Julius Li, PharmD; Kristi Traugott, PharmD, BCPS Revised 03/15 * = drug of choice

+ + + + + + + + Atypicals
± + + + + + + + + + + + + + + + + + + + + + + + + Peptostreptococcus spp.
+ + + + + + ± ± + + + + + + ± ± ± ± + ± ± + + + + Clostridium spp.
+ + + + + + + + + + + + + + + + + Prevotella spp.
+ + + + + + ± ± + + + + + + + + + Bacteroides spp.
* + + + ± Stenotrophomonas maltophilia
+ + + + + + + + + + + Pseudomonas aeruginosa
+ + + + + + + + + + + + + + + + Acinetobacter spp.
+ + + + + + + + + + + + + + + + + + + + Proteus spp.
+ + + + + + + + + + + + + * + + + Serratia spp.
+ + + + + + + + + + + + + + + * + + + Citrobacter spp.
+ + + + + + + + + + + + + + + * + + + Enterobacter spp.
+ + + + + + + + + + + + + + + + + + + + + + + + Klebsiella spp.
+ + + + + + + + + + + + + + + + + + + + + + + + + Escherichia coli
+ + + + + + + + + + ± Enterococcus faecium
+ + + + + + + + + + + * + + + + Enterococcus faecalis
± + ± + + + + + * + + + + + + Staphylococcus aureus (MRSA)
+ + + + + + + + + + + + + + + + + * + + + + + + ± * + + Staphylococcus aureus (MSSA)
+ + + + + + + + + + + + + + + + + + + + + + + + + + Streptococcus pneumoniae
+ + + + + + + + + + + + + + + + + + + + + + + + + + Viridans group streptococci
+ + ± + + + + + + + ± + + + + + + + + + + + + + * + + + + Beta-hemolytic streptococci
Bug
Refer to hospital antibiogram for susceptibility rates of specific organisms

Oxacillin

Pip-Tazo

Linezolid
Cefoxitin
Cefazolin

Cefepime
Amp-Sulb

TMP-SMX
Ampicillin

Imipenem
Amox-Clav
Penicillin G

Tigecycline
Ertapenem
Ceftaroline

Aztreonam

Polymyxins
Spectrum of Activity Against Common Bacteria

Cefuroxime

Ceftriaxone

Ceftazidime

Minocycline
Doxycycline

Quinu/Dalfo
Drug

Clindamycin
Daptomycin
Vancomycin
Meropenem

Levofloxacin
Moxifloxacin
Ciprofloxacin

Azithromycin
Nitrofurantoin
Metronidazole
Aminoglycosies

Clarithryomycin
Pocket Guide for Antibiotic Pharmacotherapy
Antibiotic Pharmacokinetics & Pharmacodynamics Microbiome Man
“Where bacteria normally live”
Oral flora
Bacteriostatic versus Bactericidal Streptococci
Staphylococci
“ECSTaTiC for bacteriostatic” “Very Proficient For Complete Cell Murder” Lactobacillus spp.
Erythromycin (macrolides) Trimethoprim Vancomycin Cephalosporins Diphtheroids
Clindamycin (lincosamides) Tetracyclines Penicillins Carbapenems Porphyromonas spp.
Sulfonamides Chloramphenicol Fluoroquinolones Metronidazole Fusobacterium spp.
Actinomyces spp.
Time-dependent Concentration-dependent Respiratory flora
Streptococci
Staphylococci
 Optimize killing by maximizing time above MIC  Optimize killing by maximizing peak concentrations Diphtheroids
 More frequent administration or extended-  Less frequent but higher doses increases efficacy Neisseria spp.
infusion increases efficacy by extending T>MIC by maximizing Cmax:MIC ratio Haemophilus spp.
 Ex: beta-lactam antibiotics  Ex: aminoglycosides, daptomycin Moraxella spp.
Yeasts
Gut flora
Enterobacteriaceae
Bacteroides spp.
Skin flora Clostridium spp.
Staphylococci Lactobacillus spp.
Streptococci Candida spp.
Diphtheroids Streptococci
Micrococci Enterococci
Propionibacterium spp. Staphylococci
Peptostreptococci
Julius Li, PharmD; Kristi Traugott, PharmD, BCPS Revised 03/15
 Antibiotic Pharmacotherapy by Class
Refer to Guidelines for Dosing in Renal Failure for both dosing in normal renal function and renal dose adjustments
Antibiotic Adverse Reactions Drug Interactions Clinical Pearls
Penicillins Generally drugs of choice for bacteria once susceptibility known
Penicillin G, oxacillin, None (e.g. MSSA, penicillin-susceptible S. pneumoniae, ampicillin-
ampicillin, amoxicillin susceptible enterococci)
Beta-lactam inhibitor Excellent anaerobic activity
combinations Sulbactam has unique activity against Acinetobacter spp. (doses
amoxicillin-clavulanate, None based on sulbactam, >6 g/day)
ampicillin-sulbactam, Consider amox-clav 500-125 mg q8h dosing for gram-negative, an-
piperacillin-tazobactam GI upset (nausea, diarrhea) aerobic, or mixed infections (more clavulanate needed)
Hypersensitivity reactions
Cephalosporins Leukopenia, thrombocytopenia (rare)
Cross-reactivity with penicillin allergy <5%
Cefazolin, ceftriaxone, Neurologic (altered mental status, seizures)
None Caution with third generation cephalosporins (e.g. ceftriaxone) and
ceftazidime, cefepime, Interstitial nephritis
SPACE bugs+ (ampC producers)
ceftaroline Hepatotoxicity (oxacillin)
Carbapenems Generally reserved for multidrug resistant gram-negatives (MDR-GN)
Ertapenem, imipenem, Drug of choice for ESBL producers
None
meropenem, doripenem Excellent anaerobic activity
Cross-reactivity with penicillin allergy <5%
Monobactams Generally reserved for severe penicillin allergy (e.g. anaphylaxis), but
None
Aztreonam may cross-react with ceftazidime allergy
Fluoroquinolones GI upset (nausea, vomiting, diarrhea)
Ciprofloxacin Neurologic (dizziness, AMS, seizures) Increasing resistance may limit use, particularly with E. coli
Moxifloxacin Phototoxicity Caution with cations (reduced Higher dose for P. aeruginosa (e.g. cipro 750 mg q12h, levo 750 q24h)
Levofloxacin Tendonitis, cartilage erosion bioavailability) Highly bioavailable, PO = IV
QT prolongation Inhibits 1A2 (cipro) Moxifloxacin = poor urine penetration (not used for UTIs)
Dysglycemia QT prolongation risk = moxi > levo >> cipro
Peripheral neuropathies
Tetracyclines GI upset (nausea, vomiting, epigastric distress) Highly bioavailable, PO = IV (doxy, mino)
Doxycycline Photosensitivity Caution with cations (reduced Tige = severe nausea, may need scheduled antiemetics pre-dose
Minocycline Teeth discoloration bioavailability) Mino, tige = has activity against multidrug resistant organisms (even
Tigecycline Vertigo (minocycline) if tetra or doxy resistant)

Macrolides
GI upset (nausea, vomiting, diarrhea)
Erythromycin, azithromy- Inhibits 3A (ery > clari >> azi) QT prolongation risk = ery >> clari > azi
QT prolongation
cin, clarithromycin
Glycopeptides Red man syndrome Red man syndrome can be prevented by slowing infusion rates or
Vancomycin Nephrotoxicity None premedicate with diphenhydramine
Neutropenia (rare) IV vanc for systemic infections, PO vanc for C. difficile infection
Cyclic Lipopeptide Generally reserved for severe, resistant gram-positive infections (e.g.
Skeletal muscle toxicity
Daptomycin None MRSA, VRE) if vancomycin failure or resistant
Eosinophilic pneumonia
Not for pulmonary infections (deactivated by lung surfactant)
Oxazolidinone Generally reserved for severe, resistant gram-positive infections (e.g.
Linezolid MRSA, VRE) if vancomycin failure or resistant
Thrombocytopenia Inhibits MAO (weak) Highly bioavailable, PO = IV
Peripheral neuropathies p-glycoprotein substrate Higher toxicity risk with long-term therapy (>2 weeks)
Higher risk for serotonin syndrome with due to MAO inhibition with
serotonergic agents (e.g. SSRIs, TCAs) and foods (e.g. red wine)
Lincosamide GI upset (diarrhea > nausea, vomiting) Increasing resistance in S. aureus and streptococci may limit use
None
Clindamycin Elevated LFTs (minor) Increasing resistance in anaerobes, particularly Bacteroides spp.
Sulfonamides Hypersensitivity reactions Highly bioavailable, PO = IV
Trimethoprim- Leukopenia, anemia None Dose for severe infections = 15 mg/kg/day based on TMP component
sulfamethoxazole Hyperkalemia, renal failure (e.g. PCP, Nocardia spp.)
Nitroimidazole Highly bioavailable, PO = IV
GI upset (nausea)
Metronidazole Excellent anaerobic activity
Peripheral neuropathy None
Avoid alcohol due to disulfiram reaction
Taste disturbances (metallic)
Higher risk for peripheral neuropathies with long-term therapy
Nitrofurans Peripheral neuropathy Only used for UTIs, but without pyelonephritis
Nitrofurantoin Pulmonary toxicity None Do not use with poor renal function (low urinary penetration)
Hepatotoxicity (rare) Low resistance = good option for multidrug resistant organisms
Aminoglycosides Nephrotoxicity Tobramycin preferred for P. aeruginosa infections
Gentamicin, tobramycin, Ototoxicity None May be used synergistically for severe gram-positive infections
amikacin Vestibular toxicity Ami = may have activity even if gent or tobra resistant
Polymyxins Nephrotoxicity Last line for MDR-GNs due to high toxicity risk and limited efficacy
None
Colistin, polymyxin B Neurotoxicity (oral/peripheral paresthesias) Consider polymyxin B for systemic infections and colistin for UTIs
Julius Li, PharmD; Kristi Traugott, PharmD, BCPS Revised 3/15
+ SPACE bugs = Serratia marcescens, Pseudomonas aeruginosa, Acinetobacter baumannii, Citrobacter freundii, Enterobacter spp. Approfed by P&T Committee 6/2015