This document provides an overview of antibiotics commonly used in the intensive care unit in 2015. It defines key terms like minimum inhibitory concentration and pharmacodynamics. It then summarizes the mechanisms of action, dosing, and clinical pearls of various antibiotic classes including vancomycin, linezolid, daptomycin, aminoglycosides, cephalosporins, piperacillin-tazobactam, carbapenems, tigecycline, fluoroquinolones, macrolides, and tetracyclines. It highlights factors like spectrum of coverage, dosing adjustments for renal impairment, monitoring parameters, and when certain antibiotics should be reserved for more resistant infections.
Aggressive preemtive multimodal including epidural or nerve block not only produce optimal analgesia but also may prevent the occurrence of chronic pain after surgical
Paracetamol as a single analgesic is only for mild and moderate pain.
However it can be combined with many analgesics to provide strong effect.
So, it can be the basic regiment for Multimodal Analgesia.
Aggressive preemtive multimodal including epidural or nerve block not only produce optimal analgesia but also may prevent the occurrence of chronic pain after surgical
Paracetamol as a single analgesic is only for mild and moderate pain.
However it can be combined with many analgesics to provide strong effect.
So, it can be the basic regiment for Multimodal Analgesia.
one can learn the step by step approach of ABG interpritation and its analysis from basics with the help of different case scenarios,Ref-NEJM article regarding physiological approach to acid base disbalance
A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops to a part of the heart, causing damage to the heart muscle. The most common symptom is chest pain or discomfort which may travel into the shoulder, arm, back, neck or jaw
one can learn the step by step approach of ABG interpritation and its analysis from basics with the help of different case scenarios,Ref-NEJM article regarding physiological approach to acid base disbalance
A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops to a part of the heart, causing damage to the heart muscle. The most common symptom is chest pain or discomfort which may travel into the shoulder, arm, back, neck or jaw
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Introduction: Clindamycin is an excellent drug for skin and soft tissue Staphylococcus aureus infections, but resistance mediated by inducible macrolide-lincosamide-streptogramin B (iMLS B ) phenotype leads to in vivo therapeutic failure even though they may be in vitro susceptible in Kirby-Bauer disk diffusion method. Objective: The study was aimed to detect the prevalence of iMLS B phenotype among S. aureus isolates by double disk approximation test (D-test) in a tertiary care hospital, Eastern India. Materials and Methods: A total of 209 consecutive S. aureus isolates were identified by conventional methods and subjected to antimicrobial susceptibility testing by Kirby-Bauer disk diffusion method. Erythromycin-resistant isolates were tested for D-test. Results: From 1282 clinical specimens, 209 nonrepeated S. aureus isolates were obtained. Majority of isolates 129 (61.7%) were methicillin-resistant S. aureus (MRSA). There was statistically significant difference between outpatients 60.1% and inpatients 39.9% (P < 0.0001). From 209 S. aureus isolates, 46 (22%) were D-test positive (iMLS B phenotype), 41 (19.6%) were D-test negative (methicillin sensitive [MS] phenotype), and 37 (17.7%) were constitutively resistant (constitutive macrolide-lincosamide-streptogramin B phenotype). The incidence of inducible, constitutive, and MS phenotype was higher in MRSA isolates compared to MS S. aureus (MSSA). The constitutive clindamycin resistance difference between MSSA and MRSA isolates were found to be statistically significant (P = 0.0086). Conclusion: The study revealed 22% of S. aureus isolates were inducible clindamycin resistant, which could be easily misidentified as clindamycin susceptible in Kirby-Bauer disk diffusion method. Therefore, clinical microbiology laboratory should routinely perform D-test in all clinically isolated S. aureus to guide clinicians for the appropriate use of clindamycin.
This presentation focuses on appropriate selection of antibiotics in the ICU and discusses different strategies to optimize this selection with the aim to decrease resistance and improve appropriateness.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
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This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
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Prix Galien International 2024 Forum ProgramLevi Shapiro
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- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
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4. Definitions
• Minimum Inhibitory Concentration
– Antimicrobial concentration that inhibits visible
microbial growth in artificial media
• Gram Stain
– Gram positive
– Gram negative
• Acid fast
5. • Problems with MIC:
•Fixed drug concentration
•All or none parameter. Growth vs. no growth
•Does not provide information on the time course of
antimicrobial activity
•Drug concentrations change throughout the dosing
interval
•Does not capture interpatient pharmacokinetic
variability
•Does not provide info on post-antibiotic effects
6. Gram staining
FOR differentiating bacterialspecies into (gram-
positive and gram-negative).
The name comes from its inventor, Hans Christian
Gram.
Gram staining differentiates bacteria by the chemical
and physical properties of their cell walls by
detecting peptidoglycan, which is present in a thick
layer in gram-positive bacteria.
7. Gram staining
In a Gram stain test, gram-positive bacteria retain
the crystal violet dye, while a counterstain
(commonly safranin or fuchsine) added after
the crystal violet gives all gram-negative
bacteria a red or pink coloring.
8. Acid-fastness
A physical property of certain bacteria (and, less
commonly, protozoa), specifically their resistance to
decolorization by acids during staining procedures.
The high mycolic acid content of certain Protozoa cell
walls, and those of Mycobacteria, is responsible for
the staining pattern of poor absorption followed by
high retention. Usually used to identify
mycobacteria.
10. • Pharmacokinetics versus
pharmacodynamics
•Pharmacokinetics mathematically describe the
relationship of antibiotic concentration to time.
• Aabsorption, distribution, metabolism, elimination,
half-life, volume of distribution, and area under the
concentration-time curve (AUC).
11. •Pharmacodynamics
•Describe the relationship of antibiotic concentration
to pharmacologic effect or microorganism death.
• The three main pharmacodynamic parameters that
are used are the
• peak to minimal inhibitory concentration ratio
(peak/MIC), the AUC to MIC ratio (AUC/MIC)
12. •Pharmacodynamics
• The time the drug concentration remains
above the MIC (T>MIC).
• Concentration independent antimicrobials include: beta-
lactams, vancomycin, macrolides, aztreonam, carbapenems,
clindamycin, tetracyclines, quinupristin/dalfopristin,
flucytosine, and azole antifungals.
15. Keys to Success
• Antibiotic covers potential infection/bacteria
• Dose of antibiotic is appropriate for treatment
of infection and adjusted for renal/hepatic
impairment
• Antibiotic penetrates site of infection
• Antibiotic is being absorbed
• Adequate treatment duration
16. Risk Factors for Resistance
• Antimicrobial therapy in the preceding 90 days
• Current hospitalization of 5 days or more
• High resistance rates in the unit
• Residence in a nursing home or extended care facility
• Immunocompromised
• Home wound care
• Chronic dialysis
18. Gram Positive Bacteria
• Cocci
– Staphylococcus
• S. aureus
• S. epidermidis
– Streptococcus
• S. pyogenes (Group A)
• S. viridians
• S. pneumoniae
– Enterococcus
• E. faecalis
• E. Faecium
• Bacilli
– Listeria monocytogenes
– Bacillus anthracis
– Corynebacterium species
– Proprionibacterium acnes
19. Vancomycin
• Spectrum of activity
– Staph (MRSA, MSSA), strep, enterococcus, c. difficile colitis (oral)
• Mechanism of action
– Inhibits synthesis of peptidoglycan/bacterial cell wall formation
• Dosing
– Actual body weight
– Loading dose = 25-30 mg/kg
– Maintenance dose = 15-20 mg/kg
– Usual Frequency = every 8-24h
– Adjust dose for renal impairment
20. Vancomycin
• Adverse effects
– Redman syndrome
– Thrombocytopenia
– Possible nephrotoxicity ??
– Ototoxicity (rare) Ototoxicity is not associated with trough
concentrations.
• Monitoring
– Goal Trough = 15-20 mcg/mL
– Bacteremia, endocarditis, osteomyelitis, meningitis, pneumonia
– Initial: trough before 4th or 5th dose
– Maintenance: trough once weekly
21. Vancomycin with Dialysis
• Continuous renal replacement therapy (CRRT)
– 15mg/kg q24h
– Hold dose if CRRT stopped > 8h
– Trough before 4th or 5th dose
• Intermittent hemodialysis (iHD)
– Pulse dosing with iHD
– iHD removes ~25% of vancomycin
– Goal Pre-iHD level < 24 mcg/mL
– Initial dose = 15mg/kg x1 dose
– Maintenance dose based on pre-iHD levels
22. Linezolid
• Spectrum of activity
– Staph (MSSA, MRSA), strep, VRE
• Mechanism of action
– Binds to bacterial ribosomes to inhibit protein
synthesis
• Bacteristatic against staph, vre but cidal
against strep pneumon
• Time dependent killing
24. Linezolid
• Clinical Pearls
– May be used for vancomycin failure or intolerance
– Oral & IV formulations
– Bacteriostatic
– No renal adjustment
– May have prescribing restrictions
– Expensive
25. Daptomycin
• Spectrum of activity
– Staph (MSSA, MRSA), strep, enterococcus (VRE)
• Mechanism of action
– Causes bacterial membranes to depolarize leading to inhibition of
protein, DNA, and RNA synthesis
• Typical Dosing
– Adjust with renal impairment
– 4-6 mg/kg (actual weight) q24-48h
• Adverse Effects
– Arthralgia
– Myalgia
– CPK elevations
26. Daptomycin
• Clinical Pearls
– Not for treatment of pneumonia
– Can use doses of 8-10 mg/kg for severe infections
– Monitor CPK at baseline and weekly
– Can falsely elevate INR
– May have prescribing restrictions
– Takes 30-60 minutes to reconstitute
– Expensive
30. Aminoglycosides
• Spectrum of activity
– Only gram negative, gram positive synergy
• Mechanism of action
– Bind bacterial ribosome and inhibit protein synthesis
• Adverse effects
– Nephrotoxicity
– Ototoxicity
– Prolonged neuromuscular blockade
Medications
Gentamicin Tobramycin Amkicacin
31. • Aminoglycoside antibiotics possess
nondepolarizing neuromuscular blocking
activity, which is additive or synergistic with
the effects of the nondepolarizing
neuromuscular blocking agents used in
anesthesia .
• Aminoglycosides cause presynaptic inhibition
of acetylcholine release and postsynaptic
reduction in sensitivity
32. Aminoglycosides
• Clinical Pearls
– Used for
• Nosocomial infections
• Double gram negative coverage
• Endocarditis (synergy)
– Two dosing schemes
• Traditional dosing
• Extended interval dosing/once daily dosing
– Levels must be monitored
• Traditional = peak & trough around 3rd dose
• Extended interval = trough before 2nd dose
– Monitor Scr daily
33. Aztreonam
• Class
– Monobactam
• Spectrum of activity
‒ Gram positive: none
‒ Gram negative: most, except S. maltophilia
• Mechanism of action
– Inhibit cell wall synthesis
• Dosing
– Usual: 1-2g IV Q8h
– Meningitis: 2g IV Q6-8h
• Adverse effects (rare)
– Transient eosinophilia
– LFT elevations
– Thrombocytopenia
**Can be used with
penicillin allergy**
35. Spectrum of Activity Primary Use
First Generation
Cefazolin (Ancef) (IV)
Cephalexin (Keflex) (PO)
• Simple Gram (+) , simple gram (-) , no
anaerobes. No ceph gets enterococci.
• Simple SSTI, surgical prophylaxis
Second Generation
Cefotetan (Cefotan) (IV)
Cefoxitin (Mefoxin) (IV)
Cefuroxime (Ceftin) (IV)
Cefaclor (Ceclor) (PO)
Cefprozil (Cefzil) (PO)
• Same spectrum as 1st Generation
• Cefotetan and Cefoxitin cover anaerobes
• Surgical prophylaxis if anaerobes,
URTI, UTI
Third Generation
Ceftriaxone (Rocephin) (IV)
Cefotaxime (Claforan) (IV)
Ceftazadime (Fortaz) (IV)
Cefpodoxime (Vantan) (PO)
Cefdinir (Omnicef) (PO)
Cefixime (Suprax) (PO)
• Better gram (-)
• Ceftazadime-pseudomonas • PNA, meningitis
Fourth Generation
Cefepime (Maxipime) (IV)
• Good gram (+), nosocomial gram (-)
including pseudomonas
• No anaerobes
• Sepsis, HAP, neutropenic fever
Fifth Generation
Ceftaroline (Teflaro)
• MRSA, MSSA, E. faecalis, s.pneumoniae,
• Some gram (-), NO pseudomonas
• Pneumonia, SSTI
Cephalosporins
36. • CABP pathogens, ceftaroline has activity
against the Gram-positive organisms S.
pneumoniae, S. aureus and Streptococcus
pyogenes, and Gram-negative species
(Haemophilus influenzae and CABP
pathogens, ceftaroline has activity against the
Gram-positive organisms S. pneumoniae, S.
aureus and Streptococcus pyogenes, and
Gram-negative species .
37. Cephalosporins
• Clinical Pearls
– Do not cover enterococcus (except ceftaroline)
– ↑ gram negative coverage with higher generations
– Used for surgical prophylaxis
– Anaerobic coverage
• Cefoxitin
• Cefotetan
– Pseudomonas coverage
• Ceftazidime
• Cefepime
40. • Mechanism of Action:
•Inhibit mucopeptide synthesis in the bacterial cell
wall, thus results in formation of defective cell walls
and osmotically unstable organisms susceptible to cell
lysis
•Tazobactam acts as a beta-lactamase inhibitor and
inactivates both plasmid and chromosome mediated
beta-lactamases
42. Carbapenems
• Clinical Pearls
– First line agent for extended spectrum beta-lactamase
(ESBL) producing bacteria
– Extended infusion meropenem
• ↑ time above MIC
– Reserved for severe infections
– May have prescribing restrictions
43. Tigecycline
• Spectrum of activity
– Enterococcus (including VRE), MSSA, MRSA, MRSE, anaerobes
– Not pseudomonas, proteus, providencia
• Mechanism of action
– Binds to bacterial ribosomes to inhibit protein synthesis
• Dose
– 100mg IV x 1 dose
– 50mg IV q12h
• Adverse effects
– Nausea and vomiting
– Hyperbiliruminemia
44. •Tigecycline has a spectrum of activity
that includes anaerobes, many gram-
positive cocci and gram-negative
bacilli w/ the exception of
Pseudomonas, Proteus, and
Providencia.
•N/V may occur in up to 2/3rds of
patients
45. Tigecycline
• Clinical Pearls
– No renal adjustment
– Hepatic dose adjustment (Child Pugh C)
• 100mg IV x 1, then 25mg IV Q12h
– Used for resistant infections
– Do not use for
• Ventilator associated pneumonia
• Bacteremia
– Can be used for
• Intra-abdominal infections
• Skin & soft tissue infections
46. •All-cause Mortality:
•An increase in all-cause mortality has been observed
•The cause of this mortality risk difference has not
been established.
•Tigecycline should be reserved for use in situations
when alternative treatments are not suitable.
•Death resulted from progression of infection
•Especially in ventilator associated pneumonia
•Reserve for use when other agents are not an
option
51. Clostridium Difficile
• IDSA Recommendations
– No probiotics - ↑ Bloodstream infections
– Stop causative antimicrobials
– Repeat testing during the same episode is discouraged
– Vancomycin taper after second reoccurrence
– Dual antimicrobials
• Ileus = IV metronidazole + vancomycin enema
**PO vancomycin is only used to treat c. diff infection**
52. • There is no evidence to support administration of
combination therapy to patients with uncomplicated
CDI.
• Although hampered by its low statistical power, a
recent trial did not show any trend toward better
results
when rifampin was added to a metronidazole
regimen.
• There is no evidence to support use of a combination
of oral metronidazole and oral vancomycin.
54. Penicillin Allergy
Avoid Use
Incidence of
Reaction
May Use
Cephalosporins
• 1st/2nd generation
cephalosporin
2% • Aztreonam
• 3rd/4th generation
cephalosporin
Carbapenems
• None? 0-11% • All carbapenems?
• Aztreonam
• Graded challenge or PCN
skin test
55. •Penicillin-cephalosporin cross-reactivity studies that
confirmed penicillin allergy by skin testing are superior
in design compared with those that diagnosed
penicillin allergy by history alone.
•Another group of studies evaluated patients with
positive penicillin skin tests (to penicilloyl polylysine
[PPL], penicillin G, and/or the minor determinant
mixture [MDM]) who were challenged with
cephalosporins and found an overall reaction rate of
3.4 percent .
56. •If this analysis is limited to studies published after
1980 (when cephalosporins were no longer
contaminated with penicillin), the reaction rate is
reduced to 2 percent.
•Thus, approximately 2 percent of patients with skin-
test proven sensitivity to penicillin can be expected to
react to cephalosporins.
•Range for cephalosporin reaction was 0-12% reported
in the literature.
58. GOOD LUCK
SAMIR EL ANSARY
ICU PROFESSOR
AIN SHAMS
CAIRO
elansarysamir@yahoo.com
Global Critical Care
https://www.facebook.com/groups/1451610115129555/#!/groups/145
1610115129555/
Wellcome in our new group ..... Dr.SAMIR EL ANSARY
Editor's Notes
Pharmacokinetics versus pharmacodynamics
Pharmacokinetics mathematically describe the relationship of antibiotic concentration to time.
Terminology that is typically associated with pharmacokinetics includes: absorption, distribution,
metabolism, elimination, half-life, volume of distribution, and area under the concentration-time
curve (AUC).
Pharmacodynamics describe the relationship of antibiotic concentration to pharmacologic effect
or microorganism death. The three main pharmacodynamic parameters that are used are the
peak to minimal inhibitory concentration ratio (peak/MIC), the AUC to MIC ratio (AUC/MIC), and
the time the drug concentration remains above the MIC (T>MIC).
concentration independent antimicrobials include: beta-lactams, vancomycin, macrolides, aztreonam, carbapenems, clindamycin, tetracyclines, quinupristin/dalfopristin, flucytosine, and azole antifungals.
Mycoplasma vs. mycobacteria
Clinical Pearls
Uses
Community acquired pneumonia
Opportunistic infections
Tic born illness
COPD exacerbations
