Antibiotics

Lecture 6: Antibiotics for

Anaerobic Infections
 Learning Objective

Know the spectrum of activity and

major side effects for antibiotics
active against anaerobic organisms.
 Examples of Anaerobic Bacteria

Oral, Neck, and Pulmonary

Infections Intraabdominal

Actinomyces Bacteroides spp.

Peptostreptococcus Clostridium spp.
Bacteroides oralis Peptostreptococcus
Fusobacterium Fusobacterium
Prevotella
(Microaerophilic streptococci)

Specific anaerobic bacteria are infrequently identified in routine

culture, and when they are, antibiotic sensitivity testing is unreliable.
Conditions in Which Anaerobes Should Generally Be
Covered Even in the Absence of Growth in Culture

Periodontal infections

Various infections of the deep spaces of the neck

Aspiration pneumonia

Lung abscess

Empyema

Intraabdominal abscess

Secondary peritonitis
 Antibiotics for Anaerobic Bacteria
Metronidazole β lactam + β 2nd Gen.
Carbapenems lactamase inh. Clindamycin Moxifloxacin
Cephalosporins
(Flagyl™) (Unasyn™, Zosyn™)

Mechanism Creates free radicals Inhibits cell Inhibits cell wall Inhibits 50S Inhibits cell wall Inhibits DNA synthesis
wall synthesis synthesis subunit synthesis
Bacteroides ++ + + +/- +/- +/-
Actinomyces - + + + ? +
Clostridium ++ + + + + +/-
(excl. C.difficile)

Peptostreptococccus, - + + + ? +
Microaerophilic Strep.
Notable Adverse Disulfram effect, ↓ seizure ↓ platelets Most common Disulfram effect QT prolongation
Reactions Metallic taste threshold AIN cause of c.diff (Specific for May exac. myasthenia gravis
colitis cefotetan) Tendonopathy
(excluding allergies)

Excellent absorption and Imipenem & Q6h dosing Less commonly Generally not
Other Info bioavailability. meropenem - may limit used for recommended in
Zero coverage of aerobes. generally compliance. anaerobic children.
Should generally not be preferred over infections.
used as monotherapy ertapenem.
for anything other than
C. diff colitis.
 A Few More Anaerobic Antibiotic Pearls…

Ampicillin and PCN G are both active against Actinomyces

and Peptostreptococcus.

Vancomycin is active against gram positive anaerobes, but

not gram negative.

Doxycycline not traditionally thought of as an anti-

anaerobic antibiotic, but with activity against Actinomyces,
and Clositridium (not C. diff).

Chloramphenicol has excellent activity against all anaerobes

except C. diff.
 Preferred Antibiotics For Suspected Anaerobic Infections

Above the Diaphragm

Clindamycin is preferred Everywhere

(Metronidazole misses actinomyces &
microaerophilic streptococci) β-lactam/β-lactamase
combinations
(e.g. Unasyn™, Zosyn™)

Carbapenems
Below the Diaphragm

Metronidazole is preferred Moxifloxacin (2nd line)

(Clindamycin misses some

Bacteroides fragilis)
 Clostridium difficile

C. diff is the major cause of infectious colitis triggered by

antibiotic use.

It’s carried in the colonic flora of up to 50% of hospitalized

adults.

As C. diff itself is resistant to most antibiotics, use of

antibiotics alters the remainder of colonic flora, and permits
C. diff itself to multiply and release diarrhea-producing
toxins.
 Clostridium difficile

There are essentially just two common antibiotics active

against C. diff:
Metronidazole (PO and IV)
Vancomycin (PO only)

The newly developed macrolide fidaxomicin may become

another option.
 Antibiotic susceptibility tables are for educational purposes only, and
are not intended to direct the care of any specific patient.

Tables were derived from The Sanford Guide to Antimicrobial Therapy 2012
(Editors: DN Gilbert, RC Moellering, GM Eliopoulos, Chambers HF, and Saag MS),
supplemented with articles on UpToDate, various references in the primary
literature, and cross referenced with antibiograms from Stanford University
Medical Center, San Francisco General Hospital, the Palo Alto VA Hospital, and the
San Francisco VA Hospital.
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