MRSA Hospital Acquired

Pseudomonas:1. Piperacillin 2. Piperacillin/Tazobactam-Zosyn 3. Ceftazidime-Fortaz 4. Ceftazidime/avibactam-Avycaz 5. Cefepime-Maxipime 6. Ceftolozane/tazobactam-Zerbaxa 7. Carbapenems: Except Ertapenem-Invanz 8. Aztreonam-Azactam 9. Ciprofloxacin-Cipro 10. Levofloxacin-Levaquin Atypicals:1. Fluoroquinolone C. difficile:1. Vancomycin PO txt for Colitis caused by C.diffcile 2. Fidaxomicin (DIFICID) PO MSSA (produce penicillinase) 1. Methicillin 2. Nafcillin-Nafcil, Nallpen 3. Oxacillin-Bactocill 4. Dicloxacillin-Dynapen 5. Ampicillin/Sulbactam-Unasyn 6. Amoxicillin/Clavulanate-Augmentin 7. Piperacillin/Tazobactam-Zosyn 8. 1st and 3rd Generation Cephalosporins (except ceftazidime) MRSA Hospital acquired : 1. Vanco (Telavancin, Dalbavancin, Oritavancin) 2. Daptomycin-Cubicin 3. Ceftaroline-Teflaro 4. Delafloxacin-Baxdela Community acquired (PO): 1. TMP/SMX-Bactrim 2. Delafloxacin-Baxdela B.fragilis 1. Ampicillin/Sulbactam-Unasyn 2. Amoxicillin/Clavulanate-Augmentin 3. Piperacillin/Tazobactam-Zosyn 4. Cefoxitin-Mefoxin 5. Cefotetan-Cefotan 6. Carbapenems : All 7. Moxfloxacin=Avelox Which one Does Not have Group 4 From Flower chart H-Influenza:1. Pen G 2. Nafcillin 3. Cefazolin 4. Vancomycin 5. Daptomycin 6. Fosfomycin 7. Ciprofloxacin Which one Does Not have Group 3 From Flower chart:1. Daptomycin 2. Vancomycin 3. Nafcillin 4. Ampicillin & Amoxicillin 5. Pen G No Renal Dose Adj:1. Polymyxin B IV 2. Moxifloxacin-Avelox 3. Nafcillin-Nafcil 4. Oxacillin-Bactocill 5. Ceftriaxone-Rocephin Indication for Urinary Tract Infection (UTI):1. Ceftriaxone-Rocephin 2. Ceftazidime/Avibactam- Avycaz (Complicated) 3. Cefepime-Maxipime 4. Ceftolozane/Tazobactam-Zerbaxa (Complicated) 5. Imipenem (Complicated) 6. Meropenem (Complicated) 7. Ertapenem-Invanz (Complicated) 8. Colistin 9. Fosfomycin- (Uncomplicated) 10. Ciprofloxacin-Cipro 11. Levofloxacin-Levaquin 12. Trimethoprim/Sulfamethoxazole-Bactrim (Uncomplicated) Intra-Abdominal Infection (IAI):1. Ceftazidime/Avibactam- Avycaz (Complicated) 2. Ceftriaxone-Rocephin 3. Cefepime-Maxipime (Complicated) 4. Ceftolozane/Tazobactam-Zerbaxa (Complicated) 5. Ertapenem-Invanz 6. Ciprofloxacin-Cipro Dosing:1. Ceftriaxone q 24 2. Ertapenem-Invanz 1 g IV q 24 3. Amoxicillin every 8-12 hours 4. Cefazolin-Ancef 1-2 g IV q 8 hrs 5. Cephalexin-Keflex PO 250-500 mg q 6 hrs 6. Cefepime-Maxipime 1-2 g IV q 8-12 hrs 7. Ceftaroline-Teflaro 600 mg IV q 12 hrs 8. Imipenem/Cilastatin-Primaxin 0.5-1 g IV q 6 hrs 9. Meropenem-Merrem 1-2 g IV q8 hrs (0.5 g IV q 6 hrs) 10. Aztreonam-Azactam 2 g IV q 8 hrs 11. Vancomycin Infusion rate 1g/hour to prevent Red man syndrome Vancomycin for MRSA AUC of 400-600, Maintenance Dose 15-20 mg/kg based on actual body weight every 8-12 hours 12. Telavancin-Vibativ 10 mg/kg IV over 60 min once a day for 1-3 weeks 13. Oritavancin, Dalbavancin q 24 hrs 14. Daptomycin-Cubicin Complicated skin and soft tissue infection 4mg/kg/day Bone Infection 6 mg/kg Blood stream infection or Endocarditis 8-10 mg/kg 15. Fosfomycin Females: single dose of 3g PO in 3-4 oz (90-120 ml) of water 16. Ciprofloxcin-Cipro 500-750 mg PO q 12 hrs, 400 mg IV q 12 hrs 17. Levofloxacin-Levaquin 500-750 mg PO/IV q 12-24 hrs 18. Moxifloxacin-Avelox 400 mg IV/PO q 24 hrs 19. TMP/SMX-Bactrim Single DoseTMP 80 mg, SMX 400 mg Double Strength TMP 160, SMX 800 MG. 1DS PO BID for 3 days Cephalosporin 1st generation : Gram (+) IV : Cefazolin IV (Ancef) PO : cephalexin (Keflex), cefadroxil 2nd generation : Gram (+) , Gram (-) IV : Cefuroxime (Kefurox,Ceftin), cefoxitin (Mefoxin), cefotetan (Cefotan) PO : Cefaclor, loracarbef, cefprozil, cefuroxime axetil 3rd generation: As good Gram (+) as 1st , better gram (-) IV : Ceftazidime (Fortaz), cefotaxime (Claforan), Ceftriaxone(Rocephin), ceftazidime/avibactam (Avycaz) PO : Cefdinir PO (Omnicef), cefixime (Suprax), cefpodoxime 4th generation : Cefepime IV(Maxipime) 5th generation : Ceftaroline IV(Teflaro),Ceftolozane/tazobactam(Zerbaxa) ● ● ● ● ● ● ● ● ● ● Notes Monobactam is only G(-) aerobic. are used in pt who have allergy to Penicillins and Cephalosporins.Resistant to Serian base and metallo-β lactamases, Penetrate BBB Carbapenems for both G + & Beta Lactamase all G + and some G Increase INR>> Bactrim, Fluoroquniolone, Sulfonamide. Photosensitivity>> Ofloxacin, Ciprofloxacin, Sulfonamide, Bactrim, Fluoroquinolone cause phototoxicity Aminopenicillin (Amox,Ampi) interact with Birth Control Beta-Lactams distribute to CSF in the presence of inflamed meninges except Cefazolin-Ancef, Zosyn. Penicillin does not readily enter CSF (penetrates easily when meningitis), Highly protein bound, increases ½ t in renal impaired and infants. Isoxazolyl penicillin same as Pen V but it also excreted via bile hepatic metabolism Aminopenicillin (Ampicillin, Pivampicillin, Amoxicillin) Carboxypenicillin, Ureidopenicillins (Piperacillin Injection ) [(antipseudomonal penicillins), Urea group at the α-position] both G + & -. Increased hydrophilic character. Did not change the effect on gram +ve activity effectiveness of drug still the same, ● ● ● ● ● ● ● ● ● Increases gram -reactivity allow drug penetration through the porins of gram -ve outer membrane. Aminopenicillin Acid resistant, Well absorbed b/c presence of EWG amine group, no steric shield so Sensitive to β-lactamase, Meth, Oxi, and Naf, the Penicillinase lack EWG so they do not well absorb no oral, they are injections so they are acid sensitive. QT prolongation:- Telavancin, Fluoroquinolones Cubicin- No pneumonia coverage: alveolar surfactant deactivates Daptomycin. It is also Against VRE, VRSA, MRSA. Need to check for CPK if elevated Stop when it is 5xUNL=1000 for Rhabdomyolysis be careful with statin Sulbactam, Tazobactam, Clavulanic acid (Irreversible), are all serin bases. Also Avibactam, Relebactam but they do not have B-Lactam rings and they are reversible. Penicillin becomes Immunogenic when they bind to human protein NH2. Cefuroxime has the greatest resistant to B-Lactams from the cephalosporins b/c Iminomethoxy group which acts as Steric shield CephamycinC, Cefoxitin, and Cefotetan, Penicillin use Steric Shield(2nd gen). Cefotetan N-methylthiotetrazolering(NMTT) cause hypoprothrombinemia (low Blood clotting) require oral vitamin K to correct, disulfiram reactions, use of alcohol must be avoided Cefuroxime and CephamycinC has Ureathen group which acts as resistant to esterases ● 3rd Gen (Ceftazidime, Ceftriaxone, and Cefotaxime) cross BBB(Monobactam) so they are used to txt Meningitis ● Replacement of furan ring with an aminothiazole ring ↑ penetration across gram -ve outer membrane, ↑ affinity for the transpeptidase. ● 4th Gen has Iminomethoxy group and Aminothiazole ring ● At Gen 5th that’s when the Transpeptidase get mutated from PBP to PBP-2a (MRSA) Or PBP-2x (MDRSP) ● Cephalosporin AD one of them is Superinfection It acts on Broad range of Bacterias killing the good Bacteria as well in our Body. ● Penicillin Binding protein is same as transpeptidase ● The Drug is Binding Because of the transpeptidase Not B-Lactamase. ● Glycopeptide target is Transglycosylation. And Beta-Lactams target Transpeptidase. ● Vancomycin is Gram + only, Bactericidal. Produced by Streptomyces orientalis. Last resort in treating drug resistant infections such as MRSA. Blocks transglycosylation. Contains 5 aromatic groups ● and 2 sugars. H-bonding interactions between the peptide and the biosynthetic building block. Property to form Dimer. Large vancomycin molecule acts as a steric shield(2nd gen as well). blocking access to the transglycosidase and transpeptidase enzymes. L-Lys-D-Ala-D-Ala tail where Vanco binds. Vancomycin Resistance are Slow to develop - Vancomycin-resistant enterococci (VRE) -Vancomycin-resistant Staphylococcus aureus (VRSA) Due to mutation in pentapeptide chain of cell wall building block. Analogue of Eremomycin are Telavancin (Vibativ), and Oritavancin(Orbactiv). Teratogenic (avoid in pregnant women) Oritavancin(Orbactiv) 1000X more active than vancomycin ● Daptomycin for MRSA, VRE, VRSA ● Telavancin for MRSA, MSSA ● Fosfomycin Oral Antibiotic used for E. coli, E. faecalis, or MDR (Multidrug Resistant) bacteria ● Cycloserine-Seromycin Acts within the cytoplasm to block biosynthesis of D-Ala-D-Ala. Mimics the structure of:D-Ala therefore, inhibits L-alanine racemase responsible for racemizing L-Ala to D-Ala. D-Ala-D-Ala ligase which are responsible for linking the 2 D-Ala units together Adverse Reaction of Cephalosporin: 1. Hypersensitivity 2. GI effects 3. Local reaction 4. Nephrotoxicity 5. Superinfection Adverse Reaction of Pencillins: 1. Toxic reactions 2. GI irritation 3. Allergic or hypersensitivity reactions β-Lactams: Cephalosporins Adverse Reactions:Cross-Reactivity With Penicillins • Allergy mild-delayed penicillin allergy → cautiously administer severe penicillin allergy → avoid for Both first & Second Generation Adverse Reaction of B-Lactams: Hypersensitivity : Higher incidence with IV or procaine formulation local anesthetic used in combination of certain antibiotic penicillin to prolong effect or enhance absorption when given via injection Skin test Cross reactivity : hard to predict, various in literatures Ex. Patients with Penicillin allergy would have Cephalosporins(2%) allergy or carbapenems (1%) allergy. But, no allergy (0%) in Monobactam (Aztreonam) Desensitization (temporary) PO is safer than IV Gastrointestinal ◦ Altered Liver function, nausea, vomiting, diarrhea, pseudomembranous colitis( C. difficile diarrhea, especially with the use of extended/broad-spectrum cephalosporins Hematologic Leukopenia, neutropenia, thrombocytopenia-prolonged therapy > 2 weeks neurologics (Irritability, jerking, confusion, seizure) Seizures from very high doses of any beta-lactam (Renal dose adjustment required) : Penicillins, carbapenems (imipenem), cefepime. Adverse Reaction of Polymyxin: 1. Nephrotoxicity 2. Neurotoxicity Adverse Reaction of Carbapenems: 1. nausea, vomiting, diarrhea, rashes, and reactions at the infusion sites 2. Excessive levels of imipenem in renal failure may lead to seizures 3. Cross-reactivity with penicillins is less than 1% Vancomycin Adverse Effects: Most reactions are reversible 1. Infusion-related: With high doses can cause nephrotoxicity and ototoxicity 2. With rapid infusion rates can cause anaphylactoid reaction hypotension, wheezing, dyspnea, urticaria, pruritis, and red man syndrome (rash) Sulfonamides: Adverse Reactions Dermatologic -most with sulfa Drugs common TMP/SMX rash, photosensitivity, exfoliative dermatitis Hematologic (rare) -bone marrow suppression with higher Doses o especially higher doses of TMP/SMX Renal -TMP/SMX can cause both true and pseudo-renal failure, crystalluria ADRs of Bactrim 1. Hypersensitivity (Sulfa allergy) 2. Photosensitivity 3. Rash 4. Steven Johnson Syndrome Cycloserine Adverse Effects: Serious, dose-related CNS toxicity with headaches, tremors, acute psychosis, and convulsions Quinolones and Fluoroquinolones: Adverse Effects • Most frequent: GI (3-17%): nausea, vomiting, diarrhea Neurologic (1-11%): dizziness, insomnia, headache • Less frequent 1. aortic dissections 2. QTc prolongation 3. arthralgia use cautiously in children (<18) 4. FDA warnings for all fluoroquinolones in 2016 reserve for patients who do not have alternative options 5. Contraindicated in pregnancy 6. Collateral Damage 7. Drug interactions : Chelation (avoid cations), inhibit CYP 450: increase INR warfarin Black Box Warnings 8. Hypersensitivity 9. Tendon rupture (> 60YO, Steroid use, Transplant) 10. Peripheral neuropathy and CNS effects 11. Glucose intolerance (Led to the withdrawal of gatifloxacin), monitor BSL 12. Hepatotoxicity (led to withdrawal of trovafloxacin) 13. Phototoxicity G(+) Aerobic: Meth, Naf, Oxa, Diclo G(-) Aerobic: Aztreonam-Azactam Anaerobic G (+) & (-): 1. Piperacillin 2. Cephamycins(Cefoxitin, Cefotetan, Cefmetazole) 3. Carbapenems 4. Moxifloxacin-Avelox How to take:1. Penicillin V and Aminopencillin (except Amoxicillin) absorption impaired by food 1-2 h before/after a meal 2. Fluoroquinolone w/wo food 3. Bactrim with food (if stomach upset) Saline Dilution : 1. Invanz 2. Unasyn 3. Ampicillin-Principen 4. Daptomycin 5. Bactrim (Diluted in Dextrose only) Surgical:1. Invanz- Prophylaxis of surgical site colorectal surgery 2. Ancef- Surgical prophylaxis agent 3. Cephamycin(Cefoxitin, Cefotetan, Cefmetazole) Prophylaxis in Intra-abdominal surgery Pregnancy Category C:1. Beta-Lactams Category B(Safe to give) 2. Imipenem/Cilastatin-Primaxin 3. Vancomycin-Vancocin 4. Telavancin-Vibativ 5. Fluoroquinolones 6. Bactrim No Refrigerate:1. Amoxicillin suspension (Except this Yes Refrigerate) 2. Cefdinir suspension 3. Fluoroquinolone 4. Bactrim