Antibiotics in icu

1. Antibiotics
& Sepsis
By Noureldin Kohaily
ICU ,Anaesethiology and pain management Resident (Alazhar university hospitals)

2. Antibiotics According its Action
Antibiotics that target
the cell wall
Antibiotics that block
protein production
Antibiotics that target
DNA and replication
All cidal cidal or static All cidal
1. β-Lactam Antibiotics
• Penicillin 4
• Cephalosporin 5
• Carbapenems 3
• monobactam 1
2. Colistin
3. Glycopeptides
• Vancomycin
• targocid
4. Fosfomycin
1. Macrolides
2. Aminoglycosides
3. Clindamycin (Dalacin)
4. Tigecycline (Tygacil)
5. Linezolid (Zyvox)
1. Quinolones
2. Metronidazole (Flagyl)
3. Sulphonamides.
• Peak serum level dependent AB = concentration dependent : given once daily as aminoglycosides.
• Steady serum level dependent AB = time dependent: multiple doses or infusion is better.

3. Types of bacteria
Gram +ve Cocci
VRSA
MRSA
MSSA
streptococcus
Gram –ve Bacilli
E.coli
Klebsiella
Pseudomonas
ESCAPPM
Acentobactr
Gram –ve Cocci
N. gonorrhea
N.Meningitides
Anaerobes
Atypical
chlamydia
legionella
• Extreme gram +ve : MRSA, VRSA.
• Extreme gram –ve : MDR (resistant to 3 or more classes).
• ESCAPPM : Enterobacter, Serratia, Citrobacter, Aeromonas, Proteus, Providencia and Morganella.

4. B Lactam Antibiotics
Antibiotics that target
the cell wall
All cidal
1. β-Lactam Antibiotics
• Penicillin 4
• Cephalosporin 5
• Carbapenems 3
• monobactam 1
2. Colistin
3. Glycopeptides
• Vancomycin
• targocid
4. Fosfomycin
• better to be given by infusion on 3 hours to maintain serum level.
1. Penicillin
Weak family with a Big boss (piperacillin).
1. Naturally occurring penicillin :
Active against gram +ve cocci
e.g. penicillin G.
2. Anti-staphylococcal penicillin :
with extended spectrum against gram +ve cocci and MSSA
e.g, Methicillin.
3. Amino-penicillin :
with activity against gram –ve
e.g. Ampicillin and Amoxicillin.
4. Extended spectrum penicillin (with beta lactamase inhibitors) :
1. Active against gram -ve & pseudomonas(piperacillin only).
2. Anaerobes.
e.g. Ampicillin sulbactam, Amoxicillin clavulanic acid and
Piperacillin (the most extensive one).

5. 1. Penicillin
Gram +ve Cocci
VRSA
MRSA
MSSA
2
3
4
5
streptococcus 1
Gram –ve Bacilli
E.coli
Klebsiella
Pseudomonas
ESCAPPM
Acentobactr 4 S
Gram –ve Cocci
N. gonorrhea
N.Meningitides 3
5
Anaerobes 4
Atypical
chlamydia
legionella
1. Naturally occurring penicillin : e.g. penicillin G.
2. Anti-staphylococcal penicillin : e.g, Methicillin.
3. Amino-penicillin : e.g. Ampicillin and Amoxicillin.
4. Extended spectrum penicillin (with beta lactamase inhibitors) : e.g. Ampicillin sulbactam,
Amoxicillin clavulanic acid 4S (sulbactam only).
5. Piperacillin tazobactam.

6. B Lactam Antibiotics
1. Penicillin
penicillins with β-Lactamase inhibitors (extended spectrum penicillin) :
• Ampicillin (1-2gm) - sulbactam (0.5-1gm) → Unasyn / Unictam (1.5-3 gm /4-6 hrs)
• Amoxicillin (1gm) - clavulanate (0.2gm) → Augmentin (1.2gm /8hrs)
• Piperacillin (4gm) - tazobactam (0.5gm) → Tazocin(4.5gm/6hrs)
unless Crcl < 40 → 2.25/6hr or 4.5/12 hrs
stability :
• Type of dilutional fluid (Dex5% vs NACL0.9% vs DW).
• Inside Refrigerator or not.

7. B Lactam Antibiotics
stability :
• Type of dilutional fluid (Dex5% vs NACL0.9% vs DW).
• Inside Refrigerator or not.
Creatinine clearance Crcl :
In septic shock :
• no adjustment of B-lactam in 1st 48hr if AKI or Acute on top of
chronic.
• But If (Chronic kidney disease adjust from the start).

8. B Lactam Antibiotics
Antibiotics that target
the cell wall
All cidal
1. β-Lactam Antibiotics
• Penicillin 4
• Cephalosporin 5
• Carbapenems 3
• monobactam 1
2. Colistin
3. Glycopeptides
• Vancomycin
• targocid
4. Fosfomycin
• better to be given by infusion on 3 hours to maintain serum level.
2. Cephalosporins
Weak family 5 members with a Big boss → (Cephalosporin B lactamase).
1. First generation
Effective against gram +ve
e.g. Cephazolin, Cephalexin.
2. Second generation
Extended activity against some gram –ve
e.g. Cefotetan, Cefoxitin.
3. Third generation
More effective against gram –ve
e.g. Ceftrixone, cefoprazone, Ceftazidime (seizures).
4. Fourth generation
Has good gram +ve and gram –ve
e.g. Cefipime.
don’t use in in neuro (TBI) can cause convulsion as Fortum, tavanic & teinam.
5. Fifth generation
Has expanded the activity against (gram +ve , Ecoli, klebsiella & community
MRSA)
e.g Ceftaroline. Zinforo
in soft tissue, diabetic foot & chest community

9. B Lactam Antibiotics
Antibiotics that target
the cell wall
All cidal
1. β-Lactam Antibiotics
• Penicillin 4
• Cephalosporin 5
• Carbapenems 3
• monobactam 1
2. Colistin
3. Glycopeptides
• Vancomycin
• targocid
4. Fosfomycin
• better to be given by infusion on 3 hours to maintain serum level.
2. Cephalosporins
Weak family 5 members with a Big boss → (Cephalosporin B lactmase).
The big boss of the family :
• Cephalosporin B lactamase :
• Cefazoline + tazobactam. (not in Egypt).
• Ceftazidime + avibactam. (not cover anaerobes). Zavicefta 2/0.5gm.
There is cross-sensitivity between penicillins
and cephalosporins.

10. 2. Cephalosporins
1. First generation e.g. Cephazolin, Cephalexin.
2. Second generation e.g. Cefotetan, Cefoxitin.
3. Third generation e.g. Ceftrixone 3a, Ceftazidime 3b.
4. Fourth generation e.g. Cefipime.
Gram +ve Cocci
VRSA
MRSA
MSSA
1 2 3a
4
streptococcus
3b
Gram –ve Bacilli
E.coli
Klebsiella
Pseudomonas
ESCAPPM 3a
Acentobactr
Gram –ve Cocci
N. gonorrhea
3a 4
N.Meningitides
Anaerobes 2
Atypical
chlamydia
legionella

11. B Lactam Antibiotics
2. Cephalosporins
Third generation Cephalosporins :
• Ceftrixone → Rocephin 2gm/24 hrs except in meningitis 2gm/12hrs. (max4gm).
• Cefoprazone → Cephobid 1-2 gm /8-12 hrs.
• Ceftazidime → Fortum 1-2gm /8-12hrs. (seizures)
• All presents in vials 0.5 or 1gm.
• NB : all 3rd generation given by divided doses
except ceftriaxone once daily.
• NB : all 3rd generation has Renal adjustment
except ceftriaxone with no renal adjustment.
• NB : Sulprazone (1gm cefoprazone + 0.5 gm sulbactam) 1.5-3gm/8-12hrs
• presents in vials 1.5gm.
• Sulprazone increase INR → Follow up INR.
• In Acintobacter MDR , we need 9gm sulbactam / 24hr.
(if high INR switch to unasyn 9gm /8hr no increase in INR)

12. B Lactam Antibiotics
2. Cephalosporins
Fourth generation Cephalosporins :
• Cefipime → Maxipime 1-2gm/8-12hrs.
don’t use in in neuro (TBI) can cause convulsion as Fortum, tavanic & teinam.
Fifth generation Cephalosporins :
Has expanded the activity against (gram +ve , Ecoli, klebsiella & community MRSA)
• Ceftaroline. e.g Zinforo
in soft tissue, diabetic foot & chest community
Cephalosporin B lactamase :
• Cefazoline + tazobactam. (not in Egypt).
• Ceftazidime + avibactam. Zavicefta 2/0.5gm.
= (Rocephin + comm acq. MRSA)

13. B Lactam Antibiotics
Antibiotics that target
the cell wall
All cidal
1. β-Lactam Antibiotics
• Penicillin 4
• Cephalosporin 5
• Carbapenems 3
• monobactam 1
2. Colistin
3. Glycopeptides
• Vancomycin
• targocid
4. Fosfomycin
• better to be given by infusion on 3 hours to maintain serum level.
3. Carbapenems
family with 3 members all of them are Big.
1. Imipenem-cilastatin
Active against gram +ve, gram –ve and anerobes.
e.g. Tienam.
2. Meopenem
active against gram +ve, gram –ve anerobes
e.g. Meronem.
3. Ertapenem
active against gram +ve, gram –ve anerobes but does not cover pseudomonas
or Acinetobacter.
e.g. Invanz.
4. Monobactam
Aztreonam
gram –ve only → cover most resistance genes
So in combination with zavicefta.
e.g. Azactam.

14. 3. Carbapenems & 4. Monobactam
1. Ertapenem e.g. Invanz.
2. Imipenem-cilastatin, Meopenem e.g. Tienam, Meronem.
3. Aztreonam e.g. Azactam.
Gram +ve Cocci
VRSA
MRSA
1
2
MSSA
streptococcus
Gram –ve Bacilli
E.coli
3
Klebsiella
Pseudomonas
ESCAPPM 1
Acentobactr
Gram –ve Cocci
N. gonorrhea
1
N.Meningitides
Anaerobes
Atypical
chlamydia
legionella

15. B Lactam Antibiotics
3. Carbapenems
• Imipenem-cilastatin → Tienam
Active against gram +ve, gram –ve and anerobes.
• better to be avoided in renal & convulsion.
• (0.5 gm/6hrs). if Ext. release 1gm/8hr. But should be on 50ml and over 3hrs.
dose for renal adjustment → calculate Crcl then MedScape.
(normal create. Dose is starting from 0.5 gm)
So balance the dose when adjust.
• Meopenem → Meronem
Active against gram +ve, gram –ve and anerobes.
• more suitable in renal impairment & head trauma less incidence of convulsion than teinam.
• (1 gm/8hrs). if Ext. release 2gm/8hr. But should be on 50ml and over 3hrs.
dose for renal adjustment → calculate Crcl then MedScape.
(normal create. Dose is starting from 1 gm) So balance the dose when adjust.
• there is interaction between depakin + meronum.
• Ertapenem → Invanz
active against gram +ve, gram –ve anerobes but does not cover pseudomonas or Acinetobacter.
• Not used in chest infection but for → abdominal & soft tissue ((1gm/24hr).
not influanz !

16. B Lactam Antibiotics
4. Monobactam
• Aztreonam → Azactam.
gram –ve only (cover most resistance genes).
• (1-2 gm/8hrs).
• has Crcl.
• in combination with zavicefta.
Zactaject

18. Colistin
Antibiotics that target
the cell wall
All cidal
1. β-Lactam Antibiotics
• Penicillin 4
• Cephalosporin 5
• Carbapenems 3
• monobactam 1
2. Colistin
3. Glycopeptides
• Vancomycin
• targocid
4. Fosfomycin
• Belongs to polymyxin group of antibiotics.
• Spectrum :
• Gram –ve only.
• not cover proteus , anaerobes, gram +ve & Providencia (ESCAPPM).
• NB : zavicefta also not cover anaerobes.
• Uses :
• the most effective antibiotic against gram -ve bacteria & MDR
• Better to be used with another agent :
except Acinetobacter → dual attack equal colistin only.
Other Agent are :
a) sulperazone/unasyn in Acinetobacter 9gm/8hrs.
or b)carbapenems
or c) tygacil
or d) maxipime.
If dual attack and no response add the triple agent :
a)Tigacyl. + b)teinam or meronum up to extended release. + C)colistin.
• Can be given by inhalational route :
dose (2million /12hrs) in cystic fibrosis or lung abscess. + IV.
cornerstone of extreme gram –ve

19. Colistin
Antibiotics that target
the cell wall
All cidal
1. β-Lactam Antibiotics
• Penicillin 4
• Cephalosporin 5
• Carbapenems 3
• monobactam 1
2. Colistin
3. Glycopeptides
• Vancomycin
• targocid
4. Fosfomycin
• Dose :
• Adults :
• Loading : 9 million units No renal adjustment.
• Maintenance : 4.5 million units/12 hrs. and should be adjusted in
renal patient.
• Pediatrics :
• 2.5 - 5 mg/kg/day of colistin base divided into 2- 3 doses.
• Calculate on 5 mg.
• (no loading dose).
• 1 million unit cloistin = 34 mg colistin base = 80 mg colistin sodium.
Calculate the dose according to colistin base not sodium.
Eg : child 14 kg :14×5=70mg = (2 millions / day ) 1million /12hrs.
• Side effects :
a) Nephrotoxic → adjusted in renal impairment but no loading adjustment.
b) ± seizures in renal pt. (NB : Fortum, Tavanic and tainam).
cornerstone of extreme gram –ve
c) poor penetration to chest & CNS so given iNhalational & iNtrathecal

20. Colistin
Antibiotics that target
the cell wall
All cidal
1. β-Lactam Antibiotics
• Penicillin 4
• Cephalosporin 5
• Carbapenems 3
• monobactam 1
2. Colistin
3. Glycopeptides
• Vancomycin
• targocid
4. Fosfomycin
• Dose adjustment in renal patients :
NB: colistin dose in dialysis : 2.5 million / 12 hr + 1 million after dialysis.
cornerstone of extreme gram –ve

21. Vancomycin
Antibiotics that target
the cell wall
All cidal
1. β-Lactam Antibiotics
• Penicillin 4
• Cephalosporin 5
• Carbapenems 3
• monobactam 1
2. Colistin
3. Glycopeptides
• Vancomycin
• targocid
4. Fosfomycin
• Spectrum :
• Gram +ve & staph.
• Dose :
• Loading :
25-30 mg/kg (Actual BW) max 2.5 gm.
(no adjustment) in critically ill cases. .. Like colistin
• Maintenance :
15 mg/kg/dose every 12 hrs ( 1 - 1.5 gm /12hrs).
has renal adjustment if Crcl<90 .. 125-250 mg PO/ 6 hrs.
in pseudomonas colitis (oral) / Inhalational : 250- 500/12hr
• Side effects :
A. nephrotoxic especially in combination with tazocin.
B. Red man syndrome :
Red man syndrome if infused at a rate > 50 mg/min.
(histamine release → VD → redness of upper half of the body
• Prevention :
Avoided by infusion over 1 hour.
• Definitive Treatment :
1- hydration.
2- anti-inflammatory.
The most effective anti-staph drug.
Narrow therapeutic index (serum level monitoring)
water soluble
with high serum level
so preferred in blood
MRSA eg CLBSI

22. Targocid
Antibiotics that target
the cell wall
All cidal
1. β-Lactam Antibiotics
• Penicillin 4
• Cephalosporin 5
• Carbapenems 3
• monobactam 1
2. Colistin
3. Glycopeptides
• Vancomycin
• targocid
4. Fosfomycin
• Spectrum :
• Gram +ve & staph.
• Dose : according to creatinine clearance
• If Crcl >60 :
800mg every 12hr for 5 doses then 400mg every 24hr.
• If Crcl 30 - 60 :
800mg every 12hr for 4 doses then 400mg every 24hr.
• If Crcl <30 :
800mg every 12hr for 3 doses then 400mg every 24hr.
• If Crcl <10 in CKD :
400 mg / 72 hr and after 3 doses 800 mg / 72 hr.
• In pediatrics :
Loading 10 mg/kg for 3 doses.
Maintenance 6-10 mg/kg/24 hrs.
• Side effects :
less nephrotoxic than vancomycin.
The most effective anti-staph drug.
no thrombocytopenia like averozolid
but poor BBB penetration so not preferred in meningitis
penetration to lung 7 times more than Vanco

23. Glycopeptides
Gram +ve Cocci
VRSA
MRSA
Glycopeptides
MSSA
streptococcus
Gram –ve Bacilli
E.coli
Klebsiella
Pseudomonas
ESCAPPM
Acentobactr
Gram –ve Cocci
N. gonorrhea
N.Meningitides
Anaerobes
Atypical
chlamydia
legionella

24. Fosfomycin
Antibiotics that target
the cell wall
All cidal
1. β-Lactam Antibiotics
• Penicillin 4
• Cephalosporin 5
• Carbapenems 3
• monobactam 1
2. Colistin
3. Glycopeptides
• Vancomycin
• targocid
4. Fosfomycin
• Uses :
• is the primarily antibiotic used in treatment of UTI.
• Dose :
• in UTI once 3gm once.
• in MDR UTI 3gm every 2 – 3 days for 3 doses.
• Not used orally in bacteremia only in cystitis as its oral absorption is 20%
only so not effective as very low level.
In UTI (just cystitis not Bacteremia)

25. Macrolides
• Uses :
• community acquired pneumonia.
• Spectrum :
• Gram +ve & atypical bacteria.
• Dose :
• Erythromycin(500/6hr).
• Clarithromycin(500/12hr).
• Azithromycin(500 loading then 250 /24hr).
• Adverse effects :
A. prolonged QT interval.
B. exaggerates toxicity of Rivaroxaban (Xarelto).
So switch to Apixaban (Eliquis).
Antibiotics that block
protein production
cidal or static
1. Macrolides
2. Aminoglycosides
3. Clindamycin (Dalacin)
4. Tigecycline (Tygacil)
5. Linezolid (Zyvox)

26. Macrolides
Gram +ve Cocci
VRSA
MRSA
MSSA
Macrolides
streptococcus
Gram –ve Bacilli
E.coli
Klebsiella
Pseudomonas
ESCAPPM
Acentobactr
Gram –ve Cocci
N. gonorrhea
N.Meningitides Macrolides
Anaerobes
Atypical
chlamydia
Macrolides
legionella

27. Aminoglycosides
Can be given by inhalation + IV.
Never inhalation alone.
• Spectrum :
• Gram -ve.
• Dose :
• gentamycin :
3 - 6mg/kg/day ( amp 80 mg).
• Amikin (Amikacin) :
1 - 1.5gm / 24hrs (vial 100-500mg).
If Inhalation : 400mg / 8 hrs.
• Adverse effects : (as lasix)
A. Nephrotoxic.
B. ototoxic.
Antibiotics that block
protein production
cidal or static
1. Macrolides
2. Aminoglycosides
3. Clindamycin (Dalacin)
4. Tigecycline (Tygacil)
5. Linezolid (Zyvox)
on peak level (concentration dependent) “so single dose ”
except in infective endocarditis
c. Narrow therapeutic index
irreversible
d. inhibit A. ch release (CI in MG)

28. Aminoglycosides
Gram +ve Cocci
VRSA
MRSA
MSSA
Macrolides
streptococcus
Gram –ve Bacilli
E.coli
Aminoglycosides
Klebsiella
Pseudomonas
ESCAPPM
Acentobactr
Gram –ve Cocci
N. gonorrhea
N.Meningitides Macrolides
Anaerobes
Atypical
chlamydia
Macrolides
legionella

29. Clindamycin (Dalacin)
• Uses :
• in soft tissue infections.
• Community acquired MRSA
• Dose :
600mg/8hrs
• Spectrum :
• Gram +ve & anaerobes.
• + anti-bacterial toxins activity (soft tissue).
• Cover Community acquired MRSA not hospital acquired MRSA.
• Disadvantage :
• poor CNS penetration
• not suitable for child C patients.
• Adverse effects :
• Pseudo-membranous colitis → diagnosed by stool analysis showing
clostridium difficile toxins and treated by :
oral flagyl or oral vancomycin : 125-250mg/6hrs
Antibiotics that block
protein production
cidal or static
1. Macrolides
2. Aminoglycosides
3. Clindamycin (Dalacin)
4. Tigecycline (Tygacil)
5. Linezolid (Zyvox)
NOT recommended with
linezolid because both
have anti toxin effect

30. Clindamycin (Dalacin)
Gram +ve Cocci
VRSA
MRSA
Clindamycin (Dalacin)
MSSA
streptococcus
Gram –ve Bacilli
E.coli
Aminoglycosides
Klebsiella
Pseudomonas
ESCAPPM
Acentobactr
Gram –ve Cocci
N. gonorrhea
N.Meningitides Macrolides
Anaerobes Clindamycin (Dalacin)
Atypical
chlamydia
Macrolides
legionella

31. Tigecycline (Tygacil)
• Uses :
• Primary deposition in soft tissue & abdomen.
• Single agent :
1. stable soft tissue.
2. Stable abdominal infection esp. (toxic megacolon).
• With another agent like :
a) sulperazone/unasyn.
or b)carbapenems
or c) Colistin.
or d) maxipime.
• In Pneumonia other than pseudomonas and in septecemia.
• If used in chest double the dose .
• Spectrum :
• Gram +ve, anaerobes & some atypical.
• Gram -ve except (2P) Pseudomonas( as invanz) & proteus.
• + anti-bacterial toxins activity (soft tissue).
• Advantages :
• used safely without adjustment in renal failure.
• Concentrated in soft tissues & abdomen → effective in in soft tissue &
abdominal infections.
Antibiotics that block
protein production
cidal or static
1. Macrolides
2. Aminoglycosides
3. Clindamycin (Dalacin)
4. Tigecycline (Tygacil)
5. Linezolid (Zyvox)
vs Colistin

32. Tigecycline (Tygacil)
• Side effects :
• ↑↑liver enz ( adjust in child C) not in A& B
• Disadvantages :
1. does not maintain adequate blood level (not used alone in septicemia).
2. weak in chest infections (inactive against pseudomonas + poor chest
penetration).
3. low level in urine (UTI).
4. adjusted in child C classification (as Dalacin or Nexium).
• Dose :
• Adult :
• Loading 100 mg once.
• Maintenance 50 mg /12 hrs.
• In chest infection, septicemia and UTI double the dose :
200 mg once then 100 mg /12 hrs + other agent.
• Pediatric :
• Loading 1.5 - 3 mg/kg once (2mg)
• Maintenance 1-2 mg/kg/dose every 12 hrs (maximum 50mg/dose).
Antibiotics that block
protein production
cidal or static
1. Macrolides
2. Aminoglycosides
3. Clindamycin (Dalacin)
4. Tigecycline (Tygacil)
5. Linezolid (Zyvox)

33. Linezolid (Zyvox)
• Uses :
• In hospital acquired staph.
• Brother of glycopeptides.
• not with dalacin.
• Not recommended for treatment of
CLBSI (central line blood stream infection)
only vancomycin or targocid.
• Used in treatment of VRSA.
• Spectrum :
• Gram +ve & staph
• + anti-bacterial toxins activity (soft tissue).
• Advantages :
• high bioavailability (easy to switch to oral therapy).
• used safely in renal failure.
• good penetration to lung & soft tissue more than vanco.
• Disadvantages :
• photosensitive (special cover).
• large volume (600 ml/day), not preferred if anuric only.
• expensive.
Antibiotics that block
protein production
cidal or static
1. Macrolides
2. Aminoglycosides
3. Clindamycin (Dalacin)
4. Tigecycline (Tygacil)
5. Linezolid (Zyvox)
no value both are anti toxin

34. Linezolid (Zyvox)
• Side Effects :
• lactic acidosis as prolonged adrenaline infusion. ‫طوية‬ ‫فترة‬ ‫ميمشيش‬
• thrombocytopenia (after 10-14 days) esp. in renal patient (rapid and more
aggressive ).
• not used with MAO inhibitors & SSRI due to HTN crisis.
• Dose :
• 600 mg/12hr= 300ml voume
Antibiotics that block
protein production
cidal or static
1. Macrolides
2. Aminoglycosides
3. Clindamycin (Dalacin)
4. Tigecycline (Tygacil)
5. Linezolid (Zyvox)
Daptomycin
anti G +ve, MRSA, VRE
4-6 mg / kg once daily (e.g 500 mg / 24 hr)
good for soft t. MRSA
inactivated by surfactant (NOT for chest)
SE: Myopathy (F/U CPK)

35. Quinolones
• Ciprofloxacin :
• (Cipro) 400mg /8-12hrs IV or 500mg/12hrs PO. Not cover anaerobes.
• Levofloxacin :
• (Tavanic ) 500-750mg/24hrs oral or IV. Not cover anaerobes.
• moxifloxacin :
• 400mg/24hr cover anaerobes but not cover pseudomonas
(as tygacil + not proteus & invanz + not Acinetobacter )
• Spectrum :
• Gram -ve, atypical & some gram +ve.
• Disadvantages :
• In Pediatrics leading to Immature closure of epiphysis → contraindicated in
children below 18 years but can be used for 1 week.
• In Geriatrics leading to DCL& convulsion. Like (Fortum, Tienam &
maxipime).
• Prolonged QT interval (increase absolute refractory period) leading to
V.tach.(as macrolides & Norvasc) & predispose to ventricular arrhythmias.
• rupture of aortic aneurysm
• hypoglycemic episodes (rare).
Antibiotics that target
DNA and replication
All cidal
1. Quinolones
2. Metronidazole (Flagyl)
3. Sulphonamides.
UTI + Abd
Chest + UTI
Chest only no renal Adjust.

36. Metronidazole (Flagyl)
• Spectrum :
• Anaerobes.
• Dose :
• In Adult :
500mg /8hr
• In Pediatric :
1.5 ml/kg/dose/8hr or 7.5mg/kg/dose/8hr.
Antibiotics that target
DNA and replication
All cidal
1. Quinolones
2. Metronidazole (Flagyl)
3. Sulphonamides.

37. Bacteria
G +ve G -ve Anaerobes Atypical
Staph
Strept
Extreme :
MRSA
VRSA
Klebsiella
Pseudomonas
Aniceto
E.coli
Enterobacter
Extreme :
MDR of :
Klebsiella
Pseudomonas
Aniceto
E.coli
Enterobacter
Metronidazole.
But if using one
of these drugs
there is no need
to add
Metronidazole :
Tazocin.
Carbapenems.
Moxifloxacin.
Clindamycin.
Macrolides.
Levofloxacin.
Moxifloxacin.
Tygacil.
Most of B
lactams.
MRSA :
Vancomycin.
Linezolid.
Tarogocid.
VRSA :
Linezolid.
Tarogocid.
Community
Acquired MRSA :
Moxifloxacin.
Clindamycin.
Ceftaroline.
Colistin.
Tygacil.
Carbapenems.
maxipime.
Zavicefta.
Tazocin.
Amikacin.
Quinolones.
Dual attack is a
must :
Carbapenems.
+ Colistin.
If no response
Tripple attack :
Carbapenems.
+ Colistin.
+ Tygacil.

38. • ESCAPPM : Enterobacter, Serratia, Citrobacter, Aeromonas, Proteus, Providencia and Morganella.

39. Common sources of sepsis
Evidence of infection
Two of : temperature > 38 C or HR 90/min, RR > 20/min, or WBC > 12000/uL or < 4000/uL.
Pneumonia/lung abscess clinically (dyspnea/cough/sputum and crepitations/wheezes)
and do (CXR, ABG, CT chest, sputum C/S, and BAL).
infective endocarditis risk groups, ECHO findings, and blood cultures.
Also suspect in FUO and if bilateral lung abscesses.
CVP line infection hyperemia/pus discharge, and do C/S (catheter tip and blood).
UTI/Pyonephrosis/pyelonephritis clinically (dysuria, loin pain, vomiting, and turbid urine)
and do (KFTS, sonar, CTU, and urine C/S).
Peritonitis/intra-abdominal
abscess/pancreatitis
clinically (tender/rigid abdomen and pain)
and do (erect X-ray, sonar, CT scan, enzymes, or exploration).

40. Common sources of sepsis
Evidence of infection
Two of : temperature > 38 C or HR 90/min, RR > 20/min, or WBC > 12000/uL or < 4000/uL.
Meningitis/encephalitis/brain
abscess
clinically (headache, neck stiffness/stretch reflexes, FNDs, or
convulsions/coma)
and do (CSF sampling and CT/MRI brain).
cellulitis/abscess/bedsores/ulcers/g
angrene
for swab and C/S.
Septic arthritis clinically (limited ROM and inflamed joint)
and do (aspiration for TLC with C/S, and joint CT/MRI).
Osteomyelitis tender/red bone with limitation, and do (X-ray/CT/MRI).

41. How to start AB
Stable patient Un stable
• Hemodynamically
unstable
• On steroid therapy.
• Immunosuppressed.
• Prolonged hospital stay >48h with
uncontrolled infection
( Fever, CRP, TLC, Lactate,
Vasoactive medics).
1st Line
• Cephalosporin (3rd or 4th g).
• Or Tazocin.
• Carbapenems (but
invanz not in chest).
• Or Tazocin for 48h if
minimal dose
vasoactive medics.
• Carbapenems (but invanz not in chest).
• Or Tazocin if no resistance for extended
spectrum B lactamase (like :
cephalosporins) in cultures.
+ another agent according to :
a) site of infection b)stable or not and deterioration d) side effects of drugs.

42. Chest infection
Focus on Antipseudomonal and Don’t Rush to MRSA.
Hospital Acquired
• >48 h after admission in hospital.
• With in 30 days of discharge.
Community Acquired
Usually G –ve and focus on Antipseudomonal.
(use double antipseudomonal).
• Strept. Pneumonie.
• H. influenza.
• Atypical.
Stable Un stable No risk of pseudomonal
risk of pseudomonal.
Or Unstable.
1. Maxipime.
OR Tazocin.
1. Carbapenems.
(Tienam or Meropenam).
Not invanz not cover
antipseudomonal.
1. Augmentin.
OR Ceftriaxone.
OR Maxipime.
2. Klacid.
OR Zithro.
NB : if patient on Tavanic
don’t add Klacid or Zithro.
As hospital Acquired.
2. Aminoglycosides (Amikacin iv and Nebulized).
OR Quinolones (Cipro or Levofloxacin).
OR Colistin (iv and Nebulized) especially in cystic fibrosis.
OR Tyagacil and double the dose.
If aspiration : as hospital acquired + or – Dalacin.
2x1

43. Chest infection
Focus on Antipseudomonal and Don’t Rush to MRSA.
• Risk of pseudomonal :
1. Alcoholism.
2. Mechanical ventilation.
3. Chronic bronchiectasis.
4. Septic shock with multiorgan failure.
• Risk of MRSA :
1. CVL infection.
2. Infective endocarditis.
3. Meningitis.
4. Soft tissue infection.
5. Burn infection (late).
• If there is risk of MRSA in chest infection add :
• Antistaph (Vanco, Targo or Linzo).
• If renal (Targo or Linzo).
• If thrombocytopenia (Vanco or Targo).
• If there is Fever + Acute Bilateral lung infiltration
think in Viral Pneumonia :
Add Tamiflu
with normal or low TLC

44. Abdominal infection
1ry peritonitis
• 1st time to be opened upon perforation.
2ry peritonitis
• Not 1st time to be opened upon perforation.
Stable Un stable
Like 1ry unstable
Carbapenems.
OR Tazocin.
+
Antistaph if MRSA suspected as before.
+
Antifungal.
Tazocin.
Or Cephalosporins 3rd or
4th G
+ Metronidazole.
Carbapenems.
OR Tazocin.
If Toxic megacolon Tyagcil + oral vanco or IV Metronidazole.

45. Soft tissue infection
Complicated Burn, Necrotizing fasciitis, Furnier gangrene and Diabetic foot extended to leg or thigh.
Stable Un stable
Tazocin.
Or Cephalosporins 3rd or 4th G.
Tyagcil
Alone.
Carbapenems.
+ Antistaph
(Vanco or Targo).
+ Antistaph
Linzo alone.
NB :
Anti bacterial
toxin.
+ Antistaph (Vanco or
Targo).
+ Antistaph
Linzo alone.
NB :
Anti bacterial toxin.
+ Clindamycin
For bacterial
toxin.
+ Clindamycin
For bacterial toxin.
Diabetic foot
Stable Un stable
Tazocin.
Or Cephalosporins 3rd or 4th G.
Carbapenems.
+ Clindamycin + Clindamycin

46. Meningitis
Hospital Acquired Community Acquired
Vancomycin
LD 20-25 Mg/Kg (max 3gm/day).
MD 15-20 Mg/Kg/dose Q8-12Hr. IV
<50 Y >50 Y or Diabetic or
immunocompromised
Vancomycin
As before
Vancomycin
As before
+
Merpenam.
OR Ceftazidime.
OR Cefipime.
2Gm/Kg/8Hr.
+
Ceftriaxone
2Gm/12Hr.
+
Ceftriaxone
2Gm/12Hr.
+
Rifambicin (Rimactane)
600Mg/24Hr.
+
Unasyn
3Gm/6Hr.
+Acyclovir 10Mg/Kg/8Hr. For 14 days.

47. Infective Endocarditis
1. Gentamycin.
+
2. Vancomycin.
+
3. 3rd generation cephalosporin.
Or Invanz/ Tienam/Meronem.
Or Tazocin.
if congenital heart or with prosthetic valve :
Rifambicin (Rimactane).
Intraocular infection or foreign body.
Vancomycin.
Compound depressed skull fracture
1. Vancomycin
+
2. 3rd generation e.g fortum.

48. After starting AB .. What is Next (/48hr) ?
If Cultures still not appearing
Patient is improving Patient is deteriorating
(fever, lactate, TLC, CRP, dose of vasopressor, cultures).
Continue with the same regimen for 10-14 days. MCA approach :
Medical, Surgical or Attached device.
If Cultures appeared
Patient is improving Patient is deteriorating
And C/S resist the
regimen and sensitive to
another AB
And C/S sensitive to the
regimen (one AB or more)
And C/S resist the regimen
and sensitive to another AB
And C/S sensitive to the
regimen (one AB or more)
Ignore the C/S and
Continue with the same
regimen.
Continue with the same
regimen (the sensitive only
and deescalate the others).
Shift to the AB in C/S. Ignore the C/S and Back to
Patient is deteriorating
without C/S.
• Medical add AB.
• Attached devices may be infected and source should be removed (chest tube, CVL, tracheostomy, drains).
• Surgical (lung abscess, empyema, pneumonia with complete obstruction, surgical wound, leakage (collection),
stoma(retracted or gangrenous), diabetic foot, burn, pockets of pus.

49. Before Medical (add another AB) search for surgical and attached
devices if the source not eliminated there is no improve.
• If the patient on stable group start with unstable.
• If the patient on unstable group add :
• Add anti MRSA & Add antifungal.
• Then Add anti extreme G –ve if suspect.