Antimicrobial Quick Reference

OVERVIEW

Format:

  • Name (alphabetical order)
  • class
  • activity against
  • dose
  • issues with use
    -> major gaps in cover

ANTI-BACTERIALS

Amikacin

  • aminoglycoside
  • Gram –ve organisms (including Pseudomonas) + some Gram +ve cover
  • 7.5mg/kg Q12 hrly (titrated to troughs)
  • nephrotoxic, ototoxic, peripheral neuritis, neuromuscular blockade potentiation
    -> used for gram negatives

Amoxycillin

  • moderate-spectrum penicillin
  • gram +ve + improved cover against gram –ve bacilli
  • 1g Q4 hrly
  • rash with EBV
    -> staphylococcus and gram negatives

Amoxicillin-clavulanate

  • broad spectrum penicillin
  • gram +ve’s, anaerobes, aerobic gram –ve bacilli
  • 1.2g Q6 hrly
  • platelet dysfunction, blood dyscrasia
    -> MRSA

Ampicillin

  • broad spectrum penicillin
  • Gram +ve and Gram –ve organisms (ineffective against Beta-lactamase producers)
  • 500mg IV Q4 hourly
  • GI upset, rash
    -> staphylococcus and gram negatives

Azithromycin

  • macrolide
  • anaerobes and non-enteric gram negatives
  • 10mg/kg LD Q24hrly -> 5mg/kg on subsequent days
  • nephritis, hepatitis
    • -> gram positive, atypical mycobacteria and toxoplasma

Aztreonam

  • monobactam
  • aerobic gram –ve including Pseudomonas
  • 2g Q6 hrly
  • phlebitis, hepatitis, thrombocytopaenia
    > gram positives

Benzylpenicillin

  • a narrow spectrum penicillin
  • gram +ve (streptococcus pneumoniae, listeria)
  • 1-5g/day in divided doses
  • increased Na+, decreased K+, GI upset – pseudomembranous colitis, seizures, nephritis, blood dyscrasias
    -> inactivated by beta-lactamases -> most staph’s are resistant
    -> streptococcus pneumonia increasing resistance

Cefepime

  • 4th generation cephalosporin
  • gram +ve and gram –ve cover and anaerobes
  • 2g Q8 hourly
  • GI upset, rash

Ceftazidime

  • 3rd generation cephalosporin (beta-lactam)
  • gram –ve and anaerobes, some gram +ve
  • 2-6g/24 hours in 2 to 3 divided doses (30-100mg/kg/day in divided doses)
    -> reduced gram positive cover

Cefuroxime

  • 2nd generation cephalosporin with anti-haemophilus cover
  • gram +ve’s + improved gram –ve cover
  • adults 1.5g Q8 hrly, paediatrics 50mg/kg Q6hrly

Ceftriaxone

  • 3rd generation cephalosporin
  • reduced gram +ve with improved gram –ve cover (improved CSF penetration)
  • 50mg/kg Q24hrs
  • reduce in renal failure, avoid in neonates due to biliary excretion

Cephazolin

  • 1st generation cephalosporin + beta lactam resistant, all induce ESBL producers
  • gram +ve and some gram –ve cover
  • 15mg/kg Q8 hrly
  • 3-6% cross reactivity with penicillins

Ciprofloxacin

  • 2nd generation quinolone
  • predominately gram –ve cover (Pseudomonas)
  • 300mg Q12 hourly
  • growing cartilage damage, achilles tendonitis, QT prolongation
    -> no anaerobic or gram positive cover

Clarithromycin

  • macrolide
  • helicobacter pylori and mycobacterium avium complex
  • 500mg Q12 hrly
  • hepatitis

Clindamycin

  • lincosamide
  • gram +ve’s, anaerobes, some non-enteric gram negative (Helicobacter), intracellular organisms (mycobacterium avium complex)
  • high bone, bile and urine concentrations)
  • 2-4mg/kg Q6 hrly
  • GI upset, elevated LFT’s, blood dyscrasias

Colistin (polymyxin E)

  • polymixin antibiotic
  • gram –ve rods and New Delhi metallo-B-Lactamase mutli-resistant Enterobacteriaceae
  • two forms with different dosing regimes
  • nephrotoxic and neurotoxic
    -> gram negatives not reliably covered: Proteus, Providencia, Serratia, Neisseria, Moraxella, Helicobacter, Brucella, Burkholderia, Stenotrophomonas (some strains)

Co-trimoxazole

  • sulphamethoxazole + trimethoprim
  • sulphonamide
  • gram +ve and gram –ve cover and protozoan
  • covers Pneumocystitis jiroveci, Stentrophomonas maltophila, Listeria monocytogenes, Norcardia
  • 25-100mg/kg of sulphamethoxazole Q6 hrly (dose varies -> consult ID)
  • SJS, blood dyscrasias, influenzae like symptoms,

Doxycycline

  • tetracycline
  • gram +ve and gram –ve but widespread resistance
  • good cover for Chlamydophila, Mycoplasma, Rickettseiae, Spirocheataes, Brucella, Coxiella brunetii
  • 200mg LD -> 100mg Q24 hrly
  • oesophagitis, tooth discolouration in kids, photosensitivity, pancreatitis, hepatitis

Erythromycin

  • macrolide
  • gram +ve, anaerobes, non-enteric gram –ve infections, intracellular organisms
  • 20mg/kg/day in divided doses
  • long QT, monomorphic VT, pancreatitis, nephrotoxicity, hepatitis

Flucloxacillin

  • narrow spectrum penicillin with anti-staph cover
  • staph (beta lactamase resistant)
  • 50-100mg/kg/day
  • cholestatic jaundice

Fusidic acid

  • chemically related to the cephalosporins
  • penicillin resistant staphylococcal infections (endocarditis and bone infections)
  • 1g Q8hrly
  • GI upset, jaundice, rashes

Gentamicin

  • aminoglycoside
  • aerobic gram –ve’s + pseudomonas coverage
  • 3-5mg/kg LD -> titrate to trough
  •  nephrotoxic, ototoxic, peripheral neuritis, neuromuscular blockade potentiation

Imipenem-cilastatin

  • carbapenem
  • broad spectrum gram +ve, gram –ve and anaerobic cover
  • 500mg Q6 hrly
  • hepatitis, CNS stimulation, rashes
    -> MRSA, VISA, VRSA, atypical pneumonia’s.

Linezolid

  • oxazolidinone
  • gram +ve’s (including multi resistant staphylococci and enterococci)
  • 600mg Q12 hrly
  • blood dyscrasias, GI upset, headache, dry mouth

Meropenem

  • carbapenem
  • broad spectrum gram +ve, gram –ve and anaerobic cover
  • up to 2g Q8 hrly (40mg/kg)
  • hepatitis, CNS stimulation, rashes
    -> MRSA, VISA, VRSA, Enterococcus faecium, Stenotrophomonas and many Pseudomonas, atypical pneumonia’s

Metronidazole

  • nitroimidazole
  • anaerobes and protozoa (including Trichomonas, Giardia and Entamobea)
  • 7.5mg/kg Q8 hrly
  • GI upset, rash, dark urine

Moxifloxacin

  • 3rd generation quinolone
  • gram –ve, gram +ve, anaerobic and intracellular organisms of atypical pneumonia
  • 400mg Q24 hrly
  • growing cartilage damage, achillies tendonitis, QT prolongation
    -> Pseudomonas

Nitrofurantoin

  • E.coli, Enterococcus, Staph aureus, Citrobacter, Klebsiella
  • 100mg QID PO (5-7mg/kg/day)
  • GI upset, headache, flatus

Norfloxacin

  • – 2nd generation quinolone
  • – predominantly gram –ve cover
  • – 400mg Q12 hourly
  • – growing cartilage damage, Achilles tendonitis, QT prolongation

Pipericillin-Tazobactam (Tazocin)

  • broad spectrum penicillin
  • gram +ve’s, anaerobes, aerobic gram –ve bacilli (superior enterococcal cover)
  • 4.5g Q8hrly
  • platelet dysfunction, blood dyscrasias
    -> MRSA, VISA, VRSA, multi-resistant gram negatives

Quinupristin/dalfopristin

  • streptogramins
  • VRSA, VRE, gram positive bacilli (Enterococcus faecium), gram negative aerobes (Neiserria and Moraxella), intracellular organisms
  • 7.5mg/kg Q8 hrly
  • arthalgia, myalgia, GI upset, headaches

Rifampicin

  • rifamycin
  • gram +ve and gram –ve, mycobacterium tuberculosis and atypical mycobacteria
  • 10-20mg/kg/day
  • drug reactions: warfarin, OCP, cyclosporine, orange secretions, hepatitis, nephritis, thrombocytopaenia

Roxithromycin

  • macrolide
  • gram +ve, anaerobes and some non-enteric gram-negative infections, intracellular organisms
  • 300mg Q24 hrly
  • hepatitis

Teicoplanin

  • glycopeptide
  • MRSA, MRSE, gram +ve, good cover against streptococcus pneumoniae and C.difficile
  • 400mg LD -> 400mg @ 12 hours -> 400mg Q24 hrs
  • nephrotoxicity, blood dyscrasias, ototoxicity

Telavancin

  • derivative of vancomycin
  • gram +ve’s (including MRSA)
  • 10mg/kg Q24 hrs
  • GI upset, metallic taste, headache, foamy urine

Tetracycline

  • tetracyclines
  • chlamydia, rickettsia, spirochaete, brucella, mycoplasma, leptospirosis
  • 500mg Q12hrly
  • stained teeth in children, renal impairment, GI upset, hepatic impairment

Tigecycline

  • glycylcycline
  • gram +ve’s (VRE, MRSA, MRSE), gram –ve’s (ESBL), anaerobes
  • 100mg LD -> 50mg Q12 hrly
  • GI upset, similar to tetracyclines

Tircarcillin

  • carboxypenicillin (often in combination with clavulanate)
  • gram –ve organisms (especially Pseudomonas)
  • 3000mg/200mg (tircarcillin/clavulanate) Q4-8 hourly
  • increased Na+, decreased K+, GI upset – pseudomembranous colitis, seizures, nephritis, blood dyscrasias

Tobramycin

  • aminoglycoside
  • aerobic gram –ve’s + Pseudomonas coverage
  • 3-5mg/kg/day in 3 divided doses -> monitor
  • nephrotoxic, ototoxic, peripheral neuritis, neuromuscular blockage prolongation

Vancomycin

  • glycopeptide derivative
  • MRSA, MRSE, gram +ves, pencillin resistant streptococcus pneumoniae and C. difficile
  • 10mg/kg LD -> dose of plasma concentration
  • red man syndrome, ototoxic, nephrotoxic

ANTI-VIRAL

Acyclovir

  • guanosine analogue
  • viral DNA polymerase inhibitor
  • anti-HSV
  • 10mg/kg Q8hrly
  • rashes, GI upset, hepatic and renal impairement, blood dyscrasias, CNS symptoms

Alpha-interferon

  • interferon
  • used hepatitis B and C and many other diseases
  • SC injection
  • complex dosing
  • flu like symptoms, GI upset, haemodynamic instability, blood dyscrasias

Amantadine

  • M2 channel inhibitor -> disruption of dissociation of viral matrix and riobnucleoprotein
  • anti-viral and anti-parkinsonian drug
  • anti-HSV and anti-influenza
  • for anti-influenzae: 100mg/day
  • GI upset, convulsions, hallucinations

Famciclovir

  • guanosine analogue
  • anti-HSV
  • 1500mg OD PO (requires renal adjustment)
  • well tolerated

Foscarnet

  • guanosine analogue
  • inhibitor of viron DNA polymerase
  • anti-CMV
  • 20mg/kg IV LD -> 20-120mg/kg according to renal function
  • GI upset, renal failure, hypocalcaemia, convulsions

Gancicilovir

  • inhibition of CMV DNA polymerase
  • anti-CMV
  • administered as a prodrug (valganciclovir)
  • 5mg/kg Q12hrly IV
  • blood dyscrasias, rash, hepatorenal impairment, GI upset

Valaciclovir

  • guanosine analogue
  • anti-HSV
  • 1000mg TDS PO
  • headache, nausea, SOB

Oseltamivir

  • neuraminidase inhibitor
  • anti-influenzae
  • 75mg BD PO
  • GI upset

Ribavirin

  • guanosine analogue
  • DNA synthesis inhibitor -> active against many RAN and DNA viruses
  • RSV and Lassa fever
  • 20mg/mL nebulised for 12-18 hours for 3-7 days
  • anaemia, worsening respiratory failure

ANTI-FUNGALS

Amphortericin B

  • polyene
  • all Candida species except C.lustanae + anti-protozoan
  • 0.5-1mg/kg Q24 hr
  • nephrotoxic, hepatotoxic, GI upset, blood dyscrasias

Caspafungin

  • echinocandin
  • all Candida species, Aspergillus
  • 70mg LD -> 50mg Q24 hrly
  • GI upset, headache, myalgia, increase in LFT’s,

Fluconazole

  • azole
  • Candida albicans and Cryptococcus
  • 50-400mg Q24 hr
  • GI upset, hepatic dysfunction, arrhythmias

Itraconazole

  • azole
  • broader anti-fungal activity than fluconazole but not as much as voriconazole – Candida albicans, Cryptococcus, aspergillus
  • 200mg Q12 hrly for 4 doses -> 200mg Q24 hrly
  • increased LFT’s, GI upset

Nystatin

  • polyene
  • Candida albicans
  • topical application

Voriconazole

  • azole
  • broadspectrum anti-fungal – Candida albicans, glabrata, krusei, Cryptococcus, Aspergillus
  • 6mg/kg Q12 hourly (loading for 24 hours) -> 4mg/kg Q12 hourly
  • transient visual disturbance, fever, rash, GI upset

ANTI-PARASITICS

Albendazole

  • benzimidzole
  • anti-nematode and cestode (worms)
  • 800mg PO in divided doses (give with fatty meal or grape juice -> increases bioavailability)
  • GI upset, headache, dizziness, hepatic impairment, pancytopaenia

Ivermectin

  • synthetic antibiotic derivative
  • anti-nematode
  • 200-400mcg/kg
  • side effects related to parasitic load in host

Mebendazole

  • benzimidzole
  • anti-nematode and cestode (worms)
  • 100mg OD PO
  • minimal side-effects

Metronidazole

  • nitroimidazole
  • anaerobes and protozoa (including trichomonas, giardia and entamobea)
  • 7.5mg/kg Q8 hrly
  • GI upset, rash, dark urine

ANTI-PROTOZOANS

Aretemether + Lumefantrine

  • anti-malarial
  • 20/120mg
  • complex dosing

Artesunate

  • IV anti-malarial
  • 2.4mg/kg IV Q 12 hrly

Atrovaquone + proguanil

  • anti-malarial
  • 250/100mg
  • complex dosing

Clindamycin

  • lincosamide
  • gram +ve’s and anaerobes (high bone, bile and urine concentrations)
  • 2-4mg/kg Q6 hrly
  • GI upset, elevated LFT’s, blood dyscrasias

Doxycycline

  • tetracycline
  • gram +ve and gram –ve but widespread resistance
  • 200mg LD -> 100mg Q24 hrly
  • oesophagitis, tooth discolouration in kids, photosensitivity, pancreatitis, hepatitis

Mefloquine

  • anti-malarial
  • 15mg/kg LD -> 500mg Q6 hrly

Quinine sulphate

  • anti-malarial
  • IV 20mg/kg LD over 4 hours -> 10mg/kg Q 8hourly
  • take with doxycycline or clindamycin or atovaquone+proguanil or mefloquine

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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