Review of Antibiotics
description
Transcript of Review of Antibiotics
![Page 1: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/1.jpg)
Review of AntibioticsReview of Antibiotics
Zagorka Popovski, Pharm.D.Clinical Pharmacist, Intensive Care
![Page 2: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/2.jpg)
CephalosporinsCephalosporins
Gram + 1st Generation
•Ancef•Keflex
![Page 3: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/3.jpg)
LESS IS MORE!!!LESS IS MORE!!!
Timing of pre op antibiotic is key
![Page 4: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/4.jpg)
POPOVSKI and TEOHPOPOVSKI and TEOHSCCM 1993 SAN DIEGO CASCCM 1993 SAN DIEGO CAREDUCTION OF POST-OP
ANTIBIOTICS FROM 72 HR TO 48HRADMINISTER PRE-OP ANTIBIOTIC IN
ORWOUND INFECTION RATE REDUCED
FROM 2% TO 0.6%
![Page 5: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/5.jpg)
CephalosporinsCephalosporins
Gram + Gram + Coverage plus:
1st Generation •Ecoli•Ancef •Proteus•Keflex •Klebsiella
![Page 6: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/6.jpg)
CephalosporinsCephalosporins
Gram + 1st Generation 2nd Generation
•Ancef •Cefuroxime •Keflex •Cefamandole
•Cefotetan +/- anaerobe•Cefoxitin
H Flu
![Page 7: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/7.jpg)
CephalosporinsCephalosporins
Gram + Gram -1st Generation 2nd Generation 3rd Generation
•Ancef •Cefuroxime•Ceftriaxone•Keflex •Cefamandole •Cefotaxime
•Cefotetan •Ceftazidime•Cefoxitin
![Page 8: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/8.jpg)
CephalosporinsCephalosporins Gram - Gram - Coverage *3rd Generation Acinetobacter
Serratia •Ceftriaxone (CNS penetration, gram neg. alternative to amnioglycosides)
•Cefotaxime
•Ceftazidime •Pseudomonas Aeruginosa
*not for enterobacter
![Page 9: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/9.jpg)
PenicillinsPenicillins Penicillin Ampicillin Cloxacillin
Amoxillin OxacillinNafcillinMethicillin
®
![Page 10: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/10.jpg)
PenicillinsPenicillins Coverage
•Ampicillin •Enterococcus•Amoxicillin •Ecoli
•Klebsiella•Proteus•H. Flu
Clavulin®=amoxicillin+clavulinic acid
![Page 11: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/11.jpg)
Antipseudomonal PenicillinsAntipseudomonal Penicillins
Piperacillin (Pipracil)Piperacillin/Tazobactam (Tazocin)Ticarcillin (Ticar)Ticarcillin/Clavulante (Timentin)
Gram +/- (including Pseudomonas a.)*anaerobic coverage
![Page 12: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/12.jpg)
+
R
R
![Page 13: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/13.jpg)
PenicillinsPenicillins
CloxacillinOxacillinNafcillinMethicillin
![Page 14: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/14.jpg)
CarbapenemsCarbapenems
Imipenem + Cilastatin (Primaxin)Meropenem (Merrem)Ertapenem (Invanz)
![Page 15: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/15.jpg)
MeropenemMeropenem
Very broad spectrum Gram negative including pseudomonas gram positive including staph and enterococcus Anaerobes
Indicated for “high-severity” intra-abdominal infections
Replaced imipenem//cilastatin at HHS
![Page 16: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/16.jpg)
5 7 15 30
FAILURE
A.P.A.C.H.E.
Imipenem
AA + AMG
Christou & Solomkin, 1990
(Intra-abdominal sepsis)
![Page 17: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/17.jpg)
Activity of Study Agents Against Activity of Study Agents Against Facultative Gram-Negative BacteriaFacultative Gram-Negative Bacteria
BacteriaTobramycin
MICImipenem
MIC
90 Resistant90 Resistant
E.ColiEnterobacterKlebsiellaProteusPseudomonas a.Citrobacter sp.Other Gram Negative Breakpoint…Tobramycin 4 Imipeneim 4
4.01.01.01.04.0
16.02.0
5000120
0.251.01.04.02.00.54.0
0001000
![Page 18: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/18.jpg)
Activity of Study Agents Against Common Activity of Study Agents Against Common Anaerobic BacteriaAnaerobic Bacteria
BacteriaClindamycin
MICImipenem
MIC
90 Resistant90 Resistant
ß. FragilisBacteroides sp.Clostridia sp.Enterococci
Breakpint…Clindamycin 2 Imipenem 4
16.016.04.0-
??4-
0.500.502.04.0
0000
![Page 19: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/19.jpg)
CONDITIONS FOR WHICH CONDITIONS FOR WHICH THERAPEUTIC ANTIBIOTICS (24h) ARE THERAPEUTIC ANTIBIOTICS (24h) ARE
NOT RECOMMENDEDNOT RECOMMENDED Traumatic and iatrogenic enteric perf’n operated
on within 12h Gastroduodenal perf’n operated on within 24h Acute/gangrenous appendicitis without perf’n Acute/gangrenous cholecyswtitis without perf’n Transmural bowel necrosis from
embolic,thrombotic or obsstructive vascular occlusion without perf’n or established peritonitis or abcess
![Page 20: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/20.jpg)
FluoroquinolonesFluoroquinolones
Nalidixic acid (NegGram)Ciprofloxacin (Cipro)Norfloxacin (Noroxin) Levofloxacin (Levaquin)Gatifloxacin (Tequin)Moxifloxacin (Avelox)
![Page 21: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/21.jpg)
FluoroquinolonesFluoroquinolones
Ciprofloxacin (Cipro) - Ps. a.Norfloxacin (Noroxin)Levofloxacin (Levaquin) Gatifloxacin (Tequin) Moxifloxacin (Avelox)
CAPStrep.+ other gram neg atypicals
![Page 22: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/22.jpg)
FluoroquinolonesFluoroquinolones
Advantages (Bioavailability, IV/PO, tissue penetration)
Drug Interactions (Calcium, Iron, Magnesium)(Theophylline,Methylxanthines)
Side Effects
![Page 23: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/23.jpg)
AminoglycosidesAminoglycosides
Gentamicin TobramycinAmikacin
![Page 24: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/24.jpg)
Aminoglycosides
MIC Serratia (Pseudomonas a.)
Gentamicin .5 2Tobramycin 2 .5
![Page 25: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/25.jpg)
OthersOthers
VancomycinLinezolidSeptra
![Page 26: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/26.jpg)
SAVING ANTIBIOTICS SAVES SAVING ANTIBIOTICS SAVES LIVES!!!LIVES!!!
PRINCIPLES:For empiric therapy, reassess at day 4,
consult IDNarrow spectrum when bacteria identifiedConvert to oral therapy when possible
![Page 27: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/27.jpg)
SAVING ANTIBIOTICS SAVES SAVING ANTIBIOTICS SAVES LIVES!!!LIVES!!!
Clinical Pulmonary Infection Score (CPIS)Takes into account
temperature,wbc,secretions,ventilation,xray</- 6 ( treat with 3 days levofloxacin or
cefotaxime) >6 ( bronch and treat with 8 days
![Page 28: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/28.jpg)
SAVING ANTIBIOTICS SAVES SAVING ANTIBIOTICS SAVES LIVES!!!LIVES!!!
BENEFITS:Reduced use of broad spectrum agentsReduced resistanceReduced LOSReduced fungal infectionsReduced costs >$200,000
![Page 29: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/29.jpg)
CPIS Use for Non-invasive CPIS Use for Non-invasive Diagnosis of HAP/VAP Diagnosis of HAP/VAP
CPIS≤6CPIS≤6
Consider treatmentConsider treatment
Calculate CPISCalculate CPIS
CPIS>6CPIS>6
Gram stain of Gram stain of Tracheobronchial (TB) Tracheobronchial (TB)
secretionssecretions
Treatment accordingTreatment according to Gram stainto Gram stain
Recalculate CPIS daily, Recalculate CPIS daily, examine Gram stainexamine Gram stain
Pugin J. Am Rev Respir Dis. 1991;143:1121-9. Pugin J. Minerva Anestesiol. 2002;68(4):261-5.
1 2 3 4 5 6 7 NextNextBackBack
![Page 30: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/30.jpg)
CPIS Antibiotic StudyCPIS Antibiotic Study
Inclusion Criteria:– Clinical Pulmonary infection score (CPIS) 6– Ventilated or non-ventilated
Exclusion Criteria:– Infected with HIV 18 years of age
Singh N, et al. Am J Respir Crit Care Med. 2000;162:505-511.
1 2 3 4 5 6 7 NextNextBackBack
![Page 31: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/31.jpg)
CPIS Antibiotic Study: CPIS Antibiotic Study: Trial DesignTrial Design
CPIS≤6CPIS≤6
Standard Standard TherapyTherapy
(antibiotics for (antibiotics for 10-21 days)10-21 days)
Experimental Experimental TherapyTherapy
Ciprofloxacin for 3 daysCiprofloxacin for 3 days
CPIS >6CPIS >6
Treat as Treat as pneumoniapneumonia
Singh N, et al. Am J Respir Crit Care Med. 2000;162:505-11.
CPIS ≤6CPIS ≤6
Discontinue Discontinue treatmenttreatment
CPIS calculated at 3 days
1 2 3 4 5 6 7 NextNextBackBack
![Page 32: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/32.jpg)
CPIS Antibiotic Study: CPIS Antibiotic Study: OutcomesOutcomes
Experimental Therapy
(n=39)
Standard Therapy (n=42)
p Value
Deaths at 3 days 0% (0/39) 7% (3/42) NS
CPIS >6 at 3 days 21% (8/39) 23% (9/39) NS
Extrapulmonary infections
18% (7/39) 15% (6/39) NS
Antibiotic continuation >3 days
28% (11/39) 97% (38/39) 0.0001
Data for patients with entry CPIS 6 subject to standard and experimental therapy
Singh N, et al. Am J Respir Crit Care Med. 2000;162:505-511.
1 2 3 4 5 6 7 NextNextBackBack
![Page 33: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/33.jpg)
CPIS Antibiotic Study: CPIS Antibiotic Study: OutcomesOutcomes
Experimental Therapy
(n=39)
Standard Therapy (n=42)
p Value
Antibiotic continuation > 3 days
0% (0/25) 96% (24/25) 0.0001
Mean duration of antibiotics, day
3 9.8 0.0001
Mean cost $259 $640 0.0001
Data for patients with CPIS 6 at the 3-day evaluation point and no extrapulmonary infections
Singh N, et al. Am J Respir Crit Care Med. 2000;162:505-511.
1 2 3 4 5 6 7 NextNextBackBack
![Page 34: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/34.jpg)
CPIS Antibiotic Study: CPIS Antibiotic Study: ConclusionsConclusions
Prolonged (i.e. >3 days) use of antibiotics in patients with an initial CPIS ≤6 may be unnecessary and inappropriate
Singh N, et al. Am J Respir Crit Care Med. 2000;162:505-511.
1 2 3 4 5 6 7 NextNextBackBack
![Page 35: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/35.jpg)
FUNGAL INFECTIONSFUNGAL INFECTIONS
RISK FACTORSTPNSteroidsBroad spectrum antibioticsAbdominal involvementImmunosuppression
![Page 36: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/36.jpg)
ANTIFUNGAL AGENTSANTIFUNGAL AGENTS
Polyenes: Amphotericin B (binds to sterols and disrupts barrier resulting in leakage of intracellular contents
For hemodynamically unstable, systemic infections
Adverse effects may limit treatment
![Page 37: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/37.jpg)
ANTIFUNGAL AGENTS cont’dANTIFUNGAL AGENTS cont’d
Azoles: Fluconazole, voriconazole, itraconazole (inhibit p450-mediated 14-alpha demethylase in the sterol)
Good activity vs C. albicans, resistance to Krusei, Glabrata
Numerous drug interactions
![Page 38: Review of Antibiotics](https://reader030.fdocuments.us/reader030/viewer/2022020716/56815e6a550346895dcce635/html5/thumbnails/38.jpg)
ANTIFUNGAL AGENTS cont’dANTIFUNGAL AGENTS cont’d
Echinocandins: Caspofungen (inhibit fungal cell wall synthesis)
Active against C. albicans, krusei, glabratacost