UNIVERSITY OF PERPETUAL HELP – DR. JOSE G.

TAMAYO MEDICAL UNIVERSITY

Dr. Jose G. Tamayo Medical University Learning Objectives:

1.Identify the different classifications of
antibiotics and give their mechanisms of actions

ANTIBIOTICS 101
Week II - FINALS

COLLEGEOFPHARMACY

UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

ANTIBIOTICS ANTIBIOTICS
Antibiotics are medicines that fight bacterial infections in people TYPES
and animals. They work by killing the bacteria or by making it • ANTIBACTERIALS
hard for the bacteria to grow and multiply. • ANTIFUNGALS
• ANTI-PARASITICS
• ANTIVIRALS

COLLEGEOFPHARMACY COLLEGEOFPHARMACY

UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

CELL WALLS
BACTERIA
• Made up of PEPTIDOGLYCAN; that contains peptides and
amino sugars mainly named NAM (NAcetylmuramic acid) &
NAG (N-Acetylglucosamine)
FUNGI
CELL WALL INHIBITORS
Week II - FINALS
• Made up of CHITIN; which is composed of NAcetylglucosamine
(NAG’S)
PLANTS
• Made up of CELLULOSE; which is composed of
monosaccharide units called glucose
COLLEGEOFPHARMACY COLLEGEOFPHARMACY
 UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

PENICILLINS PENICILLINS
2 rings: • Contains Beta Lactam Thiazolidine
Beta-Lactam Ring – cyclic amide; most Ring; called 6-APA (6-Amino
important chemical nucleus of Penicillanic Acid) or the PENAM RING
penicillin’s • Naturally occurring and Semi-
Thiozolidine Ring – sulfur containing synthethic can also be called
ring antibiotics
• “Antibiotics” produced from microbes
(fungi, bacteria)

COLLEGEOFPHARMACY COLLEGEOFPHARMACY

UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

PENICILLINS PENICILLIN G
• Came from the fungus named • Aka PEN G chemically known as
Penicillin notatum produces Pen G Benzyl Penicillin
then they improve by adding amino • Considered Drug of Choice (DOC) for
group called Amoxicillin Gram positive bacterial infections and
• Discovered by Alexander Fleming sexually-transmitted diseases such as
• Successfully isolate the chemical were “Syphilis”
Florey and Chain; used a very • It has mild adverse effects
important technique called freeze
drying or Lyophilization
COLLEGEOFPHARMACY COLLEGEOFPHARMACY

UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

PENICILLIN G PENICILLIN G
PROBLEMS AND REMEDIES PROBLEMS AND REMEDIES
• Acid-labile or acid sensitive; if drug is taken • Water insoluble; replace the hydrogen with Sodium and Potassium
orally it starts to degrade; only taken which is the salt forms of Penicillin making it water soluble already
intravenously or intramuscularly • Degraded by Beta-lactamase or Penicillinase; produced by
• Easily excreted; therefore they form Staphylococcus aureus which is resistant to Pen G
Depository (Depot) form of Pen G namely Pen
G Benzathine and Pen G Procaine; they also
combine Pen G & ‘Probenicid’ which is a
uricosuric acid (gout) that competes with the
active tubular secretion of Pen G
COLLEGEOFPHARMACY COLLEGEOFPHARMACY
 UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

PENICILLIN V
MECHANISM OF ACTION
• Aka PEN V chemically known as • Inhibition of the synthesis of peptidoglycan
Phenoxymethyl Penicillin GRAM (+) Bacteria
• It has an electron withdrawing group • Has a thick peptidoglycan; composed of 40 peptidoglycan layers cell
making it ‘acid stable’; it can be taken wall of bacteria
orally • If the cell wall is destroyed cell contains will be leak out that leads to
bacterial death
• Cell wall inhibitors are bactericidal

COLLEGEOFPHARMACY COLLEGEOFPHARMACY

UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

MECHANISM OF ACTION MECHANISM OF ACTION

• Inhibition of the synthesis of peptidoglycan PEPTIDOGLYCAN LAYER
GRAM (-) Bacteria • Peptido; peptides
• Has very thin peptidoglycan layer; only 1 peptidoglycan layer • Glycan; amino sugar named NAM & NAG
• More resistant than gram (+) bacteria because of their outer membrane • Glycan; amino sugar named NAM & NAG Alternating units of NAM &
that has antibiotic inactivating enzymes NAG are cross-link by a peptide; this step is called “transpeptidation”
• Transpeptidation is inhibited by penicillin’s and other beta-lactam
antibiotics

COLLEGEOFPHARMACY COLLEGEOFPHARMACY

UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

MECHANISM OF ACTION INSTABILITY OF PENICILLINS

• Pen G and Pen V are called as natural penicillin’s; which are naturally • In the stomach and being unable to affect Gram negative
produced by Penicillium notatum and Penicillium chrysogenum bacteria led to the development of “Extended-spectrum
• Rapidly absorbed, rapidly excreted
Penicillins”
• Sparingly soluble salts are then formulated AKA depot forms of
• Other group of Penicillins:
Penicillin:
• Pen G Benethamine
• Pen G Procaine
• Pen G Benzathine

COLLEGEOFPHARMACY COLLEGEOFPHARMACY
 UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

INSTABILITY OF PENICILLINS INSTABILITY OF PENICILLINS

• Aminopenicillins • Carboxypenicillins;
• effective to both gram (-) & gram (+) bacteria; • employed for the treatment of Gram (-) infection particularly Klebsiella
• it is polar which can pass thru the outer membrane of gram (-) bacteria; and Pseudomonas (drug resistant)
they are degraded by the enzyme “betalactamase”, making them
sensitive to it • Ureidopenicillins; derivative of urea
• they added beta-lactamase inhibitors like Clavunalic acid and
Sulbactam which is called Amoxiclav; examples of drugs are
amoxicillin and ampicillin which are not effective against staphylococcal
infection and gram (-) bacteria
COLLEGEOFPHARMACY COLLEGEOFPHARMACY

UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

CARBOCYPENICILLINS
• Carbenicillin – 1 st antipseudomonal PCN; caused by pseudomonas
aeruginosa (drug resistant)
• Carbenicillin Indanyl Sodium – derivative and given orally for UTIs
• Ticarcillin – same activity with Carbenicilllin
EXTENDED SPECTRUM
PENICILLINS
Week II - FINALS

COLLEGEOFPHARMACY COLLEGEOFPHARMACY

UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

UREIDOPENICILLINS ANTI-PSEUDOMONAL
• Derivative of Urea
•C – Carbenicillin
• Mezlocillin, Azlocillin, Piperacillin (most potent)
• All active against Gram negative bacilli such as Klebsiella pneumoniae •T – Ticarcillin
• Also active against Pseudomonas aeruginosa
• Also degraded by beta-lactamase; thus they added beta-lactamase
•M – Mezlocillin
inhibitors; examples: Piperacillin (antibiotic) + Tazobactam (BLI) = •A – Azlocillin
Piptaz® ,Tazocin® & Piper-Tazo®
•P – Piperacillin (most potent)

COLLEGEOFPHARMACY COLLEGEOFPHARMACY
 UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

ANTISTAPHYLOCOCCAL PENICILLINS ANTISTAPHYLOCOCCAL PENICILLINS

• Strains of Staphylococcus became resistant and started producing an • Orally active
enzyme, Beta-lactamase (penicillinase); which may inactive PCNs by • Food interferes with absorption
opening the B-lactam ring • EXAMPLES
• Antistaphylococcal PCNs are semisynthethic PCNs intended for • Methicillin: 1st B-lactamase Resistant Penicillin; however it causes
infections caused by B-lactamase/ Penicillinase producing Staph, but interstitial nephritis
some Strep and Pneumococci are also susceptible • Nafcillin; can’t be administered orally
• Used as monotherapy because of Bulky group that protects beta- • Oxacillin
lactamine; it’s called steric hindrance • Cloxacilin; has 1 chlorine
• Dicloxacillin; has 2 chlorine
• Flucloxacillin ; 1 fluorine & 1 chlorine
COLLEGEOFPHARMACY COLLEGEOFPHARMACY

UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

NOTE
• Oxacillin, Cloxacilllin & Dicloxicillin are called Isoxazolyl Penicillins
(Halogens); can be orally administered

• 4 GROUPS OF PCNS
BACTERIAL RESISTANCE TO
1. Natural – Pen g & Pen V
PENICILLINS
2. Amino – Amox & Ampi Week II - FINALS
3. Anti-pseudonomal – CT MAP
4. Anti-Staph – MN OCDE

COLLEGEOFPHARMACY COLLEGEOFPHARMACY

UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

BETA LACTAMASE
• Enzyme that catalyzes opening of the beta lactam ring to produce
peniicilloic acid
• Several strains are resistance due to altered penicillin binding proteins;
MOA – inhibits transpeptidation
• Some strains are resistant decreased entry or active efflux of antibiotic
BETA LACTAMASE INHIBITORS
Week II - FINALS

COLLEGEOFPHARMACY COLLEGEOFPHARMACY
 UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

CLAVULANATE POTASSIUM, USP SULBACTAM

• Isolated from Streptomyces clavuligerus
• Beta lactamace inhibitor that achieves synergistic effects with
• Irreversibly binds to beta lactamase in both Gram (+) & Gram (-)
Ampicillin and Carbenicillin
bacteria
• Ampicillin + Sulbactam
• Amoxicillin + Clavulanic acid
• Aka Sultamicillin (Unasyn®)
• Aka Co-amoxiclav (Augmentin®)
• Ticarcillin + Clavulanic acid (Tinmentin®)

COLLEGEOFPHARMACY COLLEGEOFPHARMACY

UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

TAZOBACTAM
• More potent than sulbactam and slightly broader activity than
clavulanic acid
• Piperacillin + Tazobactam (Zosyn®, Piptaz®, PiperTazo® &
Tazocin®)
CEPHALOSPORINS
Week II - FINALS

COLLEGEOFPHARMACY COLLEGEOFPHARMACY

UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

CEPHALOSPORINS 1ST GENERATION CEPHALOSPORINS

• Belong to Genus Cephalosporium spp • More effective against gram-positive
(fungi) bacteria than on gram-negative bacteria
• Structure: consists of a six-membered • Excellent gram-positive and modest gram-
dihydrothiazine ring fused to a beta negative activity
lactam ring; called 7-ACA (Amino • Alternatives for skin and soft-tissue
Cephalosporanic Acid) infections, as well as for streptococcal
• Broad spectrum and more resistant to pharyngitis
beta lactamase inactivation than • Cefadroxil, Cephalexin, Cephaloridine,
penicillins Cephalothin, cephapirin, Cefazolin,
Cephradine
COLLEGEOFPHARMACY COLLEGEOFPHARMACY
UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

1ST GENERATION CEPHALOSPORINS 2ND GENERATION CEPHALOSPORINS

• SPECTRUM • Equally effective against gram-positive
• S – Staphylococcus/ Streptococcus and gramnegative bacteria; if the
• P – Proteus (1 of the causative of UTI) causative agent is unknown it is good to
• EC – E. coli suggest 2nd generation
• K – Klebsiella • Have somewhat better activity against
gram-negative organisms with some
gram-positive action

COLLEGEOFPHARMACY COLLEGEOFPHARMACY

UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

2ND GENERATION CEPHALOSPORINS 2ND GENERATION CEPHALOSPORINS

• Include some agents with anti-anaerobe • SPECTRUM
activity • H – Haemophilus
• Treating URTI, LRTI, sinusitis and otitis • E – Enterobacter
media • N – Neisseria
• Active against E. coli, Klebsiella and
Proteus • S – Staphylococcus/ Streptococcus (G +)
• Cefaclor, cefoxitin, Cefprozil, • P – Proteus (1 of the causative of UTI)
Cefuroxamine, • EC – E. coli
• K – Klebsiella

COLLEGEOFPHARMACY COLLEGEOFPHARMACY

UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

3RD GENERATION CEPHALOSPORINS 3RD GENERATION CEPHALOSPORINS

• Activity against gram-positive organsims • SPECTRUM
and much more activity gainst the • B – Borrelia
• P – Pseudonomas
Enterobacteriaceae, with a subset active
• H – Haemophilus
against Pseudonomas aeruginosa • E – Enterobacter
• Broad-spectrum antibiotics • N – Neisseria
• Cefdinir, Cefixime, cefpodoxime, • S – Staphylococcus/ Streptococcus (G +)
Ceftibuten, Ceftriaxone, Cefotaxime, • P – Proteus (1 of the causative of UTI)
Ceftqzidime, Moxalactam (MX3), • EC – E. coli
• K – Klebsiella
Cefaperazone

COLLEGEOFPHARMACY COLLEGEOFPHARMACY
of 4 of 4

UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

4TH GENERATION CEPHALOSPORINS 4TH GENERATION CEPHALOSPORINS

• Equally effective against gram-positive • Cefepime, Cefluprenam, Cefozopran,
and gramnegative bacteria but have Cefpirome, Cefquinome
extended spectrum against negative gram
bacteria compared to the other • SPECTRUM:
generations • P – Pseudonomas
• Known as reserved agent • E – Enterobacter
• Encompass the antimicrobial spectrum of • N – Neisseria
all the thirdgeneration agents and have • S – Staph, Strep`
increased stability to hydrolysis by
inducible chromosal-lactamases
COLLEGEOFPHARMACY COLLEGEOFPHARMACY

of 4 of 4

UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

ORAL CPNs BETA-LACTAMASE RESISTANT BETA-LACTAMASE RESISTANCE

• Cefuroxime axetil – 2 nd Gen • LEAST RESISTANT
• Cefodoxime proxetil – 2 nd Gen • Cephaloridine and Cefazolin administered parenteral
• Other oral CPNs:
• Cephalexin – 1 st Gen • MOST RESISTANT
• Cephradine – 1 st Gen • Cephalotin and Cefoxitin – administered parenteral
• Cefadroxil – 1 st Gen
• Cefaclor – 2 nd Gen
• Cefprozil – 2 nd Gen
• Loracarbef – 2 nd Gen
• Cefixime – 3 rd Gen

COLLEGEOFPHARMACY COLLEGEOFPHARMACY

of 4 of 4

UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

ANTIPSEUDOMONAL CPNs ADRs and DI of CEPHALOSPORINS

Mostly 3rd or 4th generation • Caused Hypoprothrombinemia – bleeding
• Cefoperazone – 3 rd • Deficiency of the clotting factor prothrombin in the blood,
• Cefotaxime – 3 rd which results to an increased tendency to bleed
• Ceftriaxone – 3 rd • Due to inhibition of vitamin K
• Ceftazidime – 3 rd • DI: anticoagulants and warfarin
• Cefamadole, Cefotetan, Cefmetazole, Moxalactam,
• Cefepime – 4 th
Cefoperazone
• Cefpirome – 4 th • Monitor: PT-INR; prolong PT-INR means there is bleeding

COLLEGEOFPHARMACY COLLEGEOFPHARMACY
of 4

UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

ADRs and DI of CEPHALOSPORINS

• Caused Disulfiram – like reactions
• Disulfiram (Antabuse®)
• Alcohol deterrent inhibits the enzyme aldehyde
dehydrogenase; responsible for the oxidation of aldehyde
particularly acetyldehyde; alcohol dehydrogenase
enzyme catalyzes oxidation of ethanol to acetaldehyde;
MONOBACTAMS
Week II - FINALS
causes signs and symptoms of alcohol intoxication

COLLEGEOFPHARMACY COLLEGEOFPHARMACY

of 4 of 4

UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

MONOBACTAMS AZTREONAM
• Binds with PBP3 in gram-negative bacteria only
• Only has the beta-lactam • Even called “Magic Bullet for Pseudonomas”
ring and only effective • E.g: E. coli, Klebsiella, Proteus, Serratia,
against gram-negative Citrobacter and Pseudonomas
bacteria • Treats:
• UTI
• LRTI
• Intra-abdominal infection
• Gynaecological infection
• Septicimia
COLLEGEOFPHARMACY COLLEGEOFPHARMACY

of 4 of 4
of 4 of 4
of 4 of 4

UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

TIGEMONAM CARBAPENEM
• Administered Orally (PO) • Olivanic acids, Thienamycin, Imipenem, Meropenem,
• Resistant to beta-lactamases Ertapenem
• Treats • Comprise a family of fused beta-lactam rings
• UTI • Has broadest antimicrobial spectrum of any antibiotic
• Non-life threatening infections by Mos without beta- • Analogues of penicillins or clavams, the sulphur or oxygen
lactamase
being replaced with carbon
• Considered as the last line of agents against bacterial
infections.
• Reserved agents that are resistant to other antimicrobial
agents
COLLEGEOFPHARMACY COLLEGEOFPHARMACY
of 4 of 4
of 4 of 4
of 4 of 4

UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

OLIVANIC ACIDS THIAMYCINS

• Broad-spectrum antibiotics • Broad spectrum with high beta-lactamase resistance
• Potent inhibitors of beta-lactamase • Chemically unstable
• Naturally – occurring beta-lactam antibiotics • Not available in the market anymore
• Isolated from culture fluids of Sterptomyces olivaceus
• Not available in the market anymore

COLLEGEOFPHARMACY COLLEGEOFPHARMACY

of 4 of 4
of 4 of 4
of 4 of 4

UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

IMIPENEMS MEROPENEM
• N – Formimidoyl derivative of thienamycin that is very • Dimethylcarbomoyl pyrolidinyl derivative of thienamycin
resistant to beta-lactamase • More stable against dehydropeptidase enzyme
• From Streptomyces cattleya • Meropenem (Merrem IV®)
• Readily hydrolysed by renal dehydropeptidase (DHP)
• Highly nephrotoxic
• Imipinem + Cilastatin (DHP-inhibitor) (Primaxin®), Tienam®

COLLEGEOFPHARMACY COLLEGEOFPHARMACY

of 4 of 4
of 4 of 4
of 4 of 4

UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY

ERTAPENEM OTHER CELL WALL INHIBITORS

• Similar properties with meropenem but administered less • Fosfomycin
frequently • Beta Lactams
• Effective against Gram-positive bacteria. • Bacitracin
• Cycloserine
• Vancomycin
• RED MAN SYNDROME

COLLEGEOFPHARMACY COLLEGEOFPHARMACY