Antibiotics for Family Physicians -...
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Antibiotics for Family Physicians
Sarah E. Allen, MD
November 28, 2012
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“I just use imipenem for everything.”
--Anonymous Physician
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Dr. Allen’s lecture was like…
“…like having the PDR read to me.”
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Antibiotics 2012
• Penicillins
• Cephalosporins (23)
• Monobactam (Aztreonam)
• Carbapenems
• Aminoglycosides
• Clindamycin
• Daptomycin
• Linezolid
• Sulfa
• Metronidazole
• Fluoroquinolones
• Rifamycin
• Macrolides
• Fosfomycin
• Tetracyclines
• Colistin
• Nitrofurantoin
• Synercid
• Vancomycin
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Staphylococci Streptococci Enterococci Gram positive anaerobes (Mouth, Peptostrep, Clostridium) Gram negative anaerobes (Below the belt, Bacteroides)
E. Coli Klebsiella Enterobacter
Pseudomonas
Montessori Microbiology
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Staphylococci Streptococci Enterococci
Gram positive anaerobes (Mouth, Peptostrep, Clostridium) Gram negative anaerobes (Below the belt Bacteroides) E. Coli Klebsiella Enterobacter
Pseudomonas
Montessori Microbiology
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Montessori Antibiotics* *Dr. Allen is still working on this
Gram Positives Gram Negatives Vancomycin----------------------- Nafcillin Daptomycin------------------- Linezolid----------------------- Cefazolin--------------------- ------------------- Penicillin----------------------------- Bactrim---------------------------- ----- Clinda- - - - - ------------------------------------------------ Minocycline- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - > --------------Flagyl --------------------------------------------------------------------------ertepenem ----------------------------------- ------------------gentamicin ---------------------------------- ------------------tobramycin Moxiflox------------- - - - - - - - - - - ---------------------------------------- Cipro---- ---------------------Cipro-- ----------------------------- ------------------cefepime --------------------------------------------------------------------------------------------imipenem
+ Anaerobes -
M R
S A
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For Today…
• Principles of antibiotic use
• Staph antibiotics
• Making sense of the #$*# beta-lactam class – Penicillins – Cephalosporins – Carbapenems
• 2 more classes – Macrolides – fluroquinolones
• Please invite me back for Parts 2-????!
– UTI – Respiratory Tract infections (sinus, ear, lungs) – Sepsis – Diabetic Feet – OPAT services
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Principles of Antibiotic Use in the outpatient setting
• Try not to use antibiotics • Education
– Resistance – Superinfection (Yeast, C. Diff)
• Safety Net Antibiotic Prescription (SNAP) – Ear infections in children – Sinus infections – Bronchitis
• Prevention of infection – Immunization – Treat underlying disease
• Allergies
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Principles of Antibiotics in the inpatient setting
• Guidelines can be helpful
• Stanford can be helpful
• Shotgun approach is often necessary – Vancomycin + Zosyn
– Await cultures, further evaluation, consultation
• Use “cidal” antibiotics rather than “static”
• Use complimentary mechanisms of action
• Narrow antibiotic spectrum if you can
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Mechanisms of Action
• “Oh please, Dr. Allen, not that!” • Cell wall antibiotics
– Beta-lactams – Vanco – Daptomycin
• Protein synthesis antibiotics – Clindamycin – Macrolides
• Ribosomal antibiotics – aminoglycosides
• DNA gyrase (supercoiling) antibiotics – Cipro
• Folate synthesis antibiotics – Sulfa drugs
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Staphylococcus (Catalase producers)
Coagulase Producing
• Staph aureus
Coagulase negative
• Coagulase Negative Staph
• CONS
• Staph epidermitis
• Staph saprophyticus
• Staph everythingelseicus
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Staphylococcus Aureus
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Staphylococcus aureus
Methicillin Sensitive
• Methicillin sensitive
• Oxacillin sensitive
• Nafcillin sensitive
• Dicloxacillin sensitive
• Cephalosporins sensitive
Methicillin Resistant
• Methicillin resistant
• Oxacillin resistant
• Nafcillin resistant
• Dicloxacillin resistant
• Cephalosporin resistant – Except Ceftaroline
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Outpatient Staph Treatment
MSSA
• Keflex
• Augmentin
• Dicloxacillin
MRSA
• Minocycline (doxycycline)
• Bactrim
• Clindamycin
• Zyovx $$$$
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Prevention of Staph Skin Infectious
• What is the underlying skin condition?
• The skin is the portal of entry
• Eczema, psoriasis, dry skin, contact dermatitis, acne, prurigo nodularis, shaving, deodorant, onychomycosis, athlete’s foot, excessive hand-washing
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Very early home treatment for Staph
• Wet warm soaking – Heat brings blood to the area
– Must be wet heat
– Apply warm (almost hot) wash cloth repeatedly
– Soak in warm water in bath or bucket
• Apply topical anti-Staph ointment – Gentamicin (ophthalmic ointment)
– Mupiricin
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Inpatient Staph Infections
MSSA
• Nafcillin
• Beta-lactamase inhibitor – Unasyn
– Zosyn
• Cefazolin
MRSA
• Vancomycin
• Bactrim
• Clindamycin
• Ceftaroline
• Tigecycline
• Zyvox
• Daptomycin
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Beta-Lactams
• Penicillins
• Cephalosporins
• Carbapenems
• Monobactam
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Penicillins
• Penicillins
• Ampicillins
• Pseudomonas Penicillins
• Beta-lactamase inhibitor antibiotics
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Penicillin
• A drug for streptococcus
• No Staph coverage
• “Pssst!”
– A very few gram-negative organisms (Neisseria)
– Syphilis
– Mouth anaerobes (dentists use PCN all the time!)
– Human, dog, cat bite organisms
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Ampicillin
• A drug for Streptococcus
• A drug for Enterococcus (usually with Gent)
• Some H. Flu (non-beta-lactamase producers)
• No Staph Coverage
• “Pssst!” – This has a little better gram negative coverage than
penicillin but is pretty weak.
– Few E. Coli for UTIs
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Pseudomonas Penicillins
• Piperacillin
• Has beens: Ticarcillin
• Once in a while: carbenicillin (oral)
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Piperacillin
• This is not the same as Zosyn=Pip/Tazo
• Piperacillin – This is a drug for Streptococcus
– A drug for Pseudomonas and other gram negatives
– No Staph coverage
• Pit falls – Not a drug for Staph
– Not for all H. Flu (only those without B-lactamase)
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Beta-Lactamases and their inhibitors!!
• Beta-Lactamases – Many, many types
– Destroy all penicillins
• Enter the Beta-Lactamase inhibitors – Molecules that suck away beta-lactamases
– act as a decoy • Clavulanate
• Sulbactam
• Tazobactam
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B-Lactams + B-Lactamase inhibitors
• Amoxicillin + Clavulanate (Augmentin)
• Ampicillin + Sulbactam (Unasyn)
• Piperacillin + Tazobactam (Zosyn)
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B-Lactams + B-Lactamase inhibitors
• Amoxicillin + Clavulanate (Augmentin) • Ampicillin + Sulbactam (Unasyn)
• Parent drug (Amp/Amox)
– A drug for Streptococcus – Wimpy Gram negative coverage – Oral anaerobes, but not below the belt Bacteroides
• Parent drug + inhibitor – Saves the parent! – Allows “wow” broad spectrum coverage
• Staph (MSSA)* • E. Coli • Klebsiella • Bacteroides fragilis!!!!
• *Remember: MRSA=resistance to all B-lactams
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B-Lactams + B-Lactamase inhibitors
• Piperacillin + tazobactam = Zosyn
• Parent drug: piperacillin • Strep + Anti-pseudomonal gram-negative coverage • No better than penicillin for anaerobes (mouth) • No Staph coverage
• Zosyn • “wow” coverage
• Staph (MSSA) coverage • Pseudomonas • Better gram-negative coverage for more B-lactamase producers • Below the belt anaerobic coverage (Bacteroides)
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Why do we need broad spectrum drugs?
• In a perfect world, there would be one drug for each bug we want to kill – More drugs like nafcillin (just Staph/MSSA) – Fewer drugs like imipenem (everything except MRSA +
Stenotrophomonas)
• Broad spectrum drugs are used for
– Empiric treatment • Pneumonia • Neutropenic fever • Sepsis
– Polymicrobial treatment • Bite wounds • Abdominal sepsis • DM foot ulcers
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ESBL: Extended Spectrum Beta Lactamase Producing Bacteria
• Patients with recurrent UTIs • Do not use Zosyn even if it’s listed as sensitive!! • Use a carbapenem • All carbapenems
– have great anaerobic coverage – Very broad spectrum (Staph to Pseudomonas)
• Unique mechanism (porin entry) – Ertepenem
• Once a day • No anti-Pseudomonal coverage
– Imipenem – Meropenem – Doripenem
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Cephalosporins
• PDR time! • Stanford lists over 20 • Most of the “useful” Cephalosporins
– MSSA – Streptococcus/Pneumococcus – E. Coli – Klebsiella
• Cefazolin IV (Orthocillin) • Cephalexin PO (Orthocillin) • Ceftriaxone (Home-a-cillin): meningitis, SBP, PNA • Cefepime (anti-Pseudomonal)
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Fluoroquinolones
• Unique mechanism – DNA gyrase inhibitor – Prevents supercoiling of DNA – The Cell is a mess of DNA strewn everywhere!
• Cipro – Staph/MSSA – Pseudomonas and other gram negatives
• Moxifloxacin – Better Strep (respiratory flora) – Anaerobic coverage – No Pseudomonas – No UTI!!!!
• Ask every patient if they take chalky antacids or “divalent cations” (Ca, Fe, Zn, Mg)
• Adverse reactions: CNS, sun-exposure, QT prolongation
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Macrolides
• Zithromax for President! – “Respiratory” infections
• Sinus, ears, lungs
– “Recreation” infections • Chlamydia
• GC
• Remember Biaxin (Clarithromycin)? – MAC treatment
– H. Pylori
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Take Home Points
• This is complicated stuff!
• Please call PALS anytime.
• Don’t you think there should be an antibiotic ECHO?
• We can decrease antibiotic use – immunizations
– hand-washing
– education
– safety net antibiotic prescriptions (SNAP)
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What’s better than an antibiotic?
• Glycemic control • Intact skin • Good blood supply • Relieving an obstruction • Absence of nicotine • Immunizations • Clean water • Breast feeding • Hand washing • Preventive Health Care
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Thank you