6/25/2020 Antibiotic Coverage | Time of Care

Antibiotic Coverage
When doing empiric abx coverage, you want to think of covering the following as needed.

MRSA (see risk factors for MRSA)

Pseudomonas (see risk factors for Pseudomonas)
GNR (Gram-negative rods)
Gram positives (Cocci & Rods)
Anaerobes

Also, see risk factors for Multi-drug Resistant Pathogens.

Table of Contents 
1. Antibiotics that Cover Pseudomonas Aeruginosa
2. Antibiotics that Cover the Anaerobes (including Bacteroides fragilis)
3. Antibiotics that cover the difficult to kill gram-positive bacteria
4. Empiric antibiotic therapy for gram negatives and anaerobes

Antibiotics that Cover Pseudomonas Aeruginosa

1. Zosyn (piperacillin & tazobactam); Piperacillin; Timentin (Ticarcillin &
clavulanate); Ticarcillin; Carbenicillin — these are the Antipseudomonal Penicillins alone and
combined with beta-lactamase inhibitors.
2. Ceftazidime (3rd Gen Cephalosporin). Also, Cefoperazone (no longer made in the U.S.)
***Ceftriaxone does NOT cover Pseudomonas!
3. Cefepime (4th Gen Cephalosporin). ** Ceftaroline (5th Gen) does NOT cover Pseudomonas.
4. Imipenem; Meropenem, Doripenem (Carbapenems). Note: Ertapenem, a new carbapenem
doesn’t cover pseudomonas. All carbapenems are resistant to Beta-lactamases, including
Extended Spectrum Bata-Lactamases (ESBL).
5. Aztreonam (a monobactam)
6. Ciprofloxacin (Resistance is increasing) & Levofloxacin. ** Cipro and levofloxacin still provide
excellent coverage for Pseudomonas, especially after I.D. and sensitivities are back. You can use
them po. Even so, the IDSA 2016 HAP/HAV guidelines recommend using them to cover
pseudomonas.
7. Aminoglycosides – Amikacin, Gentamicin, Tobramycin
8. Polymixins

*Fluoroquinolones are the only class of antibiotics which has an oral formulation that is reliably active
against Pseudomonas aeruginosa. Use Ciprofloxacin 750mg q12h or Levofloxacin 750mg QD.

Antibiotics that Cover the Anaerobes (including Bacteroides fragilis)

1. Zosyn (piperacillin & tazobactam); Augmentin (Amoxicillin & Clavulanate); Unasyn (Ampicillin &
Sulbactam); Timentin (Ticarcillin & clavulanate) — Penicillins with beta-lactamase inhibitor*
2. Cefoxitin; Cefotetan; Cefmetazole (2nd Gen. cephalosporins)
3. Imipenem, Meropenem, Doripenem, and Ertapenem (Carbapenems)
4. Chloramphenicol
5. Clindamycin

https://www.timeofcare.com/antibiotic-coverage/ 1/3
6/25/2020 Antibiotic Coverage | Time of Care

6. Metronidazole
7. Moxifloxacin
8. Tigecycline

*Penicillins were used to treat anaerobic infections in the past but these organisms developed resistance
to PCNs by producing beta-lactamases. We outwit them by combining PCNs with beta-lactamase
inhibitors.

Options for covering both Pseudomonas and anaerobes:

1) Pip/Tazo (Zosyn), OR
2) Aztreonam + Metronizadole, OR——- This is on DRMC’s guidelines recommend this combination in
pts. with allergies to PCN who can’t take Pip/Tazo
3) Imipenem or Meropenem or Doripenem

Antibiotics that cover the difficult to kill gram-positive bacteria

Methicillin-Resistant Staph Aureus (MRSA)

1. Vancomycin
2. Linezolid
3. Daptomycin
4. Telavancin
5. Quinupristin / Dalfopristin
6. Tigecycline
7. Ceftaroline

Vancomycin-Resistant Enterococci (VRE)

1. Linezolid
2. Daptomycin
3. Tigecycline

Oral Antibiotics for MRSA

1. Bactrim
2. Clindamycin
3. Doxycycline

More on oral MRSA treatment here.

Empiric antibiotic therapy for gram negatives and anaerobes

Regimen Dose (Adult)* Comments

First choice
Monotherapy with a beta-lactam/beta-lactamase inhibitor:
E. coli resistance to Ampicillin-
Ampicillin-sulbactam sulbactam is emerging in some
3 g IV every six hours
[Amoxicillin Clav po at d/c] areas; check local susceptibility
data.
Piperacillin-tazobactam 3.375 or 4.5 g IV every six hours
Ticarcillin-clavulanate 3.1 g IV every four hours
Combination third-generation cephalosporin PLUS metronidazole:
Ceftriaxone plus 1 g IV every 24 hours or 2 g IV every
https://www.timeofcare.com/antibiotic-coverage/ 2/3
6/25/2020 Antibiotic Coverage | Time of Care

12 hours for CNS infections

Metronidazole 500 mg IV every eight hours
Alternative empiric regimens
Combination fluoroquinolone PLUS metronidazole:
Fluoroquinolones are generally
Ciprofloxacin or 400 mg IV every 12 hours avoided in pregnant women due to
potential fetal toxicity.
Levofloxacin plus 500 or 750 mg IV once daily
Metronidazole 500 mg IV every eight hours
Monotherapy with a carbapenem:
Imipenem-cilastatin 500 mg IV every six hours
Meropenem 1 g IV every eight hours
Doripenem 500 mg IV every eight hours
Ertapenem 1 g IV once daily

Antibiotic doses should be adjusted appropriately for patients with renal insufficiency or other dose-
related consideration.

https://www.timeofcare.com/antibiotic-coverage/ 3/3