Supporting document of how to choose empirical antibiotics in ICU video lecture

Dr. Ankur Gupta, Intensivist, Video link: https://youtu.be/xoWKR_suFq0

Common antibiotics classification

Cell wall Protein synthesis DNA replication
Beta-lactam antibiotics Rifamycins Sulfa drugs
• Penicillins Aminoglycosides Quinolones
• Cephalosporins Macrolides Metronidazole
• Carbapenems Tetracylines/Glycylcyclines
• Monobactam Chloramphenicol
Glycopeptides Clindamycin
Daptomycin Linezolid
Colistin/Polymyxin-B Nitrofurantoin

Class /mechanism Generic names G+ G- An. At. Remarks

Abx that target cell envelope
Beta lactam abx
Penicillins Atypical bugs not affected as they do not have cell wall.
1. Natural Pencillins Pencillin G Streptococci
Penicllin V ! ! ! 🗴
2. Antistaphlylococcal Nafcillin Bulky side chains prevent
Penicillins Oxacillin binding by beta lacatamases.
Dicloxacillin ! 🗴 🗴 🗴 Used for S. aureus and S.
epidermidies
NOT MRSA And MRSE
3. Amino penicillins Ampicillin Amnio grp in side chain ,
Amoxicillin
! ! ! 🗴 increases hydrophlicity , helps
penetrates through porins Gm-ve
bact.
4. Aminopenicillins / Ampicillin – Very broad spectrum
beta-lactamase sulbactum Except C.difficle
inhibitors Amoxicillin- 🗸 ! 🗸 🗴
combinations clavulanate
5. Extended spectrum
penicillins
Piperacellin
Ticaracillin
! ! ! 🗴 Side chain allows greater
penetration into gram-ve bact.
6. Extended spectrum Piperacellin – 🗸 🗸 🗸 🗴 Very broad spectrum
penicillins / beta- tazobactum Except C.difficle
lactamase inhibitors Ticarcillin-
combinations clavulanate
Cephalosporins Gram –ve activity increases with each generation except 5th gen.
1. First Generation Cefazolin
Cefadroxil
! 🗴 🗴 🗴 Staphyloccoci NOT MRSA And MRSE
and streptococcoi

2. Second Generation Cefotetan*

Cefoxitin*
! ! ! 🗴 More bugs
potent against gram –ve

(*cephamycins) Cephamycins have moderate

Cefuroxime anaerobic activity
3. Third generation Cefotaxime
Ceftazidime
! 🗸 🗴 🗴 Enhanced ve bugs.
activity against gram-

Ceftriaxone Resistance common, should be

Cefoparazone used in combination. (Amp-C

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ESBICM – Educational Society of Bedside Intensive Care Medicine
 Supporting document of how to choose empirical antibiotics in ICU video lecture
Dr. Ankur Gupta, Intensivist, Video link: https://youtu.be/xoWKR_suFq0

beta-lactamase)
Only ceftazidime active against
P. aeruginosa at the cost of
antisphyloccoal activity.
Ceftriaxone long half-life.
4. Fourth Generation Cefepime
! 🗸 🗴 🗴 Enhanced activity against P.
aeruginosa without
compromising gram+ve cocci
activity.
5. Fifth Generation 🗸 🗸 ! 🗴 Active against MRSA and
MRSE
Carbapenems Quite small and have charge characteristics allows to penetrate gm-ve bugs.
Enterococcus faecium and MRSA intrinsically resistant.
🗸 🗸 🗸 🗴
Imipenem-cilastatin Not active against C.difficle
Highest seizure activity.
Meropenum
Doripenem Least seizure risk
Lower rate of resistance to P.
aeruginosa
Ertapenem Once a day dosing
Less active against P.
aeruginosa
Monobactams Aztreonam 🗴 🗸 🗴 🗴 Not nephrotoxic
Only active against gm-ve
Can be used in patients allergic
to pencillins.
Glycopeptides Very large molecule, active against gm+ bugs only.
Poorly absorbed orally; must be given IV only.
🗸 🗴 ! 🗴
Vancomycin MRSA
Active against C.difficle (orally)
Hearing loss, red man syndrome
, neutropenia
Teicoplanin MRSA
Thrombocytopenia
Lipopeptide Daptomycin 🗸 🗴 ! 🗴 MRSA, VRE, Pencillin resistant
streptococci
Causes reversible myopathy
Poor activity in lungs( should
not be used to treat pneumonia)
Polymyxin grp. Colistin 🗴 🗸 🗴 🗴 Positively charged, causes cell
lysis.
Nephrotoxic
Polymyxin-B 🗴 🗸 🗴 🗴 Active drug and relatively renal
safe.
Abx that that block protein
production
Rifamycins Potent inducers of cytochrome-P-450 system
! 🗴 🗴 🗴
Rifampin Used is TB.

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ESBICM – Educational Society of Bedside Intensive Care Medicine
 Supporting document of how to choose empirical antibiotics in ICU video lecture
Dr. Ankur Gupta, Intensivist, Video link: https://youtu.be/xoWKR_suFq0
Aminoglycosides
Macrolides
Tetracyclilnes and
Glycylcyclines
Chloramphenicol
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Most potent inducer of
cytochrome-P-450 system
Orange discolouration of tears,
urine and other body fluids.
Rifabutin Less potent inducer of
cytochrome-P-450 system
Can be used as an alternative to
rifampin in HIV patients .
Rifapentine Long half life , once a week
dose in TB.
Rifaximin Treatment of travellers’
diarrhoea.
Positively charged , quite large (but smaller than glycopeptides). Easily penetrate
gm-ve bugs. Works poorly in anaerobic conditions and acidic environment (like
abcesses). Resistance is not always class-wise. Can be used in low doses with
beta-lactams for synergistic doses. Nephrotoxic and ototoxic.
! 🗸 🗴 🗴
Streptomycin TB
Gentamicin Both gm+ve and gm-ve
Tobramycin Lacks activity against
enterococci.
Amikacin Can be used if resistant against
gentamicin and tobramycin.
Lacks activity against
enterococci
Resistance to one macrolide grp usually implies to resistance to all members.
Thrombophlebitis and QT prolongation. Inhibitor of cytochrome-P-450 system.
Blurred vision.
! ! 🗴 !
Erythromycin Less useful for respiratory
infections as lacks activity
against H.influenzae
Clarithromycin
Azithromycin Taken up in tissues and released
over subsequent days.
Not to be given to children and pregnant women. Phototoxicity.
🗴 ! ! 🗸
Tetracycline
Doxycycline Long half life
Minocycline MRSA
Blue black hyper-pigmentaion
of skin and mucus membranes.
Tigecycline 🗸 🗸 🗸 🗸 Very broad spectrum, MRSA,
VRE, Acinetobactor spp.
Anaerobic activity less than
carbapenems and pipercillins.
Not active against P.aeruginosa
and Proteus spp.
! ! 🗸 🗸 Bone marrow suppression
 Supporting document of how to choose empirical antibiotics in ICU video lecture
Dr. Ankur Gupta, Intensivist, Video link: https://youtu.be/xoWKR_suFq0

Clindamycin
! 🗴 ! 🗴 Causes Clostridium difficile
colitis.
Active against community
acquired MRSA
Linezolid 🗸 🗴 🗴 🗴 Gram-ve bugs intrinsically
resistant.
Completely synthetic drug.
Should not be used with MAO
inhibitors (causes serotonin
syndrome). Pancytopenia.
Metabolic acidosis.
Nitrofurantoin ! ! 🗴 🗴 Only for cystitis
Accumulates in urine.
Abx that target DNA
replication.
Sulpha drugs ! ! 🗴 🗴
Trimethoprim- Steven Johnson syndrome
Sulfamethoxazole
Dapsone For leprosy

Quniolones Causes cartilage abnormalities, Achilles tendon rupture. QT prolongation.

! 🗸 ! 🗸
Ciprofloxacin Most potent of quinolones
against gram –ve organisms
including Psuedomonas
aeruginosa.
Weak against gram+ve ones.
Levofloxacin Active against grm+ve and –ve
ones. But less against
Psuedomonas aeruginosa.
Ofloxacin Less potent than levofloxacin.
Moxifloxacin More active against S.
Gemifloxacin pneuomanie (including pencillin
resistant strains).
Some activity against anaerobes.
Metronidazole 🗴 🗴 🗸 🗴 Very small molecule and diffuse
very fast. Disulfiram like
reaction.

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ESBICM – Educational Society of Bedside Intensive Care Medicine
 Supporting document of how to choose empirical antibiotics in ICU video lecture
Dr. Ankur Gupta, Intensivist, Video link: https://youtu.be/xoWKR_suFq0

Gram +ve bacteria Gram –ve bacteria Atypical bacteria

Staphylococci1 Enterobacteriaceae2 Legionella
Pneumococci Pseudomonas Chlamydia
Other Streptococci Neisseria Mycoplasma
Enterococci H. Influenzae Brucella
Listeria monocytogenes Campylobacter jejuni3 Rickettsia
B. anthracis Helicobactor pylori3
Acinetobactor
Anaerobic bacteria Spirochetes Mycobacteria
Clostridia4 Treponema pallidum M. tuberculosis
Bacteroides Borrelia burgdorferi M. avium complex
Leptospira interrogans M. leprae

1. S. pyogenes, S. agalactiae, S. viridians

2. E.coli, Klebsiella, Proteus spp., Salmonella enterica, Shigella spp.,
3. V. cholera
4. C. perfringens, C. botulinum, C. tetani , C. difficlie

Summary of common bacteria

Bacteria Remarks
Gram positive
Staphylococcus Resistant to heat and drying. Persist on fomites for longer time.
aureus Skin and soft tissue infections, TSS, pneumonia, endocarditis,
osteomyelitis, bacteraemia . Produces lots of toxins.
Staphylococcus Infections involving foreign objects (catheters, valves, joints).
epidermedies
Pneumococci Boldly and forcefully attack the human body. Human are carriers.
CAP, sinusitis , meningitis, otitis media.
S. pyogenes Pharyngitis, skin and soft tissue infections, TSS.
S. agalactiae Colonolize female genital tract . sepsis and meningitis in neonates.
S. viridans Colonise the human GI and urogenital tract. Infective endocarditis and
abscesses.
Enterococci Fickle residents of human GI tract. Intraabodominal infections, uti,

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ESBICM – Educational Society of Bedside Intensive Care Medicine
 Supporting document of how to choose empirical antibiotics in ICU video lecture
Dr. Ankur Gupta, Intensivist, Video link: https://youtu.be/xoWKR_suFq0

wound infections,endocarditis , bacteremia,

Highly resistant to drugs (bacterocidil drugs are bacteriostatic against
it) . E. faecium more resistant than E. faecalis.
Listeria (bacillus) Widespread in soil and fecal flora of many animals. gasteroenteritis in
healthy subjects and meningitis in immunocompromised people.
Bacillus anthracis Spore forming bacillus. Inhalational, cutaneous, GI anthrax. (central
black eschar. ) hemorraghic mediastinal adenopathy, bloody pleural
effusions, bacteraemia)
Gram negative
Enterobacteriaceae Most of inhabiting the human GI tract. Opportunistic pathogens.
(bacilli) Nosocomial infections .
E.coli Gasteroenteritis , meningitis (neonates)
Klebsiella CAP. HCA infections , UTI, HAP, bacterimia, wound infections, intra-
abdominal infections.
Proteus spp.
Pseudomonas Opportunistic pathogens. Normal inhabitant soil, water, plant, animals.
(bacilli) HAP, wound infections, uti. Very fast develops resistance.
Always should use 2 abx from 2 different groups .
Nessiria (diplococci)
N. meningitis
N. gonorrhoeae Genitourinary tract and skin and soft tissue infections.
Campylobacter Gasteroenteritis (colonoise wild and domestic animals ) . infection
through contaminated food and water.
H. plyori Peptic ulcer disease
H. influenza Cap, meningitis, sinusitis , otitis media, conjcuctivitis, septic arthritis.
(pleomorphic) Droplet infection
Acinetobacter (rod Wound infections, pneumonia , bacteremia
shaped and coco- Soil organaisms (trauma patient)
bacilli)
Anaerobic
Clostridia (positive)
C. tetani
C. botulinum
C. perfringens
C. difficle
Bacteroides Oral cavity, gi tract, vagina.
PID, pulmonary infections, periodontal, intra-abdominal abscesses.
Atypical bacteria
Chlamydia Obligate intracellular bug,
CAP , eye infections. STD
Mycoplamsa Smallest living organism , pneumonia .
Legionella Inhabit natural and man made water.
Pneumonia with altered sensorium and hyponatremia . also liver and
renal involvement.
Brucella (cocco- Transmitted through animals. Milk and milk products (cheese).
bacilli) Prolonged fever.
Rickettsia gram Obligate intracellular organism.
negative Arthropod borne infections, rash and eschar.
Spirochetes
Treponema pallidum STD
Borrelia burgodoferi Lymes disease (cardiac disease, meningitis, arthritis, rash)
Leptospira Urine of domestic and wild animals . hepatitis, renal disease,

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ESBICM – Educational Society of Bedside Intensive Care Medicine
 Supporting document of how to choose empirical antibiotics in ICU video lecture
Dr. Ankur Gupta, Intensivist, Video link: https://youtu.be/xoWKR_suFq0

meningitis. Febrile illness.

Mycobacteria
M. tuberculosis
M. avium complex
M. leprae

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