S.pneumoniae, S.pyogenes* Streptococcus:S.pneumoniae, S.pyogenesS.viridian's, S.faecalis(enterococci).S.viridian's, S.faecalis(enterococci).
GramGram--positive cocci(Anaerobic):positive cocci(Anaerobic):
putridus
GramGram--positive bacilli(Aerobic):positive bacilli(Aerobic):* Non* Non--poring: Corynobacterium(c.dipht.),poring: Corynobacterium(c.dipht.),Listeria (L.monocytogens)..B.Anthrax(Spor).Listeria (L.monocytogens)..B.Anthrax(Spor).
GramGram--
positive bacilli(Anaerobic):positive bacilli(Anaerobic):* Sporing:* Sporing: Clostridium tetani,welchiiClostridium tetani,welchii..* Non* Non--sporing: propionibacter(p.acnes)sporing: propionibacter(p.acnes)
Actinomycetes(A.israelii). Actinomycetes(A.israelii).
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GramGram--negative cocci (Aerobic):negative cocci (Aerobic):
**
Nersseria: N.meningitidis, N.gonorrhoae.Nersseria: N.meningitidis, N.gonorrhoae.GramGram--negative cocci (Anaerobic):negative cocci (Anaerobic):
Gram negative bacilli (Aerobic):Gram negative bacilli (Aerobic):
(a) Enterobacteria: E.coli, K.aerogenes,(a) Enterobacteria: E.coli, K.aerogenes,Proteus S.typhi, Sh.sonnei, Serrattia.Proteus S.typhi, Sh.sonnei, Serrattia.
(b) Pseudomonas: P.aeruginosa.(b) Pseudomonas: P.aeruginosa.( c)Parvobacteria: Haemophilus( H.influenza)( c)Parvobacteria: Haemophilus( H.influenza)Brucella(B.abortus), Bordetella(B.pertussis).Brucella(B.abortus), Bordetella(B.pertussis).
(d) Vibrios(V.cholerae).(d) Vibrios(V.cholerae).(e) Legionella: L.pneumoehila.(e) Legionella: L.pneumoehila.
GramGram--negative bacilli (Anaerobic)negative bacilli (Anaerobic)
* Bacteroides(B.fragelis).* Bacteroides(B.fragelis).
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InIn intensive care units approximately 25% ofintensive care units approximately 25% of
infections are confirmedinfections are confirmed gram negativegram negative,,25%25% gram positivegram positive, 20%, 20% mixed grammixed gram
positive/gram negativepositive/gram negative, and 3%, and 3% fungafungal.l.
Of the gram negative organismsOf the gram negative organisms, the, the
organisms in order of likelihood areorganisms in order of likelihood are e.colie.coli(25%),(25%), klebsiellla/citrobacter klebsiellla/citrobacter (20%),(20%),
pseudomonaspseudomonas (15%),(15%), enterobacter enterobacter (10%)(10%)andand proteusproteus (5%); the remaining 25% is(5%); the remaining 25% is
made up of dozens of differentmade up of dozens of different bacteriaebacteriae..
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Of the gram positive infectionsOf the gram positive infections, by far, by far
the most common isthe most common is staphylococcusstaphylococcusaureusaureus (35%), followed by(35%), followed by enterococcusenterococcus
(20%),(20%), coagulasecoagulase negative staphylococcusnegative staphylococcus
(15%) and(15%) and streptococcusstreptococcus pneumoniaepneumoniae
(10%). The vast majority of(10%). The vast majority of fungalfungal
infections areinfections are candidalcandidal..
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ORGANISMS & SITE of INFECTIONORGANISMS & SITE of INFECTION
** S.aureusS.aureus skin,soft tissue,bone,IV linesskin,soft tissue,bone,IV lines..
** Strept(A).Strept(A).
skin,soft tissue,fascial infectionskin,soft tissue,fascial infection** EnterococciEnterococci Biliary,urinaryBiliary,urinary, colonic infection, colonic infection
** Pseudomonas aerugPseudomonas aerug..
lung, skin infectionlung, skin infection** KlebsiellaKlebsiella Infection around biliary TractInfection around biliary Tract
** ProteusProteus Urosepsis.Urosepsis.
** E.coliE.coli Intraabdominal pelvic or urinaryIntraabdominal pelvic or urinary
** ClostridiumClostridium skin,soft t., biliary, colonicskin,soft t., biliary, colonic
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PENICILLINSPENICILLINS
Penicillins have predictable activity againstPenicillins have predictable activity against
gram+ve coccigram+ve cocci →→(Streptococci).(Streptococci).
Ampicillin Ampicillin && Amoxycillin Amoxycillin →→some gramsome gram--ve bacillive bacilli
MethicillinMethicillin ((StaphcillinStaphcillin)) →→ StaphStaph albusalbus..
Piperacillin, Ticracillin, Mezlocillin and AzlocillinPiperacillin, Ticracillin, Mezlocillin and Azlocillin
→→ Anti Anti--pseudomonas penicillins.pseudomonas penicillins.
They should be used in combination with anThey should be used in combination with an
aminoglycoside or agent with antiaminoglycoside or agent with anti-- gramgram--Ve.Ve.
They have no anti gramThey have no anti gram--veve activity.activity.
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CEPHALOSPORINSCEPHALOSPORINS●●11stst
generationgeneration→→
active against gram+ve.active against gram+ve.e.g.:Cephalexine.g.:Cephalexin
((KeflexKeflex), Cephardine (), Cephardine (Velosef Velosef ))
●●33₫ ₫ generationgeneration→→
active against gramactive against gram--ve.ve.e.g.:e.g.: CefotaximeCefotaxime
((ClaforanClaforan), Cefoperazine), Cefoperazine((Cefobid),Cefobid),
Cefotriaxone (Cefotriaxone (RociphenRociphen),),
Ceftazidime (Ceftazidime (FortumFortum))
●●22₫ ₫ generationgeneration→→
mixed activity.mixed activity.
e.g.: Cefuroxime (e.g.: Cefuroxime (Zinnat).Zinnat).44thth
generationgeneration: gram: gram--ve(p.auregve(p.aureg.) +.) +strept.+staphstrept.+staph+limited activity against anaerobes.+limited activity against anaerobes.
e.g.; Cefipime (e.g.; Cefipime (MaxipimeMaxipime))
P i illi S l F dP i illi St t l F t d
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Penicillin Structural Features andPenicillin Structural Features and
Requirements for Antibacterial ActivityRequirements for Antibacterial Activity
PenicillinsPenicillins
have similar structures: ahave similar structures: a
thiazolidinethiazolidine
ring (A)ring (A) atachedatached
to ato a ßß--
lactamlactam
ring (B).ring (B).
SubstituentsSubstituents
are attached to the aminoare attached to the aminogroup (R). Moieties A and B togethergroup (R). Moieties A and B together
constitute the 6constitute the 6--aminopennicillanicaminopennicillanic
acid nucleus required foracid nucleus required for
antibacterial activity.antibacterial activity.
Cleaving theCleaving the ßß--lactamlactam
ring byring by
penicillinasespenicillinases
((ßß--lactamaseslactamases) results) results
in loss of antibacterial properties.in loss of antibacterial properties.
PenicillinsPenicillins
may also be inactivated bymay also be inactivated by
amidasesamidases..
Static figure (left top): Nitrogen atomsStatic figure (left top): Nitrogen atoms
are red, sulfur light blueare red, sulfur light blue--green andgreen and
oxygen atoms are green.oxygen atoms are green.
3D interactive figure (left, bottom) atoms3D interactive figure (left, bottom) atoms
areare identifiedidentified
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BETABETA--LACTAMASE INHIBITORSLACTAMASE INHIBITORS
BetaBeta--LactamasesLactamases are bacterial enzymes thatare bacterial enzymes thatinactivateinactivate betabeta--lactams antibioticslactams antibiotics ((PenicillinsPenicillins &&cephalosporinscephalosporins).).
BetaBeta-- lactamase inhibitors bind to the enzymeslactamase inhibitors bind to the enzymespreventing them from inactivating antibiotics.preventing them from inactivating antibiotics.
e.g. Sulbactam + ampicillin =e.g. Sulbactam + ampicillin = Unasyn.Unasyn.Clavulanate +amoxycillin =Clavulanate +amoxycillin = Augmentin. Augmentin.
Tazobactam +piperacillin =Tazobactam +piperacillin = Tazocin.Tazocin. They are active against betaThey are active against beta--lactamases oflactamases of
nisseria gonorrhea, K.pneumonia, H.influenza,nisseria gonorrhea, K.pneumonia, H.influenza,s.aureuss.aureus m.cattaralis but less to Pseudomonasm.cattaralis but less to Pseudomonas
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CARBAPENEBSCARBAPENEBS
Imipenem & MeropnemImipenem & MeropnemThey are active against mostThey are active against most aerobicaerobic
andand
anaerobicanaerobic
gram +vegram +ve
&& gramgram – –veve
organismsorganisms.. Imipenem (Imipenem (TienemTienem))→→ Cilastatin sodium toCilastatin sodium to
prevent renal metabolism &prevent renal metabolism &↓↓ nephrotoxicitynephrotoxicitybut have CNS adverse effect (seizuresbut have CNS adverse effect (seizures).).
Meropenem (Meropenem (MeronemMeronem))→→ nono cilastatincilastatin
↓↓
epileptogenic &epileptogenic &↓↓Renal degradation.Renal degradation.↑↑activity against aerobic gramactivity against aerobic gram – –ve bacillive bacilli..
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MONOBACTAMS & AMINOGLYCOSIDESMONOBACTAMS & AMINOGLYCOSIDES
Aztreonam Aztreonam
(( A Azactamzactam):):
Extremely effective againstExtremely effective against aerobic gramaerobic gram--vevebacillibacilli including P.aeuroginosa.including P.aeuroginosa.
Narrow spectrumNarrow spectrum →↓→↓emergence ofemergence of resistantresistantbacteria.bacteria.
Aminoglycosides Aminoglycosides::
Gentamicin, AmikacinGentamicin, Amikacin
Have great activity againstHave great activity against gramgram--ve bacilli.ve bacilli.
Post antibiotic effectPost antibiotic effect→→ ↑↑dose interval.dose interval.
Nephrotoxicity and Ototoxcicity.Nephrotoxicity and Ototoxcicity.
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MACROLIDESMACROLIDES
ErythromycinErythromycin
AzithromycinAzithromycin ClarithromycinClarithromycin
All have activity against Clamydia pneumoniae, All have activity against Clamydia pneumoniae,Mycoplasma pneumoniae & Ligionella spices.Mycoplasma pneumoniae & Ligionella spices.
The latter two have greater activity against H.infleunzaThe latter two have greater activity against H.infleunza
& nontuberculus mycobacterium.& nontuberculus mycobacterium. Used in critically ill patients suspected of havingUsed in critically ill patients suspected of having
Atypical pneumonias.Atypical pneumonias.
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QUINOLONESQUINOLONES
They bind to bacterial DNA, prevent replicationThey bind to bacterial DNA, prevent replication
Excellent bioavailabilityExcellent bioavailability
((effective orally as IVeffective orally as IV).).
Ciprofloxacin,Ciprofloxacin, OfloxacinOfloxacin , , NorfloxacinNorfloxacin::
Active against gram Active against gram--ve (ve (antianti--pseudpseud.) &Staph..) &Staph.
Limited activity against anaerobes &Limited activity against anaerobes & StreptStrept..
LevofloxacinLevofloxacin , Moxifloxacin,Garifloxacin , Moxifloxacin,Garifloxacin::
↑↑activity against Anaerobic&Strept.pneumon.activity against Anaerobic&Strept.pneumon.
activity against atypical Pneumon(Ligionella).activity against atypical Pneumon(Ligionella).
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VANCOMYCIN VANCOMYCIN
•• TricyclicTricyclic glycopeptideglycopeptide
active against:active against:BB lactamlactam
resistant Gram +ve (MRSA &resistant Gram +ve (MRSA &
enterocoocienterocooci
))..
•• No activity for GramNo activity for Gram --ve.ve.
* Used in pts. with implanted heart prosthesis, dental* Used in pts. with implanted heart prosthesis, dental
prophylaxis, Enterococcal endocarditisprophylaxis, Enterococcal endocarditis(combination with aminoglycosides ).(combination with aminoglycosides ).
* Oral :Antibiotic induced* Oral :Antibiotic induced colitis(C.difficillecolitis(C.difficille).).
*PO: 0.25g/12h. IV :0.5g/12h.(Renal excretion)*PO: 0.25g/12h. IV :0.5g/12h.(Renal excretion)*Side effects: Serious(*Side effects: Serious(ototoxicityototoxicity, neutropenia, neutropeniaNephrotoxicityNephrotoxicity,, rashsrashs, hypotension if rapid IV), hypotension if rapid IV)
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LINEZOLIDSLINEZOLIDS
Oxazolidinones group :Oxazolidinones group :
They have a novel mechanismThey have a novel mechanism →→blockblockbacterial protein synthesis at the ribosomebacterial protein synthesis at the ribosomeat a very early stage.at a very early stage.
So, it does not share crossSo, it does not share cross--resistance withresistance withother antimicrobial agentsother antimicrobial agents
SpectrumSpectrum→→ Identical to VancomycinIdentical to Vancomycin..
Major indicationMajor indication →→ VancomycinVancomycinresistanceresistance..
Excellent oral bioavailability.Excellent oral bioavailability.
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TRIAZOLESTRIAZOLES
They are fungistatic drugs.They are fungistatic drugs.
Fluconazole (Fluconazole (DiflucanDiflucan):):
High volume of distribution.High volume of distribution. Active against Active against Candida albicansCandida albicans,C,C tropicalistropicalis,,
Cryptococcus neoformans.Cryptococcus neoformans. 80% excreted unchanged in urine80% excreted unchanged in urine→→ no needno need
to adjust for renal insufficiency.to adjust for renal insufficiency.
Itraconazole (Itraconazole (ItrapexItrapex , , ItranoxItranox):):
Greater activity againstGreater activity against aspergillusaspergillus,,
Blastoyces dermatidis & HistoplasaBlastoyces dermatidis & Histoplasa capsulatcapsulat..
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AMPHOTERICIN B AMPHOTERICIN B
Empirical therapy in febrile patient withEmpirical therapy in febrile patient with
neutropenia.neutropenia. StandardStandard fungicidalfungicidal drug for treatment of severedrug for treatment of severe
mycoses.mycoses.
Adverse effect Adverse effect→→ nephrotoxicitynephrotoxicity.. 3 new formula3 new formula→→ ↓↓ nephrotoxicity:nephrotoxicity:
-- Amphotericin B Lipid complex. Amphotericin B Lipid complex.-- Amphotericin B colloidal dispersion. Amphotericin B colloidal dispersion.
--Liposomal Amphotericin B.Liposomal Amphotericin B.
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PneumoniaPneumonia
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KlebsiellaKlebsiella
pneumoniae pneumoniae
ProteusProteus
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PneumoniaPneumonia
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Treatment for Ambulatory Patients: Treatment for Ambulatory Patients:
Oral macrolide ( erythromycin, azithromycin(Zythromax), or clarithromycin(Biaxin)), doxycycline (Vibramycin, Doryx), or
fluoroquinones with good anti-pneumococcalactivity (levofloxacin (Levaquin), grepafloxacin,trovafloxacin)
Older patients or patients with underlying
disease: recommendation -- levofloxacin
(Levaquin)- grepafloxaci - trovafloxacin
C itCommunity i d b t i lacquired bacterial
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CommunityCommunity--acquired bacterialacquired bacterial
pneumoniapneumonia Most frequent cause: StreptococcusMost frequent cause: Streptococcus pneumoniaepneumoniae
((pneumococcipneumococci))
Other pathogens:Other pathogens: HaemophilusHaemophilus influenzaeinfluenzae
StaphylococcusStaphylococcus aureusaureus
KlebsiellaKlebsiella pneumoniaepneumoniae
occasionally: other gramoccasionally: other gram--negative bacilli and anaerobicnegative bacilli and anaerobicmouth organismsmouth organisms
""Atypical" pathogensAtypical" pathogens:: LegionellaLegionella MycoplasmaMycoplasma pneumoniaepneumoniae ChlamydiaChlamydia pneumoniaepneumoniae
respiratory viruses tuberculosisrespiratory viruses tuberculosis
PneumocystisPneumocystis cariniicarinii
Treatment: In Hospitalized PatientsTreatment: In Hospitalized Patients
http://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htm
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Treatment: In Hospitalized Patients Treatment: In Hospitalized Patients
Pending culture results and susceptibility testing:Pending culture results and susceptibility testing:
ReasonableReasonable firstfirst--choicechoice:: cefotaximecefotaxime oror
ceftriaxoneceftriaxone CefotaximeCefotaxime ((ClaforanClaforan),), ceftriaxoneceftriaxone
((RocephinRocephin
),),
VancomycinVancomycin ((VancocinVancocin): high resistance): high resistance
VancomycinVancomycin ((VancocinVancocin) and cephalosporin:) and cephalosporin:
severe illnesssevere illness---- not responding to a betanot responding to a beta--
lactamlactam..
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Treatment: In Hospitalized Patients Treatment: In Hospitalized Patients--
A A macrolidemacrolide ((erythromycinerythromycin,, azithromycinazithromycin
((ZythromaxZythromax), or), or clarithromycinclarithromycin ((BiaxinBiaxin))
added toadded to
aa fluoroquinonefluoroquinone (good activity against S.(good activity against S.
pneumoniaepneumoniae ---- levofloxacinlevofloxacin ((LevaquinLevaquin),),grepafloxacingrepafloxacin andand trovafloxacintrovafloxacin) can be) can be
used to coverused to cover LegionellaLegionella,, MycoplasmaMycoplasma,,
chlamydiachlamydia..
IfIf aspiration pneumoniaaspiration pneumonia is a concern:is a concern:
clindamycinclindamycin ((CleocinCleocin) or) or metronidazolemetronidazole ((FlagylFlagyl))may be addedmay be added
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Treatment for hospitalTreatment for hospital--acquiredacquired
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Treatment for hospital Treatment for hospital acquiredacquired
bacterial pneumoniabacterial pneumonia Most often cause byMost often cause by gramgram--negative bacilli:negative bacilli:
KlebsiellaKlebsiella
Enterobacter Enterobacter
SerratiaSerratia Acinetobacter Acinetobacter AND AND
Pseudomonas aeruginosaPseudomonas aeruginosa
StaphylococcusStaphylococcus aureusaureus ((gram + positivegram + positive))
Treatment for hospitalTreatment for hospital acquiredacquired
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Treatment for hospital Treatment for hospital--acquiredacquired
bacterial pneumoniabacterial pneumonia The initial treatment: thirdThe initial treatment: third--generationgeneration
cephalosporin :cephalosporin :
cefotaximecefotaxime
((ClaforanClaforan
))
ceftizoximeceftizoxime ((CefizoxCefizox)) ceftriaxoneceftriaxone ((RocephinRocephin))
ceftazidimeceftazidime ((FortaxFortax,, TaxidimeTaxidime,, Tazicef Tazicef ))
Or:Or: cefepimecefepime ((MaxipimeMaxipime))
ticarcillinticarcillin ((Ticar Ticar )/)/ clavulanicclavulanic acidacid
piperacillinpiperacillin ((Pipracil)/tazobactamPipracil)/tazobactam
meropenemmeropenem ((MerremMerrem IV)IV)
imipenemimipenem
TT f h i l di d
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Treatment for hospital Treatment for hospital--acquiredacquired
bacterial pneumoniabacterial pneumonia ConsideringConsidering thirdthird--generationgeneration cephalosporinscephalosporins::
CefotaximeCefotaxime ((ClaforanClaforan),), ceftizoximeceftizoxime ((CefizoxCefizox),),andand ceftriaxoneceftriaxone ((RocephinRocephin)} limited activity)} limited activity
against Pseudomonasagainst Pseudomonas
CeftazidimeCeftazidime ((FortaxFortax,, TaxidimeTaxidime,, Tazicef Tazicef )} more)} more
activity against staphylococci and other gramactivity against staphylococci and other gram--
positivepositive coccicocci..
with or without thewith or without the aminoglycosideaminoglycoside
{{tobramycintobramycin ((NebcinNebcin), gentamicin), gentamicin
(Garamycin), or(Garamycin), or amikacinamikacin (( Amikin Amikin)})}
Treatment for hospitalTreatment for hospital--acquiredacquired
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Treatment for hospital Treatment for hospital--acquiredacquired
bacterial pneumoniabacterial pneumonia In the intensive care unitIn the intensive care unit ---- nosocomialnosocomial
pneumonia due to highly resistant grampneumonia due to highly resistant gram--
negative bacteria and Pseudomonasnegative bacteria and Pseudomonasaeruginosa:aeruginosa:
Good first choicesGood first choices---- imipenemimipenem
meropenemmeropenem ((MerremMerrem IV)IV)
plusplus aminoglycosideaminoglycoside
addadd vancomycinvancomycin ((VancocinVancocin) in hospitals) in hospitals
wherewhere methicillinmethicillin ((StaphcillinStaphcillin))--resistantresistantstaphylococci (MRSA) are commonstaphylococci (MRSA) are common
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GenitourinaryGenitourinary
Urinary tract infection (UTI)Urinary tract infection (UTI)
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y ( )y ( )
Acute, uncomplicated UTIAcute, uncomplicated UTI ttrimethoprimrimethoprim--sulfamethoxazolesulfamethoxazole ((BactrimBactrim))
(3(3--day course of treatment)day course of treatment) Alternative: Alternative: fluoroquinonefluoroquinone (three(three--day courseday course
of treatment)of treatment)
Alternative (longer treatment): Alternative (longer treatment): oral cephalosporinoral cephalosporin
amoxicillinamoxicillin (( Amoxil Amoxil PolymoxPolymox)(many)(many
urinary pathogensurinary pathogens ---- resistance toresistance toamoxicillin)amoxicillin)
fosfomycinfosfomycin ((MonurolMonurol)(single)(single dosedose ) )
Urinary tract infection (UTI)Urinary tract infection (UTI)
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RepeatedRepeated UTIsUTIs
or UTI occurring in theor UTI occurring in thehospitalhospital
may be due to antibioticmay be due to antibiotic--resistant gramresistant gram--negative bacillinegative bacilli
Treatment:Treatment:
fluoroquinonefluoroquinoneoral amoxicillinoral amoxicillin ((AmoxiAmoxi))
Polymox)/clavulanicPolymox)/clavulanic acidacid
oral thirdoral third--generation cephalosporingeneration cephalosporin((cefiximecefixime ((SupraxSuprax),), cefpodoximecefpodoxime((VantinVantin),), ceftibutenceftibuten) or) or idanylidanyl ester ofester of
carbenicillincarbenicillin
Urinary tract infection (UTI)Urinary tract infection (UTI)
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Urinary tract infection (UTI)Urinary tract infection (UTI)
in patients hospitalized with UTI:in patients hospitalized with UTI:
thirdthird--generation cephalosporingeneration cephalosporin
ticarcillinticarcillin ((Ticar Ticar )/)/clavulanicclavulanic acidacid
piperacillinpiperacillin ((PipracilPipracil)/)/ttazobactamazobactam
imipenemimipenem (occasionally in(occasionally in
combination withcombination with aminoglycosideaminoglycoside))
S iS i
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SepsisSepsis
SepsisSepsis
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SepsisSepsis
Initial treatmentInitial treatment LifeLife--threatening sepsis and adults:threatening sepsis and adults:
Third or fourth generation cephalosporinThird or fourth generation cephalosporin
cefotaximecefotaxime ((ClaforanClaforan)) ceftizoximeceftizoxime ((CefizoxCefizox))
ceftriaxoneceftriaxone ((RocephinRocephin))
cefepimecefepime ((MaxipimeMaxipime))
ticarcillinticarcillin ((Ticar)/clavulanicTicar)/clavulanic acidacid
piperacillinpiperacillin ((Pipracil)/tazobactamPipracil)/tazobactam imipenemimipenem oror meropenemmeropenem ((MerremMerrem IV)IV)
{{eacheach together withtogether with aminoglycosideaminoglycoside
[[gentamicingentamicin ((GaramycinGaramycin),), tobramycintobramycin((NebcinNebcin), or), or amikacinamikacin ((AmikinAmikin)]})]}
S iS i
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SepsisSepsis
IfIf methicillinmethicillin--resistant staphylococci isresistant staphylococci is
a considerationa consideration::
vancomycinvancomycin ((VancocinVancocin) alone or) alone or
vancomycinvancomycin ((VancocinVancocin) with) with gentamicingentamicin
((GaramycinGaramycin) and/or) and/or rifampinrifampin ((RimactaneRimactane)) If bacterialIf bacterial endocarditisisendocarditisis is a considerationis a consideration
(prior to pathogen identification):(prior to pathogen identification):
vancomycinvancomycin ((VancocinVancocin) plus) plus gentamicingentamicin((GaramycinGaramycin))
SepsisSepsis
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SepsisSepsis
Treatment of intraTreatment of intra--abdominal or pelvic infection (abdominal or pelvic infection (likelylikely
to involve anaerobes):to involve anaerobes):
ticarcillinticarcillin ((Ticar)/clavulanicTicar)/clavulanic acid)acid)ampicillinampicillin ((PrincipenPrincipen,, Omnipen)/sulbactamOmnipen)/sulbactam))
piperacillinpiperacillin ((Pipracil)/tazobactamPipracil)/tazobactam))
imipenemimipenem
meropenemmeropenem
cefoxitincefoxitin ((MefoxinMefoxin) or) or cefotetancefotetan ((CefotanCefotan))
{each with or without an{each with or without an aminoglycosideaminoglycoside,,
metronidazolemetronidazole ((FlagylFlagyl) OR) OR
clindamycinclindamycin ((CleocinCleocin) with an) with an aminoglycosideaminoglycoside
S iS i
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SepsisSepsis
gramgram--negative bacilli:negative bacilli:Third or fourth generationThird or fourth generation cephalosporinscephalosporins
cefotaximecefotaxime ((ClaforanClaforan))
ceftizoximeceftizoxime ((CefizoxCefizox))
cefoperazonecefoperazone ((CefobidCefobid)) ceftriaxoneceftriaxone ((RocephinRocephin))
cefepimecefepime ((MaxipimeMaxipime))
ceftazidimeceftazidime (plus activity against gram(plus activity against gram--positivepositive coccicocci))
imipenemimipenem,, meropenemmeropenem ((MerremMerrem IV),IV),
aztreonamaztreonam (( Azactan Azactan ) )
S iS p i
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SepsisSepsis
CephalosporinsCephalosporins (other than(other than cefoperazonecefoperazone
((CefobidCefobid),), cefepimecefepime ((MaxipimeMaxipime), and), and
ceftazidimeceftazidime ((FortaxFortax,, TaxidimeTaxidime,, Tazicef Tazicef )):)):limited efficacy against Pseudomonaslimited efficacy against Pseudomonas
aeruginosaaeruginosa
Pseudomonas aeruginosaPseudomonas aeruginosa::
effectively treated witheffectively treated with imipenemimipenem,, meropenemmeropenem
((MerremMerrem IV), andIV), and aztreonamaztreonam (( Azactan Azactan).). Aztreonam Aztreonam (( Azactan Azactan): poor activity against): poor activity against
gramgram--positive organisms and anaerobespositive organisms and anaerobes
SepsisSepsis-- Special CasesSpecial Cases
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pp
pp
NeutropenicNeutropenic
patients with suspected bacteremia patients with suspected bacteremia ceftazidimeceftazidime ((FortaxFortax,, TaxidimeTaxidime,, Tazicef Tazicef ))
imipenemimipenem
meropenemmeropenem ((MerremMerrem IV)IV)
cefepimecefepime ((MaxipimeMaxipime) (in more seriously ill) (in more seriously ill
patients,patients, add anadd an aminoglycosideaminoglycosideamikacinamikacin (( Amikin Amikin) and) and ceftriaxoneceftriaxone ((RocephinRocephin))
(single daily doses)(single daily doses)
piperacillinpiperacillin ((Pipracil)/tazobactamPipracil)/tazobactam plusplus amikacinamikacin Addition of Addition of vancomycinvancomycin ((VancocinVancocin)): in: in neutropenicneutropenic
cancer patients with bacteremia due tocancer patients with bacteremia due to methicillinmethicillin
((StaphcillinStaphcillin))--resistant staphylococci & some strains ofresistant staphylococci & some strains ofviridansviridans
A 69 year old female, with no past medical
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history, is admitted from home with pleuritic
chest pain, shortness of breath, pyrexia and
tachycardia
Presumed diagnosisPresumed diagnosis
::
community acquired pneumonia incommunity acquired pneumonia in
anan immunocompetentimmunocompetent hosthost..
The most likely organisms areThe most likely organisms are
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The most likely organisms areThe most likely organisms are
pneumococcipneumococci,, MycoplasmaMycoplasma andandLegionellaLegionella..
The patient requires coverage for bothThe patient requires coverage for bothgram positivegram positive andand atypical organisms.atypical organisms.
Cephalosporin iv +Cephalosporin iv +
macrolidemacrolide
popo
or or
fluroquinolonefluroquinolone
Cefuroxime/CeftriaxoneCefuroxime/Ceftriaxone iv +iv +azithromycinazithromycin popo oror levofloxacinlevofloxacin
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An 85 year old female is admitted An 85 year old female is admitted
unconscious and hypotensive from aunconscious and hypotensive from a
nursing home.nursing home.
She has a fever and aShe has a fever and a leucocytosisleucocytosis andand
her urine is foul smelling.her urine is foul smelling.
Presumed diagnosisPresumed diagnosis – – urinary tracturinary tract
infection.infection.
The most common organisms causing urinaryThe most common organisms causing urinary
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g g y
tract infections aretract infections are EnterobacteriacaeEnterobacteriacae andand
enterococcienterococci,, and the treatment isand the treatment is ciprofloxacin orciprofloxacin or
ampicillinampicillin andand gentamycingentamycin..
In this case, however, the patient has beenIn this case, however, the patient has beenadmitted from a nursing home and pseudomonasadmitted from a nursing home and pseudomonas
is a strong possibility.is a strong possibility.
Twin therapyTwin therapy is often requiredis often required,,
Anti Anti--pseudomonalpseudomonal quinolonequinolone oror aminoglycosideaminoglycoside
plus antiplus anti--pseudomonalpseudomonal penicillin orpenicillin or
cephalosporin.cephalosporin.
Ciprofloxacin /Ciprofloxacin /gentamycin/amikacingentamycin/amikacin
plusplus piperacillinpiperacillin
oror ceftazidimeceftazidime
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An 62 year old male presents with
abdominal pain, hypotension,tachycardia, tachypnea, hypothermia
and neutropenia.
Presumed diagnosis –
perforateddiverticulum
and fecal peritonitis
This patient requires surgical source control andThis patient requires surgical source control and
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This patient requires surgical source control andThis patient requires surgical source control and
antibiotics. The most likely infecting organismsantibiotics. The most likely infecting organismsareare EnterobacteriaceaeEnterobacteriaceae,, enteococcienteococci, S., S.
pneumoniaepneumoniae and anaerobesand anaerobes..
Broad spectrum treatment is required, withoutBroad spectrum treatment is required, withoutcover for pseudomonascover for pseudomonas..
PenicllinPenicllin+ beta+ beta LactamLactam inhibitor orinhibitor orampicillin+aminoglycoside+antiampicillin+aminoglycoside+anti--anaerobicanaerobic agentagent
Ampicillin+Sulbactam Ampicillin+Sulbactam oror
Piperacillin+TazobactamPiperacillin+Tazobactam oror ampicillinampicillin ++gentamycin/aztreonamgentamycin/aztreonam ++metronidazolemetronidazole oror
imipenemimipenem
A 48 year old intellectually subnormalA 48 year old intellectually subnormal
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y yy y
lady is admitted with red hotlady is admitted with red hot induratedindurated skin over her left buttockskin over her left buttock..
Presumed diagnosisPresumed diagnosis – – cellulitiscellulitis The most likely organisms are streptococciThe most likely organisms are streptococci
and staphylococci, ifand staphylococci, if community acquiredcommunity acquired
thenthen cloxicillincloxicillin is adequate,is adequate, again this patient was institutionalized, andagain this patient was institutionalized, and
must be treated as hospital acquired:must be treated as hospital acquired:
VancomycinVancomycin
++ gentamycingentamycin..
The patient becomes progressivelyThe patient becomes progressively stuperosestuperose andand
hypotensivehypotensive as the day goes on She isas the day goes on She is intubatedintubated
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hypotensivehypotensive
as the day goes on. She isas the day goes on. She is intubatedintubated
and CT of her pelvis reveals gas in the muscles andand CT of her pelvis reveals gas in the muscles and
along thealong the fascialfascial
planes of her left buttockplanes of her left buttock..
Confirmed diagnosisConfirmed diagnosis – – necrotizingnecrotizing fasciitisfasciitis
This patient requires immediate surgicalThis patient requires immediate surgical
intervention andintervention and
debridementdebridement
of necrotic tissue.of necrotic tissue.
The infection has probably arisen from anThe infection has probably arisen from an ischioischio--
rectal abscess and isrectal abscess and is polymicrobialpolymicrobial in nature:in nature:
Streptococci, Staphylococci,Streptococci, Staphylococci, BacteroidesBacteroides,,Clostridium (1).Clostridium (1).
Penicillin (high dose) or ciprofloxacin (ifPenicillin (high dose) or ciprofloxacin (if
penicllinpenicllin allergic) +allergic) + clindamycinclindamycin
On the 8th day following admission, this patient isextubated. Four hours later she becomes severely
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dyspneic
and hypoxemic. She is reintubated
and
chest x-ray reveals a new infiltrate in her left base..
Presumed diagnosisPresumed diagnosis – – aspirationaspiration pneumonitispneumonitis
In most cases, aspiration events are sterile, andIn most cases, aspiration events are sterile, andantimicrobials are unnecessary . In the case ofantimicrobials are unnecessary . In the case ofpatients already in intensive care, however,patients already in intensive care, however,
nasopharyngeal colonization withnasopharyngeal colonization with gram negativegram negativeorganismsorganisms has occurred, and aspiration of infectedhas occurred, and aspiration of infectedmaterial should be presumed, Although it has beenmaterial should be presumed, Although it has beenconventional toconventional to treat these patients with antitreat these patients with anti--anaerobeanaerobecoveragecoverage,, it is unlikely that this is necessary.it is unlikely that this is necessary.
Add Add ampicillin+sulbactamampicillin+sulbactam oror piperacillin+tazobactampiperacillin+tazobactam
..
A 75 year old male presents withA 75 year old male presents with
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A 75 year old male presents with A 75 year old male presents with
hypotension, pyrexia andhypotension, pyrexia and leucocytosisleucocytosis ..
Presumed diagnosisPresumed diagnosis -- sepsis, cause unknownsepsis, cause unknown
Broad spectrum coverage is required, toBroad spectrum coverage is required, to
covercover gram positivesgram positives,, gram negativesgram negativesandand pseudomonaspseudomonas
Suggested modalities are:Suggested modalities are:
CombiningCombining either either
ti dti d ll h l i (h l i ( ft idift idi ))
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antipseudomonaantipseudomonall
cephalosporin (cephalosporin (ceftazidineceftazidine))oror antipseudomonalantipseudomonal
penicillin (penicillin (piperacillinpiperacillin
++azobactamazobactam) (particularly if anaerobes are) (particularly if anaerobes are
suspected) with either ansuspected) with either an aminoglycosideaminoglycoside ((gentamycingentamycin
oror amikacinamikacin) or a) or afluoroquinolonefluoroquinolone
(ciprofloxacin(ciprofloxacin).).
If anIf an antipseudomonalantipseudomonal
cephalosporin is used andcephalosporin is used andanaerobes are a possible cause, theanaerobes are a possible cause, theaddition ofaddition of metronidazolemetronidazole
oror clindamycinclindamycin
should be consideredshould be considered..Piperacillin+Tazobactam/ImipenemPiperacillin+Tazobactam/Imipenem
++GentamycinGentamycin /Ciprofloxacin /Ciprofloxacin
PROPHYLACTIC ANTIBIOTICSPROPHYLACTIC ANTIBIOTICS
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PROPHYLACTIC ANTIBIOTICSPROPHYLACTIC ANTIBIOTICS
Surgical ProphylaxisSurgical Prophylaxis
antimicrobial useantimicrobial use
PROPHYLACTIC ANTIBIOTICSPROPHYLACTIC ANTIBIOTICS
http://www.dental.mu.edu/oralpath/spresent/leukemia/img018.jpg
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The prophylactic antibiotics must be inThe prophylactic antibiotics must be inplace alreadyplace already before the bacteria land inbefore the bacteria land in
the woundthe wound
. For prevention of the
. For prevention of thepostoperative infection,postoperative infection,
The antibiotics are usually injected someThe antibiotics are usually injected some
30 minutes before the start of the30 minutes before the start of theoperationoperation..
In this way the levels of the antibiotic inIn this way the levels of the antibiotic inthe blood will attain concentrations that willthe blood will attain concentrations that willkill occasional bacteria that may land in thekill occasional bacteria that may land in the
operation wound.operation wound.
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Studies demonstrated that for Studies demonstrated that for prophylaxis againstprophylaxis against
postoperative wound infectionpostoperative wound infection administeringadministering
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postoperative wound infection,postoperative wound infection, administeringadministering
antibiotics during only one day after the operationantibiotics during only one day after the operationhas been equally effective as a two day or longerhas been equally effective as a two day or longer
antibiotic prophylactic regime.antibiotic prophylactic regime.
For occasions later on, when you need antibioticFor occasions later on, when you need antibiotic
protection during dental surgery and like,protection during dental surgery and like, usuallyusually
one dose of antibiotics before the dental and otherone dose of antibiotics before the dental and othersurgery is sufficient.surgery is sufficient.
use the antibiotics only when really necessaryuse the antibiotics only when really necessary, and, andthen use them onlythen use them only during the shortest intervalduring the shortest interval
possible.possible.
Choice of agents (principles)Choice of agents (principles)
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g (p p )g (p p )
need not eradicate every potential pathogenneed not eradicate every potential pathogen
Effective agent exampleEffective agent example ---- cefazolincefazolin (( Ancef Ancef ,,DefzolDefzol))
long serum half long serum half --lifelife
vancomycinvancomycin ((VancocinVancocin))
routine use ofroutine use of vancomycinvancomycin ((VancocinVancocin) for) for
prophylaxisprophylaxis---- discouraged since it promotesdiscouraged since it promotesvancomycinvancomycin ((VancocinVancocin))--resistant strains.resistant strains.
Colorectal surgery & appendectomyColorectal surgery & appendectomy
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g y pp yg y pp y
cefoxitincefoxitin ((MefoxinMefoxin) or) or cefotetancefotetan ((CefotanCefotan))preferred due to enhanced activity relative topreferred due to enhanced activity relative tocefazolincefazolin (( Ancef Ancef ,, DefzolDefzol) a) against anaerobesgainst anaerobes
(bowel), e.g.(bowel), e.g. BacteriodesBacteriodes fragilisfragilis Agents not recommendedAgents not recommended
ThirdThird--generationgeneration cephalosporinscephalosporins
((cefotaximecefotaxime ((ClaforanClaforan),), ceftriaxoneceftriaxone((RocephinRocephin),), cefoperazonecefoperazone ((CefobidCefobid),),ceftazidimeceftazidime ((FortaxFortax,, TaxidimeTaxidime,, Tazicef Tazicef ), or), or
ceftizoximeceftizoxime ((CefizoxCefizox)) FourthFourth--generationgeneration cephalosporinscephalosporins: e.g.: e.g.
cefepimecefepime ((MaxipimeMaxipime ))
Choice of agents (principles)Choice of agents (principles)
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g (p p )g (p p )
Rationale:Rationale:
expense, some are less activeexpense, some are less activecefazolincefazolin (( Ancef Ancef ,, DefzolDefzol) (against) (againststaphylococci)staphylococci)
nonnon--optimal spectrum of actionoptimal spectrum of action(includes activity against organisms not(includes activity against organisms notcommonly encountered in electedcommonly encountered in elected
surgerysurgery widespread for prophylaxis encourageswidespread for prophylaxis encourages
emergence of resistanceemergence of resistance
Gastrointestinal diseasesGastrointestinal diseases
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Gastrointestinal diseasesGastrointestinal diseases
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Antibiotic prophylaxisAntibiotic prophylaxis recommended for esophageal surgery withrecommended for esophageal surgery with
obstructionobstruction ---- obstruction increases infection riskobstruction increases infection risk
factors that promote high infection risk afterfactors that promote high infection risk aftergastroduodenalgastroduodenal surgery:surgery:
reduced gastric acidity and gastrointestinalreduced gastric acidity and gastrointestinalmotilitymotility – –
reduction may occur because of:reduction may occur because of: obstruction hemorrhageobstruction hemorrhage
gastric ulcer malignancygastric ulcer malignancy
treatment with Htreatment with H22 blocker {ranitidine (Zantac)}blocker {ranitidine (Zantac)}or proton pump, inhibitors {e.g.or proton pump, inhibitors {e.g. omeprazoleomeprazole((PrilosecPrilosec)})}
morbid obesitymorbid obesity
Gastrointestinal diseasesGastrointestinal diseases
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Antibiotic prophylaxisAntibiotic prophylaxis not indicatednot indicated for:for: routineroutine gastroesophagealgastroesophageal endoscopyendoscopy
(may be used for high(may be used for high--risk patientsrisk patients
undergoing esophageal dilatation orundergoing esophageal dilatation orsclerotherapysclerotherapy ofof variciesvaricies ). ).
GenitourinaryGenitourinary
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y
GenitourinaryGenitourinary
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Probable pathogens:Probable pathogens:
enteric gramenteric gram--negative bacilli,negative bacilli,
enterococcienterococci
ProphylaxisProphylaxis
highhigh--risk only (risk only (urinate cultureurinate culturepositive/unavailable; preoperativepositive/unavailable; preoperative
catheter,catheter, transrectaltransrectal prostaticprostatic biopsy)biopsy) ----
ciprofloxacinciprofloxacin ((CiproCipro)) {PO or IV}{PO or IV}
Head & Neck SurgeryHead & Neck Surgery
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Incision through oral/pharyngeal mucosaIncision through oral/pharyngeal mucosa..
Probable pathogens:Probable pathogens:
Anaerobes, Anaerobes, enteric gramenteric gram--negative bacilli,negative bacilli,
StaphylococcusStaphylococcus aureusaureus
ProphylaxisProphylaxis
clindamycinclindamycin (Cleocin) + gentamicin
(Garamycin) reduce the high incidence of wound infectionreduce the high incidence of wound infection
following head/neck operations which utilizefollowing head/neck operations which utilize
incisions through oral or pharyngeal mucosalincisions through oral or pharyngeal mucosal
NeurosurgeryNeurosurgery
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CraniotomyCraniotomy
Probable pathogens:Probable pathogens: StaphylococcusStaphylococcus aureusaureus,
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Probable pathogens:Probable pathogens: StaphylococcusStaphylococcus aureusaureus,,
StaphylococcusStaphylococcus epidermidisepidermidis
ProphylaxisProphylaxis:: cefazolincefazolin
(( Ancef Ancef ,, DefzolDefzol) or) or vancomycinvancomycin
((VancocinVancocin) (IV)) (IV)Antibacterial prophylaxisAntibacterial prophylaxis
cerebrospinal fluid shuntcerebrospinal fluid shunt: conflicting research results: conflicting research results
CraniotomyCraniotomy:: antistaphylococcalantistaphylococcal antibioticantibiotic ---- reducedreducedinfection incidenceinfection incidence
Spinal surgerySpinal surgery: antibiotics not effective in reducing the: antibiotics not effective in reducing the
already low postoperative infection rate followingalready low postoperative infection rate followingconventional lumbarconventional lumbar discectomydiscectomy..
Questionable effectiveness (not yet demonstrated inQuestionable effectiveness (not yet demonstrated in
controlled clinical trials) for spinal fusion, prolonged spinecontrolled clinical trials) for spinal fusion, prolonged spinesurgery, or insertion of foreign materialsurgery, or insertion of foreign material
OphthalmicOphthalmic
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OphthalmicOphthalmic
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Probable pathogens:Probable pathogens: StaphylococcusStaphylococcus epidermidisepidermidis,,StaphylococcusStaphylococcus aureusaureus, streptococci, enteric gram, streptococci, enteric gram--negative bacilli, Pseudomonasnegative bacilli, Pseudomonas
ProphylaxisProphylaxis::
gentamicingentamicin
(Garamycin),(Garamycin), tobramycintobramycin
((NebcinNebcin),), ciprofloxacinciprofloxacin
((CiproCipro),), ofloxacinofloxacin
((FloxinFloxin), or), orneomycinneomycin--gramicidingramicidin--polymixinpolymixin
B;B; cefazolincefazolin
(( Ancef Ancef ,,DefzolDefzol))
Most ophthalmologist use antibioticMost ophthalmologist use antibiotic eyedropseyedrops forforprophylaxis in view of the potential for extremely seriousprophylaxis in view of the potential for extremely seriouspostoperativepostoperative endophthalmitis.{limitedendophthalmitis.{limited data to supportdata to supporteffectiveness of prophylactic antimicrobials}effectiveness of prophylactic antimicrobials}
No evidence for the rational basis for use ofNo evidence for the rational basis for use ofprophylactic antibiotics when procedures do notprophylactic antibiotics when procedures do not
invade the globeinvade the globe
OrthopedicOrthopedic
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OrthopedicOrthopedic
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Total joint replacement, internal fracture fixationTotal joint replacement, internal fracture fixation Probable pathogens:Probable pathogens: StaphylococcusStaphylococcus aureusaureus,,
StaphylococcusStaphylococcus epidermidisepidermidis
ProphylaxisProphylaxis cefazolincefazolin
(( Ancef Ancef ,, DefzolDefzol) or) or vancomycinvancomycin((VancocinVancocin) (IV)) (IV)
Rationale for Prophylaxis:Rationale for Prophylaxis:
antistaphylococcalantistaphylococcal agents decrease incidence of early &agents decrease incidence of early &late infection following joint replacementlate infection following joint replacement
decrease infection rate in compound/open fractures anddecrease infection rate in compound/open fractures and
when hip & other fractures are managed with internalwhen hip & other fractures are managed with internalfixation using nails, plates, screws, or wiresfixation using nails, plates, screws, or wires
For diagnostic & operative arthroscopic surgeryFor diagnostic & operative arthroscopic surgery ----antibody prophylaxis is not justifiedantibody prophylaxis is not justified
Vascular Vascular
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Vascular VascularArterial surgery (involving: a prosthesis,
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Arterial surgery (involving: a prosthesis,Arterial surgery (involving: a prosthesis,
abdominal aorta, or groin incisionabdominal aorta, or groin incision))
Probable pathogenProbable pathogen:: StaphylococcusStaphylococcus aureusaureus,,StaphylococcusStaphylococcus epidermidisepidermidis, enteric gram, enteric gram--negative bacillinegative bacilli
ProphylaxisProphylaxis:: cefazolincefazolin
(( Ancef Ancef ,, DefzolDefzol) or) orvancomycinvancomycin
((VancocinVancocin))
A lower extremity amputation for ischemiaA lower extremity amputation for ischemiaProbable pathogen:Probable pathogen: StaphylococcusStaphylococcus aureusaureus,,
StaphylococcusStaphylococcus epidermidisepidermidis, enteric gram, enteric gram--
negative bacilli, clostridianegative bacilli, clostridiaProphylaxisProphylaxis::
cefazolincefazolin
(( Ancef Ancef ,, DefzolDefzol))----or or
cefoxitincefoxitin ((MefoxinMefoxin) for better anaerobic coverage) for better anaerobic coverage----oror vancomycinvancomycin
((VancocinVancocin ) )
Vascular Vascular
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Rationale for prophylaxisRationale for prophylaxis:: CephalosporinCephalosporin: reduced likelihood of postoperative: reduced likelihood of postoperative
infection incidences following arterial reconstructiveinfection incidences following arterial reconstructive
surgery on the abdominal aorta, vascular limbsurgery on the abdominal aorta, vascular limboperations involving groin incisions, and loweroperations involving groin incisions, and lower
extremity amputation for ischemiaextremity amputation for ischemia
Recommended:Recommended: for any vascular prosthetic material implantation (e.g.for any vascular prosthetic material implantation (e.g.
grafts supportinggrafts supporting hemodialysishemodialysis))
Not indicated for carotidNot indicated for carotid endarterectomyendarterectomy or brachialor brachialartery repair (assuming no prosthetic materialartery repair (assuming no prosthetic material
involvedinvolved ) )
Cardiac SurgeryCardiac Surgery
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Cardiac SurgeryCardiac Surgery
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Prosthetic valve, coronary bypass, other openProsthetic valve, coronary bypass, other open--heartheartprocedures, pacemaker/defibrillator implantationprocedures, pacemaker/defibrillator implantation
Probable pathogenProbable pathogen:: ---- StaphylococcusStaphylococcusepidermidisepidermidis, Staphylococcus, Staphylococcus aureusaureus,,CorynebacteriumCorynebacterium, enteric gram, enteric gram--negative bacillinegative bacilli
Antibacterial drug:Antibacterial drug: cefazolincefazolin (( Ancef Ancef ,, DefzolDefzol),), cefuroximecefuroxime
((Zinacef Zinacef ,, CeftinCeftin))---- IVIV
VancomycinVancomycin,, IVIV((VancocinVancocin) (if above agents) (if above agentsare ineffective or contraindicated)are ineffective or contraindicated)
Antibacterial drug pre Antibacterial drug pre--treatment reducestreatment reducesinfection incidence after cardiac surgery;infection incidence after cardiac surgery;
Thoracic ( Thoracic (noncardiacnoncardiac
))
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Probable pathogens:Probable pathogens: StaphylococcusStaphylococcus aureusaureus,,StaphylococcusStaphylococcus epidermidisepidermidis, streptococci, enteric, streptococci, entericgramgram--negative bacillinegative bacilli
TreatmentTreatment::
cefazolincefazolin (( Ancef Ancef ,, DefzolDefzol) or) or
cefuroximecefuroxime
((Zinacef Zinacef ,, CeftinCeftin) or) or vancomycinvancomycin ((VancocinVancocin))Rationale for ProphylaxisRationale for Prophylaxis::
commonly used for routine pulmonary surgery;commonly used for routine pulmonary surgery; limitedlimited
research supportresearch support insertion of chest tubes following closedinsertion of chest tubes following closed--tubetube
thoracostomythoracostomy following chest trauma:following chest trauma: cephalosporincephalosporin(multiple doses) can prevent infection(multiple doses) can prevent infection
single preoperativesingle preoperative cefazolincefazolin (( Ancef Ancef ,, DefzolDefzol) dose) dose(pulmonary resection): decrease in the incidence of(pulmonary resection): decrease in the incidence ofwound infectionwound infection ---- no decrease in incidence ofno decrease in incidence ofpneumonia orpneumonia or empyemaempyema
Gynecologic & ObstetricGynecologic & Obstetric
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Gynecologic & ObstetricGynecologic & Obstetric
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Antibacterial prophylaxis:Antibacterial prophylaxis: reduces infection incidence following vaginalreduces infection incidence following vaginal
hysterectomy & abdominal hysterectomyhysterectomy & abdominal hysterectomy
(probably)(probably) PerioperativePerioperative/preoperative antibiotics:/preoperative antibiotics:
prevention of infection when givenprevention of infection when given::
following cord clamping in emergencyfollowing cord clamping in emergencycesarean sectioncesarean section
highhigh--risk situations {active Labor, prematurerisk situations {active Labor, premature
membranemembrane rupture,after rupture,after midmid--trimestertrimesterabortion}abortion}
Possibly substantial protective effect ofPossibly substantial protective effect ofperioperativeperioperative antibiotics in all womenantibiotics in all womenundergoing therapeutic abortionsundergoing therapeutic abortions
Gynecologic & ObstetricGynecologic & Obstetric
V i l bd i l hV i l bd i l h
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Vaginal or abdominal hysterectomyVaginal or abdominal hysterectomy Probable pathogens:Probable pathogens: Enteric gramEnteric gram--negatives,negatives,
anaerobes,anaerobes, enterococcienterococci, Group B strep, Group B strep
ProphylaxisProphylaxis
cefazolincefazolin
(( Ancef Ancef ,, DefzolDefzol) or) or cefotetancefotetan ((CefotanCefotan) or ) or
cefoxitincefoxitin
((MefoxinMefoxin)(IV)(IV))
Cesarean sectionCesarean section Probable pathogens:Probable pathogens: Enteric gramEnteric gram--negatives,negatives,
anaerobes,anaerobes, enterococcienterococci, Group B strep, Group B strep
ProphylaxisProphylaxis::
highhigh--risk {active labor or prematurerisk {active labor or prematuremembrane rupturemembrane rupture};};
cefazolincefazolin (( Ancef Ancef ,, DefzolDefzol)) ---- IV after cord clampingIV after cord clamping
Gynecologic & ObstetricGynecologic & Obstetric
Ab tiAb ti
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AbortionAbortion Probable pathogensProbable pathogens:: Enteric gramEnteric gram--negatives,negatives,
anaerobes,anaerobes, enterococcienterococci, Group B strep, Group B strepProphylaxisProphylaxis::
first trimester first trimester , high, high--risk {patients withrisk {patients withprevious pelvic inflammatory disease,previous pelvic inflammatory disease,
previous gonorrhea or multiple sex partners)previous gonorrhea or multiple sex partners)
----
aqueous penicillin Vaqueous penicillin V
((PenPen--VeeVee
KK,,VeetidsVeetids) or ) or
doxycyclinedoxycycline ((VibramycinVibramycin,, DoryxDoryx ))
PROPHYLACTIC ANTIBIOTICSPROPHYLACTIC ANTIBIOTICS
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Medical ProphylaxisMedical Prophylaxis
antimicrobial useantimicrobial use
PREVENTION of ENDOCARDITISPREVENTION of ENDOCARDITIS
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Heart valve lesions or prosthetic valve.Heart valve lesions or prosthetic valve.
(A)(A)Dental procedure under No orDental procedure under No or L.AnasthL.Anasth..::Pt.Pt. HavnHavn’’tt
endocarditisendocarditis
AmoxycillinAmoxycillin(3g PO)(3g PO) 1h before operation1h before operation
ClindamycinClindamycin (600mg PO)(600mg PO) Penicill.AllergyPenicill.Allergy
Pt. WithPt. With endocarcitisendocarcitis
( AS under GA ):( AS under GA ):
AmoxycillinAmoxycillin(1g IV)(1g IV) ++ GentamicinGentamicin(120mg)(120mg)
VancomycinVancomycin(1g IV)(1g IV) Allergy to Penicillin Allergy to Penicillin
OrOr ClindamycinClindamycin(300mg IV)(300mg IV) Over 10Over 10 minmin..
PROPHYLACTIC ANTIBIOTICPROPHYLACTIC ANTIBIOTIC
((B)B)D t l d d GAD t l d d GA
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((B)B)Dental procedure under GADental procedure under GA
::Pt.Pt. HavnHavn’’tt
endocarditis :endocarditis :
AmoxycillinAmoxycillin (1g IV at induction) or (1g IV at induction) or (3g PO 4h before induction)(3g PO 4h before induction)
Pt. With endocarditis( At risk) :Pt. With endocarditis( At risk) :
AmoxycillinAmoxycillin(1g )(1g )++ GentamicinGentamicin(120mg)(120mg) atatinduction or 15 min.before induction.induction or 15 min.before induction.
OrOr VancomycinVancomycin 1g1g ++ GentamicinGentamicin(120mg)(120mg) OrOr ClindamycinClindamycin 300mg IV300mg IV over 10 min (15over 10 min (15
min before induction)min before induction)..
PROPHYLACTIC ANTIBIOTICSPROPHYLACTIC ANTIBIOTICS
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MENINGITISMENINGITIS
((meningococcalmeningococcal--N.menigitidisN.menigitidis))
* For close contacts(children& adults).* For close contacts(children& adults).
RifampicinRifampicin(600mg)(600mg) /12h/2days/12h/2days..
oror CiprofloxacinCiprofloxacin (500mg)(500mg) Single doseSingle dose
oror CeftriaxoneCeftriaxone(250mg)(250mg) Single dose.Single dose.
Empiric treat. Of suspectedEmpiric treat. Of suspected bact.meningitbact.meningit..
**Penicillin GPenicillin G
IV:2IV:2
--MU immediatelyMU immediately
.
.
ANTIBIOTIC PROPHYLAXISANTIBIOTIC PROPHYLAXIS
RHEUMATIC FEVER:RHEUMATIC FEVER:
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RHEUMATIC FEVER:RHEUMATIC FEVER: BenzathineBenzathine penicillinpenicillin (IM)(IM) monthlymonthly oror
Penicillin V Penicillin V ( PO)( PO) twice dailytwice daily** oror SulphadiazineSulphadiazine
(PO)(PO) 1g/day1g/day
**
During childhood & early teenage .During childhood & early teenage .GAS GANGERENE (L.L.Amputation) :GAS GANGERENE (L.L.Amputation) :
* Penicillin G* Penicillin G 300300--600mg(500000600mg(500000--1000000U)/ 6h/5 days .1000000U)/ 6h/5 days .
**MetronidazoleMetronidazole(Allergy to Penicillin)(Allergy to Penicillin)500 mg/8h.500 mg/8h.
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Head & Neck SurgeryHead & Neck Surgery
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QUINUPRISTIN/DAFLOPRISTINQUINUPRISTIN/DAFLOPRISTIN
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A formulation of two bacteriostatic agents A formulation of two bacteriostatic agentswhen combined are bactericidal.when combined are bactericidal.
MechanismMechanism→→ inhibit protein synthesis at theinhibit protein synthesis at the505 ribosome.505 ribosome.
Spectrum: Similar to Vancomycin i.e. ActiveSpectrum: Similar to Vancomycin i.e. Activeagainst Streptococci, S.aureus andagainst Streptococci, S.aureus andcoagulasecoagulase – –negative Staph.negative Staph.
Used in treatment ofUsed in treatment of VancomycinVancomycin – –resistant cases.resistant cases.
KlebsiellaKlebsiella pneumoniaepneumoniae ProteusProteus
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KlebsiellaKlebsiella
pneumoniae pneumoniae
ProteusProteus
SepsisSepsis--
Special CasesSpecial Cases
Resistant gramResistant gram-negative bacillinegative bacilli
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Resistant gramResistant gram--negative bacillinegative bacilli
GramGram--negative bacilli resistant to:negative bacilli resistant to:
aminoglycosidesaminoglycosides thirdthird--generationgeneration cephalosporinscephalosporins
aztreonamaztreonam ((AzactanAzactan)) These bacilli susceptible to:These bacilli susceptible to:
imipenemimipenem
meropenemmeropenem ((MerremMerrem IVIV))
ciprofloxacinciprofloxacin ((CiproCipro))
SepsisSepsis--
Special CasesSpecial Cases
Pseudomonas aeruginosa strains resistantPseudomonas aeruginosa strains resistanti i (G i )
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Pseudomonas aeruginosa strains resistantPseudomonas aeruginosa strains resistantgentamicin (Garamycin)gentamicin (Garamycin)
Susceptible to:Susceptible to:
amikacinamikacin (( Amikin Amikin))
ceftazidimeceftazidime ((FortaxFortax,, TaxidimeTaxidime,, Tazicef Tazicef ))
cefepimecefepime ((MaxipimeMaxipime)) imipenemimipenem meropenemmeropenem ((MerremMerrem IV)IV)
ciprofloxacinciprofloxacin ((CiproCipro)) trovafloxacintrovafloxacin
aztreonamaztreonam
possiblypossibly tobramycintobramycin ((NebcinNebcin) or) or netilmicinnetilmicin
((NetromycinNetromycin
Gastrointestinal diseasesGastrointestinal diseases
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Gastrointestinal diseasesGastrointestinal diseases
Esophageal/Esophageal/gastroduodenalgastroduodenal
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Esophageal/Esophageal/gastroduodenalgastroduodenalProbable pathogens:Probable pathogens:
enteric gramenteric gram--negative bacilli,negative bacilli,
gramgram--positivepositive coccicocci
Treatment: (highTreatment: (high--risk only,risk only, i.e. esophageali.e. esophagealobstruction, decreased gastricobstruction, decreased gastric
acidity/gastrointestinal motility, morbidacidity/gastrointestinal motility, morbid
obesityobesity))
CefazolinCefazolin (( Ancef Ancef ,, DefzolDefzol) () (IVIV))
Gastrointestinal diseasesGastrointestinal diseases
BiliBili t tt t
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BiliaryBiliary
tracttractProbable pathogens:Probable pathogens:
enteric gramenteric gram--negative bacilli,negative bacilli,
enterococcienterococci, clostridia, clostridia
Treatment: (highTreatment: (high--riskrisk only,only,i.ei.e. age > 70,. age > 70,acuteacute cholecystitischolecystitis, non, non--functioningfunctioninggallbladder, obstructive jaundice orgallbladder, obstructive jaundice or
common duct stonescommon duct stones)) CefazolinCefazolin (( Ancef Ancef ,, DefzolDefzol)) IVIV
Gastrointestinal diseasesGastrointestinal diseases
A d f d
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Appendectomy, nonAppendectomy, non--perforatedperforated
Probable pathogens:Probable pathogens:
enteric gramenteric gram--negative bacilli,negative bacilli,
anaerobes,anaerobes, enterococcienterococci
TreatmentTreatment::
CefoxitinCefoxitin ((MefoxinMefoxin))
SepsisSepsis
Factors in selecting appropriate drugs toFactors in selecting appropriate drugs to
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Factors in selecting appropriate drugs toFactors in selecting appropriate drugs to
manage sepsis syndromemanage sepsis syndrome::
source of infectionsource of infection
gram staingram stain
immune statusimmune status bacterial resistance patterns in the communitybacterial resistance patterns in the community
and hospitaland hospital
SepsisSepsis
Factors in selecting appropriate drugs toFactors in selecting appropriate drugs to
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Factors in selecting appropriate drugs toFactors in selecting appropriate drugs to
manage sepsis syndromemanage sepsis syndrome::
source of infectionsource of infection
gram staingram stain
immune statusimmune status bacterial resistance patterns in the communitybacterial resistance patterns in the community
and hospitaland hospital
ANTIBIOTIC SELECTION ANTIBIOTIC SELECTION
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ByBy
Prof. ABDEL FATTAH ABDEL SATTARProf. ABDEL FATTAH ABDEL SATTAR
HEAD OF ANESTHESIA & PAIN RELIEFHEAD OF ANESTHESIA & PAIN RELIEF
DEPARTMENTDEPARTMENTNATIONAL CANCER INSTITUTENATIONAL CANCER INSTITUTE
CAIRO UNIVERSTIYCAIRO UNIVERSTIY20072007
A 43 year old lady with short bowel syndromeA 43 year old lady with short bowel syndrome
following surgery forfollowing surgery for CrohnCrohn’’ss
disease, ondisease, on
home TPN, is admitted with hypoxemia,home TPN, is admitted with hypoxemia,tachycardia pyrexia and neutropeniatachycardia pyrexia and neutropenia
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, yp ,, yp ,tachycardia, pyrexia and neutropenia.tachycardia, pyrexia and neutropenia.
PresumedPresumed diagnosisdiagnosis
--
infected intravenousinfected intravenous
catheter (line sepsiscatheter (line sepsis).).
A 54 year old male develops a fever,A 54 year old male develops a fever,leucocytosisleucocytosis
and inflammation around hisand inflammation around his
midlinemidline sternotomysternotomy
site 5 days aftersite 5 days after
undergoing coronary bypass surgery.undergoing coronary bypass surgery. Presumed diagnosisPresumed diagnosis – –
wound infection,wound infection,
possiblepossible mediastinitismediastinitis..
There is a strong possibility of infection in both ofThere is a strong possibility of infection in both ofthese cases withthese cases with staphylococci,staphylococci, coagulasecoagulase--positivepositive or negative.or negative.
VancomycinVancomycin should be added to for exampleshould be added to for example
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VancomycinVancomycin should be added to, for example,should be added to, for example,piperacillin+azobactampiperacillin+azobactam..
Once the infecting organisms have been isolated,Once the infecting organisms have been isolated,thethe spectrum of antimicrobials should bespectrum of antimicrobials should benarrowednarrowed
(if(if methacillinmethacillin resistantresistant staphstaph aureusaureus – –MRSAMRSA-- isisisolated, theisolated, the piperacillinpiperacillin++ azobactamazobactam should beshould bediscontinued).discontinued).
VancomycinVancomycin
++ Piperacillin+TazobactamPiperacillin+Tazobactam
ororCiprofloxacinCiprofloxacin
The lady withThe lady with CrohnCrohn’’ss disease and presumed linedisease and presumed linesepsis does not respond to line removal and thesepsis does not respond to line removal and theantibiotic regimen above, blood cultures comeantibiotic regimen above, blood cultures comeback positive forback positive for unspeciatedunspeciated candidacandida. Confirmed. Confirmeddi idi i f l if l i
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diagnosisdiagnosis – – fungal sepsis.fungal sepsis.The options areThe options are
1) start high dose1) start high dose fluconazolefluconazole and if there is noand if there is noresponse move over to the more toxic agent,response move over to the more toxic agent,amphoteracinamphoteracin,,
2) start2) start amphoteracinamphoteracin immediately. In this patientimmediately. In this patient’’sscase, she is severely ill, and has depletedcase, she is severely ill, and has depletedphysiologic reserve and may well bephysiologic reserve and may well be
immunocompromisedimmunocompromised (steroids), I would start(steroids), I would startamphoteracinamphoteracin B. If there is a question of renalB. If there is a question of renalinsufficiency, I would prescribe the less toxicinsufficiency, I would prescribe the less toxiccolloidal orcolloidal or liposomalliposomal form.form.
A 17 year old female presents with a 2 hour history of A 17 year old female presents with a 2 hour history of
confusion, pyrexia, headacheconfusion, pyrexia, headacheand aand a purpuricpurpuric rashrash..
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and aand a purpuric purpuric rash rash ..
This patient has This patient has meningococcal septicemiameningococcal septicemia untiluntil
otherwise proven.otherwise proven. The most likely alternative organisms are The most likely alternative organisms are
pneumococci pneumococci, H., H. InfluenzaeInfluenzae andand,, rarely,rarely,
EnterobacteriaceaeEnterobacteriaceae andand ListeriaListeria.. Third generation cephalosporin Third generation cephalosporin ++ vancomycin vancomycin (if(if
penicillin resistant S.penicillin resistant S. pneumoniaepneumoniae suspected) +suspected) +
ampicillinampicillin (if(if ListeriaListeria suspected)suspected) ..
CefotaximeCefotaxime
++ Vancomycin Vancomycin
Gastrointestinal diseasesGastrointestinal diseases
Esophageal/Esophageal/gastroduodenalgastroduodenal
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p gp g ggProbable pathogens:Probable pathogens:
enteric gramenteric gram--negative bacilli,negative bacilli,gramgram--positivepositive coccicocci
Treatment: (highTreatment: (high--risk only,risk only, i.e. esophageali.e. esophagealobstruction, decreased gastricobstruction, decreased gastric
acidity/gastrointestinal motility, morbidacidity/gastrointestinal motility, morbid
obesityobesity))
cefazolincefazolin (( Ancef Ancef ,, DefzolDefzol) () (IVIV))
Gastrointestinal diseasesGastrointestinal diseases
BiliaryBiliary tracttract
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BiliaryBiliary
tracttractProbable pathogens:Probable pathogens:
enteric gramenteric gram--negative bacilli,negative bacilli,
enterococcienterococci, clostridia, clostridia
Treatment: (highTreatment: (high--riskrisk only,only,i.ei.e. age > 70,. age > 70,acuteacute cholecystitischolecystitis, non, non--functioningfunctioninggallbladder, obstructive jaundice orgallbladder, obstructive jaundice or
common duct stonescommon duct stones)) cefazolincefazolin (( Ancef Ancef ,, DefzolDefzol)) IVIV
Gastrointestinal diseasesGastrointestinal diseases
Appendectomy nonAppendectomy non perforatedperforated
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Appendectomy, nonAppendectomy, non--perforatedperforated
Probable pathogens:Probable pathogens:
enteric gramenteric gram--negative bacilli,negative bacilli,
anaerobes,anaerobes, enterococcienterococci
TreatmentTreatment::
cefoxitincefoxitin ((MefoxinMefoxin)) LorcetLorcet ((hydrocodonehydrocodone/acetaminophen) (IV)/acetaminophen) (IV)
Thoracic ( Thoracic (noncardiacnoncardiac
)) Probable pathogens:Probable pathogens:
StaphylococcusStaphylococcus
aureusaureus
,,
StaphylococcusStaphylococcus epidermidisepidermidis, streptococci, enteric, streptococci, entericti b illiti b illi
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gramgram--negative bacillinegative bacilli
TreatmentTreatment:: cefazolincefazolin (( Ancef Ancef ,, DefzolDefzol) or) or cefuroximecefuroxime((Zinacef Zinacef ,, CeftinCeftin) or) or vancomycinvancomycin ((VancocinVancocin))
Rationale for ProphylaxisRationale for Prophylaxis::
commonly used for routine pulmonary surgery;commonly used for routine pulmonary surgery; limitedlimited
research supportresearch support insertion of chest tubes following closedinsertion of chest tubes following closed--tubetube
thoracostomythoracostomy following chest trauma:following chest trauma: cephalosporincephalosporin(multiple doses) can prevent infection(multiple doses) can prevent infection
single preoperativesingle preoperative cefazolincefazolin (( Ancef Ancef ,, DefzolDefzol) dose) dose(pulmonary resection): decrease in the incidence of(pulmonary resection): decrease in the incidence ofwound infectionwound infection ---- no decrease in incidence ofno decrease in incidence ofpneumonia orpneumonia or empyemaempyema
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PROPHYLACTIC ANTIBIOTICSPROPHYLACTIC ANTIBIOTICS
Pneumococcal meningitisPneumococcal meningitis ::
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Pneumococcal meningitisPneumococcal meningitis ::
** CefotaximeCefotaxime
(Vancomycin if resistant).(Vancomycin if resistant). H.influenza meningitisH.influenza meningitis ::
**CefotaximeCefotaxime
or or
ChloramphenicolChloramphenicol
++RiphampicinRiphampicin
(4days before discharge)(4days before discharge)
Listeria meningitisListeria meningitis ::
**AmoxycillinAmoxycillin
++gentamicingentamicin
ORGANISMS & SITE of INFECTIONORGANISMS & SITE of INFECTION
** S.aureusS.aureus skin,soft tissue,bone,IV linesskin,soft tissue,bone,IV lines..
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**
Strept(A).Strept(A). skin,soft tissue,fascial infectionskin,soft tissue,fascial infection..
* Enterococci* Enterococci Biliary,urinary , colonicBiliary,urinary , colonicinfection.infection.
**
Pseudomonas aerugPseudomonas aerug.. lung, skin infectionlung, skin infection* Klebsiella* Klebsiella Infection around biliary T.Infection around biliary T.
* Proteus* Proteus Urosepsis.Urosepsis.* E.coli* E.coli Intraabdominal pelvic or urinaryIntraabdominal pelvic or urinary
* Clostridium* Clostridium skin,soft t., biliary, colonicskin,soft t., biliary, colonic