Infectious Disease [ANTIBIOTIC LADDER]

Intro
The bugs that cause disease largely stay the same; the antibiotics
that treat them don’t. Case in point, Staph aureus was the most
common cause of osteomyelitis 50 years ago and still is today.
Abx Resistance means the drugs to treat are constantly evolving.
Cephalosporins
The earlier generations of cephalosporins (the 1st Generation)
were designed to cover strep and staph. As you move up the
generation ladder the amount of gram negative coverage
increases, but the staph coverage decreases.

In general, start with penicillin. It’s a cidal (kills bacteria) and 1st Generation Cephalosporins are used to cover skin infections
typically successful. such as regular ole’ cellulitis. Cefazolin.

There are two pathways from there - those that cover staph and
those that cover gram negative rods.
Staph
The Methicillins (oxacillin, cloxacillin, dicloxacillin, and
nafcillin) are very good at killing staph. Unfortunately, they’re all
really good at making MRSA. When sensitive to methicillin, any
of the –cillins should be used. In general, this isn’t empiric.
Vancomycin is the typical drug used for empiric coverage of
Staph. It covers MRSA. However, just because it’s a “big gun”
doesn’t imply it has broad coverage – it’s weak against everything
else.
3rd Generation Cephalosporins have sufficient gram negative
and positive coverage. They also cross the blood brain barrier.
They’re chosen first for meningitis and inpatient pneumonia.
Ceftriaxone.
4th Generation Cephalosporins means only Cefepime; it kills
pseudomonas. Like carbapenems, they’re reserved for
neutropenic fever or similarly immunosuppressed or severe
conditions.

Linezolid is top of the line. It’s the last resort for Vancomycin-
resistant Enterococcus (VRE) or Staph (VSA). Use this sparingly
- resistance to this means there’s nothing left.

Gram Negatives
To obtain gram negative coverage start with Amoxicillin or
Ampicillin together ( with or without a beta-lactamase
inhibitor). They don’t cover pseudomonas.

If pseudomonas coverage is needed, step up to Ticarcillin or

Piperacillin with a Beta-Lactamase Inhibitor. These also cover
gram positives (minus staph) and anaerobes. Use should be
restricted to pseudomonas to prevent resistance.

The Quinolones (Cipro, levo, gatti, and moxifloxacin) are oral

medications that kill a little bit of this and a little bit of that.
Ciprofloxacin covers gram negatives (UTIs) and has the same
bioavailability PO or IV Moxi has the gram negative coverage
but also gets some gram positives (Pneumonia).

The Aminoglycosides (gentamicin, amikacin) are synergistic

with penicillins but almost exclusively gram negative. This is
rarely the first choice for empiric treatment.

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 Infectious Disease [ANTIBIOTIC LADDER]

Anaerobes
Anaerobic coverage comes in many forms. Zosyn (Pip/Tazo) has
coverage, as do the penems. But when the focus is strictly on
anaerobes there are two options: metronidazole (gut and vagina)
and clindamycin (everywhere else).

Understanding Quinolones
The more advanced the generation of quinolone, the more
coverage it obtains. That’s to say, 1st generation ciprofloxacin has
gram negative coverage only; it’s used to treat associated gram
negative infections. Third generation moxifloxacin has additional
gram positive coverage, but DOESN’T LOSE its gram negative
application. This makes moxi a highly attractive medication to
use (single-agent, covers everything) – but it also breeds
resistance. Stay away from medications like this because they’re
rarely the right answer. No Quinolone covers Staph or
Pseudomonas, though Cipro can be used in “double-coverage” of
pseudomonas.

Pulling the trigger and going broad

In general, the goal’s to narrow the antibiotics to exactly what’s
being treated. For a staph infection, pick Nafcillin. For MRSA,
pick Vanc. For a UTI, pick Ampicillin or Cipro. For
pseudomonas, pick Zosyn.

But there will be a time when a person is just ill. They’re super
sick and missing the bug could be fatal. When the person is sick
as shit (think septic shock) it’s ok to just “go broad” – make sure
you get it all. This is why Vanc + Zosyn is so popular in the
hospital. It’s also why it will be the wrong answer on the test.
Once cultures and sensitivities come back, it’s then possible to
narrow the antibiotics. You can also de-escalate, one antibiotic at
a time, and assess the clinical response.
Condition Drugs
Penicillin Rash: Cephalosporins OK
Real Life Antibiotics Allergic Anaphylaxis: Cephalosporins NOT ok
Memorize the prevalence and patterns of infections and your MRSA Vancomycin, Linezolid, Daptomycin
institutions and use the empirically-derived-data for empiric Pseudomonas Pip/Tazo (Zosyn), Carbapenems, Cefepime
coverage. This is the list to the right. Outpatient Doxycycline, Azithromycin, Moxifloxacin
Pneumonia
Inpatient 3rd Gen Cephalosporin + Azithromycin (CAP)
Pneumonia Vancomycin + Zosyn (HAP)
Neutropenic 4th Gen Cephalosporin (Cefepime)
Fever Carbapenems
UTI TMP-SMX, Nitrofurantoin
Meningitis Vanc, Ceftriaxone, +/- Steroids, +/- Ampicillin
Cellulitis Cefazolin, Bactrim, Clindamycin
IV Vancomycin

© OnlineMedEd. http://www.onlinemeded.org