ANTIBIOTICS

FIRST LEARN HOW TO USE THEM

THEN USE THEM RATIONALLY

GINO TANN

ANTIBIOTICS A SIMPLIFIED LIST

Beta - Lactams
The remaining Penicillins
Penicillin G never existed in Indonesia
Amoxycillin
Amoxycillin-clavulanic acid
Ticarcillin-clavulanic acid
FLUCLOXACILLIN

PIPERACILLIN-TAZOBACTAM (Tazocin)
Carbapenems
IMIPENEM-CILASTATIN (Tienam)
MEROPENEM (Meronem)
Monobactams
AZTREONEM
Forget the rest unless a newcomer appears
!

THE CONFUSING CEPHALOSPORINS

First G

Good for Gram positives

No good for Gram negatives

Parenteral
CEPHAZOLIN

Oral
Cephalexin
Cefadroxil

Second G Not so good for Gram positives, but still OK

Good for some ordinary Gram negatives
Parenteral
Cefuroxime
Cefotiam
Cefmetazole

Oral
Cefuroxime
Cefaclor

Cefamandole
Third G

No good for Gram positives

Good for Gram negatives
No good for E. faecalis

Parenteral
Cefotaxime
Ceftriaxone
CEFTAZIDIME
Cefoperazone
Newcomer
Parenteral
CEFIPIME (Maxipime)

Oral
Many
I use only one
I refuse to remember the rest

Aminoglycosides
Streptomycin
Gentamicin
AMIKACIN
MACROLIDES
Erythromycin
Spiramycin
Clarithromycin
Roxithromycin
Azitrhomycin
Tetracyclines
DOXYCYCLINE
MINOCYCLINE
Sulfonamides and trimethoprim
COTRIMOXAZOLE

Quinolones
Nalidixic acid
Norfloxacin
Perfloxacin
Ofloxacin
CIPROFLOXACIN
Levofloxacin
Sparfloxacin
GATIFLOXACIN

Miscellaneous
Chloramphenicol and thiamphenicol
METRONIDAZOLE
CLINDAMYCIN
VANCOMYCIN
TEICOPLANIN
Fusidic acid
Mupirocin
RIFAMPICIN
FOSFOMYCIN

CLINICAL CLASSIFICATION OF MICORORGANISMS

THE GOOD, THE BAD, AND THE UGLY
THE GOOD There are no good ones
Normal flora perhaps
THE BAD

- Community-acquired infections

THE UGLY - Hospital (Nosocomial infections)

Pseudomonas aeruginosa
MRSA
VREF
Many others

COMMUNITY ACQUIRED INFECTIONS

GINO TANNS GUIDELINES
INFECTIONS ABOVE THE BELT
Head and Neck
Oral cavity
Throat
Bronchitis
Pneumonia
Low risk
High risk

Macrolide
Amoxycillin, Metronidazole
Most throat infections are viral
Mostly viral except in asthmatics and COPD

- Macrolide
- Macrolide plus 2G or 3G cephalosporin
Macrolide plus quinolone

INFECTION BELOW THE BELT

Gall-bladder
Enteric fever

- Amocycillin-clavulanic acid
- Amoxycillin, Cotrimoxazole, Thiamphenicol useless
Quinolones starting to be useless
2G, 3G cephalosporin or combination

UTI

- What is UTI ?

SKIN INFECTIONS
FLUCLOXACILLIN Not available UNFORTUNATELY
Macrolide
Topical Fusidic acid or Mupirocin
PLEASE DO NOT USE TOPICAL GENTAMICIN !!!
SPECIAL INFECTIONS
Actinomycosis
Nocardia
Rickettsia
Leptospira

Amoxycillin-clavulanic acid
- Cotrimoxazole
- Tetracycline
- Amoxycillin

SURGICAL PROPHYLAXIS
MY APOLOGIES TO ALL SURGEONS
WE HAVE A BIG PROBLEM !!!
PLEASE DO NOT USE PESAN SPONSOR
YOU ARE CREATING PROBLEMS FOR EVERYBODY !!!

AN EXAMPLE OF ANTIBIOTIC GUIDELINES FOR SURGICAL

PROPHYLAXIS FROM BASEL CITY HOSPITAL

ORTHOPEDIC
Open fracture Cefamandole(2G) 2 g IV, Augmentin 3x2.2 g IV 5d
Hip surgery
- Cefamandole 2 g
Amputation
- Cefamandole 2 g
VISCERAL SURGERY
Bile ducts
- Cefamandole 2 g
Colorectal
Appendix
- Cefamandole 2 g, metronidazole 500 mg

UROLOGY
Cystectomy
Trauma
TUR

- Cefamandole 2 g, metronidazole 500 mg

- Bactrim forte 2 amp in 500 ml Nacl, metronidazole
500 mg bd

NEUROSURGERY
Trauma
Fucidin 500 mg in 2 hours
Brain damage Ceftriaxone 2 g a day
HEART SURGERY
- Cefamandole 2 g IV
Continue 1 g /6 hours for 72 hours
If > 72 hours Infectious diseases consultant
or
Vancomycin 1 g over 60 , tobramycin 120 mg IV
Continue Vancomycin 500 mg / 6 h
Tobramycin 80 mg / 8 h for 72 hours
THORACOTOMY
Augmentin 1.2 g, then 1.2 g/8 h as long as vein
catheter is in, then 625 mg qid until thorax drain
is slight

LESSONS FROM BASEL

No 3 G Cephalosporin used ABUSE !!!
IMPORTANT MICRO-ORGANISMS TO BE CONSIDERED IN
SURGICAL PROPHYLAXIS ARE GRAM POSITIVES.

So use 1 G or 2 G Cephalosporins !!!

3 G Cephalosporins are NO GOOD for Gram positives !!!
In some situations anaerobic bacteria need to be considered.
Antibiotics are given for one or two doses only !!!
When antibiotics are needed for > 72 hours an Infectious
Diseases Consultant is called in

MRSA VERSUS MSSA

MONOTHERAPY OR COMBINATION

THE UGLY

S. aureus Infections in Intensive Care Units in the National Nosocomial Infections

Surveillance System, 1987 through 1997

Lowy, F. D. N Engl J Med 1998;339:520-532

Resistance of Nosocomial Isolates of Enterococci to Vancomycin in the National Nosocomial

Infections Surveillance System, 1989 through the First Six Months of 1999

Murray, B. E. N Engl J Med 2000;342:710-721

Schematic Diagram of the Mechanism of Resistance to Vancomycin

Murray, B. E. N Engl J Med 2000;342:710-721

Possible Antimicrobial-Drug Regimens for the Treatment of Clinically Important Infections

Caused by Enterococci Resistant to Both Ampicillin and Vancomycin

Murray, B. E. N Engl J Med 2000;342:710-721

The Formation of a Biofilm by Pseudomonas aeruginosa

Prince, A. S. N Engl J Med 2002;347:1110-1111

HOSPITAL (NOSOCOMIAL) INFECTIONS SIMPLIFIED

G. Tann 2004
Gram positive infections
MSSA
Macrolide
1 G Cephalosporin
MSRA
Teicoplanin

FLUCLOXACILLIN
VANCOMYCIN

Gram negative infections THE UGLY

Monthly rotation of
Piperacillin-tazobactam (Tazocin)
Cefipime
Meropenem
Imipenan-cilastatin (Tienam)
Aztreonam
Fosfomycin
Monotherapy or Combination Clinical judgment

Relearn on how to use amikacin in COMBINATIONS !

LESSONS TO REMEMBER
Microbiologist Infectious diseases key person
Physicians and Surgeons - get cultures
Dont look down on the Gram stain
Antibiotic Spectrum in every hospital unit
Antibiotic policy in the hospital
Frequent use of an antibiotic Increase resistance
Differentiate between the bad and the ugly
Monotherapy versus Combination
Rotate antibiotics
Surgeons must be compliant in the use of antibiotics
Remember Pseudomonas is a soil organism
Many ugly organisms live in water
No gardens, no fountains !!!

ARE WE READY TO CHANGE OUR BEHAVIOUR ?

THANK YOU

GT19082004