Antibiotics

1. Vancomycin (IV only)

a. CLASS: Glycopeptides
b. Coverage
i. ALL GRAM POSITIVES!!! – except VRE
1. Staphs and Vanc SENSITIVE Enterococci
2. Streps (including Strep. pneumo)
3. Gram positive rods (GPRs)
a. NOTE: C. dif is the ONLY time PO Vanc is used!
ii. NO Gram negative coverage 
c. NOT as bactericidal as the beta-lactams (womp, womp)
d. If prolonged therapy – monitor trough level (measure before 4th dose)
i. Serious infections – trough goal is 15-20
ii. Continuous infusion – trough goal is 20-30
e. S/E:
i. Red Man Syndrome – TRUE allergic rxn is not very common
ii. Nephrotoxicity – primarily occurs when used w/ other nephrotoxins
2. PCNs
a. PCN G (IV) or PCN VK (PO)
i. Reliably kills Strep (EXCEPT SOME Strep. pneumo!)
ii. Neisseria meningitidis (meningitis), Treponema pallidum (syphilis)
iii. Resistance will NOT develop DURING therapy
iv. Therefore, if the organism is sensitive to PCN G, USE IT!!!
1. CHEAP and ‘CIDAL!
b. Oxacillin/Nafcillin (IV) or Dicloxacillin (PO)
i. Ox/Naf achieve higher serum concentration than Diclox
ii. NARROW SPECTRUM – destroys Staph and Strep
1. MISSES: MRSA, GRAM NEGS!
iii. MOST ‘cidal agent against SUSCEPTIBLE Staph. aureus (MSSA)
iv. DOC for endocarditis, osteomyelitis (if these are caused by MSSA)
c. Ampicillin (IV) or Amoxicillin (PO)
i. Susceptibile to beta-lactamase :/ womp womp!
ii. BROADER SPECTRUM than PCN G and Oxacillin
1. Covers CERTAIN Gram negs
2. Misses Staph 95% of the time
a. NOTE: If Staph is RES to PCN, then IT IS RES to Amp/Amox!
3. Use for: Otitis media, bronchitis, sinusitis, UTI (uncomplicated)
4. DOC for Enterococcus (if it’s sensitive)
5. Do NOT use empirically for COPD exacerbation
d. Unasyn AKA Amp/Sulbactam (IV) and Augmentin AKA Amox/Clavulanic Acid (PO)
i. BROADER SPECTRUM due to beta-lactamase INHIBITOR (Sul and Clav)
1. Covers MANY Gram pos, Gram negs, AND ANAEROBES!
2. MISSES: MRSA, Pseudomonas (GNR), Atypicals, and RES Gram negs :/
e. Piperacillin/Tazobactam AKA Zosyn (IV ONLY!)
i. About AS BROAD AS YOU CAN GET!
ii. Covers: Gram pos, Gram neg (INCLUDING PSEUDOMONAS), Anaerobes
1. AND Enterococcus (IF susceptible to Amp)
iii. MISSES: MRSA, VRE, Atypicals and ESBL Gram negs
1. NOTE: ESBL=extended spectrum beta-lactamases
3. Carbapenems (IV ONLY!): some cross rxn w/ PCN allergic pts (avoid if possible!)
a. Meropenem/Imipenem
i. Almost same coverage as Zosyn, but a little LESS resistance
ii. BUT tends to PROMOTE RESISTANCE so use Zosyn if possible
iii. “Ace in the hole” abx – save it until needed!
iv. Imipenem can cause seizures! (LOWERS THE THRESHOLD! STEP 1 QUESTION!!!)
4. Aztreonam (IV ONLY!)
a. Monobactam, expensive $$$!
b. OK to use in PCN allergic pts (this is its ONLY use)
i. NOTE: UNLESS allergy is to Ceftazidime (then can’t use)
c. Covers: ONLY Gram negatives (INCLUDING PSEUDOMONAS)
i. So basically only use this when you need to cover Pseudo in a PCN allg pt!
5. Cephalosporins
a. 1st gen: Cefazolin (Ancef) and Cephalexin (Keflex)
i. Similar to Ox/Diclox
1. REMEMBER??? NARROW SPECTRUM – destroys Staph and Strep
a. MISSES: MRSA, GRAM NEGS!
2. MOST ‘cidal agent against SUSCEPTIBLE Staph. aureus (MSSA)
3. DOC for endocarditis, osteomyelitis (if these are caused by MSSA)
ii. Cefazolin (Ancef)=mainly a surgical prophylactic abx
b. 2nd gen:
i. Cefuroxime: similar to Amox
1. REMEMBER??? BROADER SPECTRUM than PCN G and Oxacillin
a. Covers CERTAIN Gram negs
b. Misses Staph 95% of the time
i. NOTE: If Staph is RES to PCN, then IT IS RES to Amp/Amox!
c. Use for: Otitis media, bronchitis, sinusitis, UTI (uncomplicated)
d. DOC for Enterococcus (if it’s sensitive)
ii. Cefotetan and Cefoxitin: also kills anaerobes (surg ppx w/ abd surgs)
c. 3rd gen:
i. Cefotaxime and Ceftriaxone AKA Rocephin (IV)
1. Covers: Gram pos (Strep. pneumo), more Gram neg than 1st and 2nd gens
2. Does NOT cover: MRSA, Enterococcus, Pseudomonas, Anaerobes, or Atyps
3. Penetrate the BBB!!!
4. Use for: Pna (in combo w/ Azithro), pyelo, gonorrhea, and meningitis
ii. Ceftazidime: KILLS PSEUDOMONAS (but use Cefepime due to resistance)
d. 4th gen: Here’s your Cefepime!!! (IV)
i. VERY BROAD SPECTRUM COVERAGE!!!
1. Covers: Gram pos, Gram neg, PSEUDOMONAS
2. MISSES: Enterococcus, Anaerobes, Atypicals
3. Use for: NEUTROPENIC FEVER!!! Gram negs, and PSEUDOMONAS!!!
e. 5 gen: CEFTAROLINE (IV) AKA ONLY beta-lactam that covers MRSA!!!
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i. Use for: cellulitis and CAP (MRSA community acquired pneumonia)

6. Fluoroquinolones (IV and PO)
a. ALWAYS try to use PO – near 100% bioavailability
b. NOT GOOD FOR: Staph. aureus
c. Moxifloxacin
i. Excellent for Strep. pneumo, most Gram negs, and Atypicals
ii. Just OK for other Gram pos
iii. MISSES: Pseudomonas, MRSA, anaerobes
iv. Does NOT penetrate URINE well so DO NOT use for UTI or pyelo!!!
 d. Levofloxacin AKA Levaquin
i. Similar to Moxi except THIS ONE COVERS PSEUDOMONAS at 750mg daily!
e. Ciprofloxacin
i. Not as good for S. pneumo, Gram pos
ii. Best FQ for Pseudomonas, Gram neg, and URINE INFXNS!!!
7. Macrolides
a. Azithromycin (PO/IV)
i. Very long half life – stays therapeutic for up to 7 days after tx stopped (Zpack)
ii. Covers: S. pneumo, some Gram negs, and Atypicals
iii. Use for: bronchitis, otitis media, urethritis, and pna (w/ 3rd gen cefs)
b. Clarithromycin – similar, just BID
8. Clindamycin (PO/IV)
a. Covers: OK for Anaerobes and Gram pos (Staph, Strep)
b. MISSES: Gram negs
c. Use for: Aspiration pna, abdominal infxns
d. INTERESTING FACT: may decrease toxin production in severe Staph/Strep infections
(cellulitis, and particularly Fournier’s gangrene)
9. Aminoglycosides (Gentamicin, Tobramycin, Amikacin)
a. Covers: Gram negs, PSEUDOMONAS; and Staph and Enterococcus when used w/ PCN
(synergy)
i. ***Tobra is MOST active against Pseudomonas!***
b. MISSES: Gram pos and anaerobes
c. S/E: ototoxicity and nephrotoxicity (reduced w/ once daily dosing)
10. Bactrim (TMP/SMX)
a.