Practical Points : Empiric-ing Antibiotic for Extern

( )

order antibiotic

.... choice
( )

( )

Key 1 : Empiric antibiotic ?

Skill Empiric antibiotic

specimen (by .)
inadequate specimen, inadequate culture
discharge Empiric antibiotic
antibiotic

identify basic lab
gram positive, gram negative culture, sens

. common
ICU

Key 2 : approach

3
3W : What ? Who ? Where?
What? What is suspected? localize ? common

?

Who?Who is the patient? ? host factor healthy

immunocompromised host systemic disease cardiopulmonary disease, chronic lung
disease, diabetes mellitus catheter

Where? Where is the patient? ( )? environmental factor

community-acquired hospital-acquired infection
hemodialysis
Where are you?
review antibiotic 3

Important note before lesson

aggressive treatment
clinical

Key 3 : Antibiotic short course

order introduction antibiotic
( )

1>

Beta-lactam penicillin. aminopenicillin , cephalosporins, carbapenems
Glycopeptide vancomycin
Fosfomycin
2>

Aminogylcoside amikacin, gentamicin
Macrolide roxithromycin, clarithromycin, azithromycin
Tetracycline doxycycline, minocycline
Lincosamide clindamycin
Glycylcycline tigecycline

3>
metabolite
TMP-SMX

4>
Fluoroquinolone (FQ)

5> Metronidazole

cover

** Penicillin derivatives
most commonly use antibiotic ampicillin, amoxycillin, cloxacillin, piperacillin
Basic penicillin gram positive
Ampicillin, amoxycillin Enterococci
Cloxacillin, Dicloxacillin S.aureus
Piperacillin Pseudomonas aeruginosa

beta-lactamase inhibitor
Ampicillin + Sulbactam (Unasyn) -> A.baummannii
Amoxycillin + Clavulonic acid (Augmentin) -> S.aureus, gram negative
Piperaciilin + Tazobactam (Tazocin) -> P.aeruginosa

** Cephalosporin generation
gen gram gen gram pseudo
 generation

1st generation : gram +ve, S aureus

e.g. cefazolin ( pre-op skin incision), cephalexin

2nd generation : cover gram -ve

e.g. cefuroxime, cefoxitin

3rd generation : gram +ve gram -ve Cef-three! (

) Pseudomonas
hospital-acquired pseudo
empiric Cef-three
e.g. ceftriaxone, cefotaxime Cefdinir Cefspan
> 3rd gen cover special organism Pseudo Melioid Ceftazidime (Fortum)
gram +ve

4th generation : anti-pseudomonal cephalosporin gram +ve

e.g. Cefepime, Cefpirome Ceftazidime Fortum

Ceph => pre-op 1st gen, Cef3, pseudo,melioid Fortum

**Carbapenems
cephalosporin Hi-so
imipenem, meropenem, doripenem, ertapenem

anaerobes nocardia
hospital-acquired CRE
(Carbapenem-resistant enterococci)
** pseudo, A. buam Ertapenem Erta empiric hospital-acquired
Meropenem
 : hospital acquired cephalosporin 3rd gen
community-acquired !! community hospital

community-acquired
ceftazidime, cefoperazone, piperacillin, carbapenem hospital-acquired

gram +ve penicillin, ampicillin, amoxycillin

gram +ve gram -ve anaerobe augmentin
S.aureus Cloxa, Dicloxa, 1st gen cephalosporin
gram +ve, gram -ve 3rd gen cephalosporin
pseudo piperacillin, ceftazidime, carbapenem ( Erta)
melioid ceftazidime
hospital acquired carbapenem at least 3rd gen cephalosporin pseudo

Glycopeptide ( ) vancomycin
vancomycin
MRSA (methicillin resistant S. aureus)
catheter-related sepsis S.aureus
S.aureus S.aureus
cloxa, dicloxa
MRSA fosfomycin ( VRE ), fusidic acid, linezolid, tigecycline

Aminoglycoside: broad spectrum gram -ve
anaerobe ++ oxygen
concentration-dependent prolonged effect
ototoxicity
nephrotoxicity amikacin gentamicin
> amikacin Pseudo
gram -ve
Dose Gentamicin 5.1 mg/kg/day, Amikacin 15 mg/kg/day OD dose
Hepatobiliary infection

Macrolide Lincosamide (Clindamycin)

Macrolide gram +Ve streptococci, staphylococci
CAP, respiratory tract infection, STD
macrolide Lincosamide (Clindamycin) atypical Mycoplasma,
Chlamydia Legionella Azithromycin, Clarithromycin treat MAC

Tetracycline gram +ve

doxycycline Rikettsia infection scrub typhus therapeutic
diagnosis
( 24-48 hrs )

azithromycin doxycycline treat scrup, lepto effective

doxy cost-effective
azithromycin fatal arrhythmia
Levofloxacin

antimetabolite TMP-SMX Co-trimoxazole

indication
> Nocardia infection
> PCP, treatment and prophylaxis
> Melioidosis ( ceftazidime)
> treat shigella, UTI
:
: SJS/TEN, Fixed drug eruption

FQ (Fluoroquinolone)
 Norfloxacin, ofloxacin, levofloxacin, ciprofloxacin moxifloxacin
gram -ve
Rx infection hepatobiliary
Ciprofloxacin pseudo, levoflox high dose (750 mg)
"Respiratory quinolone" levoflox moxiflox gram +Ve
atypical organism

anaerobes
Above diaphragm : Clindamycin
Below diaphragm : Metronidazole
( concept )

review short cause antibiotic empiric antibiotic system

Key 4 : Empiric antibiotic system

** empiric

1st 2nd choice

CNS infection
> meningitis S.pneumoniae, N. meningitidis, S.suis, Listeria monocytogenes
Ceftriaxone 2 gm IV q 12 hours vancomycin
listeria add ampicillin 2 gm IV q 6 hours
( dose ceftriaxone bid OD)

Acute sinusitis gram +ve (S.pneumo, H.influ, M. catarrhalis)

amoxycillin (1 g tid), augmentin, respiratory quinolone(levoflox, moxiflox), 3rd gen cep
 URI
viral infection antibiotic
supportive treatment follow up
antibiotic****

amoxicillin Augmentin ****

Acute pharyngotonsilitis strep GAS, antibiotic Penicillin

10 COMPLICATION ****

CAP (community-acquired pneumonia)

host factor
clinical combination alone clinical
> healthy (walking pneumonia) : Atypical pneumonia macrolide, respiratory FQs
> alcoholism: S.pneumo, gram -ve, anaerobe ( ) : 3rd gen + clindamycin, respiratory
FQs
> COPD: H.influ, S.pneumo, M.catarrhalis : 3rd gen cephalosporin, respiratory FQs
> Post-obstructive airways: S.pnuemo, anaerobes: Augmentin, 3rd gen + clindamycin
> Tropical infection: 3rd gen + doxycycline or azitrhomycin
> Melioidosis ( DM, Thalassemia, CKD, Farmer) Ceftazidime + Co-trimoxazole, meropenem
> PCP: Co-trimoxazole
> HAP (hospital-acquired pneumonia)
admit <5 days CAP
admit > 5 days HAP : A.baum, pseudo. klebsiella, E.coli

A.baum : cefoperazone/sulbactam -> colistin, tigecycline
Pseudo : ceftazidime, meropenem, tazocin
gram-ve: 3rd gen + resp FQs
ESBL: Tazocin, FQs
MRSA: vancomycin, fosfomycin
Aspiration pneumonia : anaerobes : Clindamycin, Augmentin
Bacterial endocarditis
host factor
IV drug user : MSSA -> Cloxacillin + gentamicin, Cefazolin + gentamicin
valvular heart disease -> S.viridans, enterococci: Ampicillin + gentamicin, Ceftriaxone + gentamicin

Intra-abdominal infection
Enterobacteriaceae + anaerobes : 3rd generation cephalosporin + metronidazole
Complicated infection: Antipseudomonal agent (post-op infection)

Osteomyelitis
S.aureus : cloxacillin

Septic arthritis
S.aureus : cloxacillin
Salmonella: ciprofloxacin
Staph, Strep : Cloxacillin

Cellulitis
Salt or freshwater + animal exposure : vibrio, aeromonas -> 3rd gen cep + FQ (ciprofloxacin)
Animal bite : Augmentin
Previous surgery of limbs : Penicillin, clindamycin

Community-acquired sepsis
unknown primary site host factor ?
host risk : Ceftriaxone 2 gm IV OD
host risk meloidosis Ceftazidime 2 gm IV q 8 hours -> Co-trimoxazole
Hospital-acquired sepsis unknown source
Meropenem ( )
review
 antibiotic
empiric culture sens response
antibiotic clinical , HR

dose creatinine clearance

Death Note : ( host, bact factors )

Community-acquired
Respi : cef3+Macrolide(azithro,clarithro), RespiFQ, Anti-psedo Cep, Aspirate: cef3+clinda
GI : cef3 + metro
Skin : Cloxacilin, Augmentin, ciproflox+cef3 for Cirrhosis,sea, Cef3+clinda
GU: cef3, FQ
CNS: cef3 s/sc ampicillin + amikacin or vancomycin

Hospital-acquired
Respi: mero+vanco+colistin
GI: mero+amikacin
Skin: mero+vanco
GU: mero+vanco
CNS : mero+vanco

Hospital-acquired system Mero start Tazocin

meropenem gram +ve MRSA vancomycin

Source
- . . Principles of Antimicrobial
therapy in general practice
-Rational use of antibiotics
Emergency care the pocket guide book RAMA
 antibiotic admin