1. DR MAGED ABULMAGD,MD,EDIC
CONSULTANT INTENSIVIST, EBGH
ANTIBIOTICS IN ICUANTIBIOTICS IN ICU

2. Antibiotics are amongst the most commonlyAntibiotics are amongst the most commonly
used therapies in critical careused therapies in critical care
Optimising antibiotic use improves patientOptimising antibiotic use improves patient
outcomesoutcomes
Optimising antibiotic use should minimiseOptimising antibiotic use should minimise
pressures on emerging antibiotic resistancepressures on emerging antibiotic resistance
Is antibiotic stewardship the answer?Is antibiotic stewardship the answer?

3. Stewardship “…the careful and responsible management of
something entrusted to one's care
Antimicrobial Stewardship
Healthcare institutional program to ensure appropriate
antimicrobial use
Primary goal optimize clinical outcome while minimizing unintended
consequence
Secondary reduce healthcare costs without adversely impacting quality
of care
Antimicrobial Stewardship
-- “Antimicrobial Management
Team”

4. Value of Stewardship Programs
•
Effective programs can be financially self supporting
and improve patient care
•
Comprehensive programs have consistently
demonstrated a decrease in antimicrobial use
•
51/66 (77%) studies of interventions to improve
antibiotic use in hospitals had positive results
Davey P et al. Cochrane Database of Syst Rev 2005
CID 2007;44:159-77.

5. Principles of antibiotic prescriptionPrinciples of antibiotic prescription
 Right antibioticRight antibiotic
guidelinesguidelines
alert antibioticsalert antibiotics
auditaudit
drug bug mismatchesdrug bug mismatches
inappropriate antibiotics (dual anaerobic cover etc)inappropriate antibiotics (dual anaerobic cover etc)
 Right doseRight dose
dose optimisationdose optimisation
iv to oral switchiv to oral switch
 Right timeRight time
golden hour of sepsisgolden hour of sepsis
 Right durationRight duration
de escalationde escalation

6. Inappropriate Antimicrobial Use is Common
Antimicrobials account for up to 30% of hospital pharmacy
budgets
As many as 50% of antimicrobial regimens are
considered “inappropriate”
Wrong drug, route, interval, frequency, duration
Inappropriate use is associated with:
Increased morbidity and mortality
Increased length of stay (LOS)
Increased adverse events and antimicrobial resistance
Increased costs

7. 33%
32%
16%
10%
0%
5%
10%
15%
20%
25%
30%
35%
REASON UNNECESSARY
Dur. Of Therapy Longer than
Needed
Noninfectious/Nonbacterial
Syndrome
Treatment of
Colonization/Contamination
Redundant
Hecker MT. Arch Intern Med. 2003;162:972-978.
Unnecessary Antimicrobials
Where Do We Go Wrong?
“Unnecessary” Antimicrobial Therapy
• 129 patients/2 wk period
• 576 (30%) of 1941Antimicrobial Day
%UNNECESSARY

8. Total Approved Antibacterials: US
0
5
10
15
20
1983-1987 1988-1992 1993-1997 1998-2002 2003-2007
Total # New
Antimicrobial Agents
IDSA. CID. 2008; (46):155-164, (Modified)
We have Bad Bugs,
No New Drugs Coming!

9. Conventional antibiotics
 Penicillins
 Cephalosporins
 Carbapenems
 Quinolones
 Aminoglycosides
 Macrolides
 Tetracyclines
 Metronidazole
 clindamycin
 Vancomycin
 Teicoplanin
 Cotrimoxazole

10. Newer Classes
 Cyclic lipopeptides (daptomycin)
 Bactericidal against Gram-positive, including
MRSA
 Glycylcyclines (tigecycline)
 Bacteriostatic against Gram-pos, Gram-neg and
MRSA
 Oxazolidinones (linezolid)
 Bacteriostatic and bactericidal against Gram-positive,
including MRSA, VRE

11. Classes
 Bacteriostatic vs Bactericidal
 Narrow vs Broad spectrum

12. Classes
 Bacteriostatic
 Aminoglycosides (Streptomycin, Amikacin,
Gentamicin, Tobramycin)
 Lincosamides (Clindamycin)
 Macrolides (Azithromycin)
 Tetracyclines (Doxycycline)
 Linezolid

13. Bactericidal
 Penicillins
 Cephalosporins
 Monobactams (Aztreonam)
 Carbapenems (Meropenem)
 Quinolones
 Sulfonamides
 Aminoglycosides
 Glycopeptides (Vancomycin)
 Lipopeptides (Daptomycin)
 Metronidazole

14. THE IDEAL
ANTIBIOTIC?:PENICILLIN

Narrow spectrum

Bactericidal

Very selective mode of action

Low serum protein binding

Widely distributed in body esp. CNS

Excreted by the kidneys

15. B-Lactams: Penicillins

Penicillin

Use: pneumococcus, strep, enterococcus, N. meningitidis, syphilis,
listeria, leptospirosis and oral anerobes: peptostreptococcus and
prevotella

Amoxicillin

Use: Covers same stuff as penicillin and expanded activity against
gram negatives ( E.coli, Proteus,H. influenza, H. pylori, N.
meningitidis, shigella, klebsiella); covers most spirochetes including
lyme disease. Clavulanate enhances the gram negative spectrum to
include additional anaerobes such as bacteroides.

Oxacillin/Nafcillin/Dicloxacillin

Use: Only good for staphylococcal spp (except MRSA),
pneumococcus and other streptococci

Piperacillin and Ticarcillin

Use: Piperacillin covers pneumococcus, streptococcal spp
including
enterococcus, gram negative including pseudomonas.

Does not cover MRSA.

16. PENICILLIN IS GENERALLY VERY
SAFE BUT….

Allergic reactions not uncommon-rashes

Most severe reaction being anaphylaxis

A history of anaphylaxis, urticaria, or rash immediately after
penicillin indicates risk of immediate hypersensitivity after a
further dose of any penicillin or cephalosporin (therefore
these must be avoided)

Allergy is not dependent on the dose given ie, a small dose
could cause anaphylaxis

Very high doses of penicillin can cause neurotoxicity

Never give penicillin intrathecally

17. What antibiotics can be used in
penicillin allergy?
• Macrolides: erythromycin, clarithromycin

(mainly gram positive cover)
• Quinolones: ciprofloxacin, levofloxacin
(mainly gram positive cover)
• Glycopeptides (serious infections)
• Fusidic acid, rifampicin, clindamycin (mainly
gram positive)

18. B-Lactams: Cephalosporins
1st generation

Cefazolin:

Use: staph, non-enterococal strep; prophylactic in clean
surgeries, cellultis, folliculitis

Limitations: respiratory tract infections, animal bites or
surgeries involving the colon
2nd Generation

Cefuroxime:

Use: respiratory infections--Strep pneumoniae, H.influenzae
and M.cattarhalis; , meningitis due to pneumococcus,H.flu and
N.meningitidis.

Limitations: enteric organisms/abdominal anaerobes

Cefoxitin/Cefotetan:

Use: intra-abdominal infections especially anerobes

Limitations: staph and other gram positives

19. B-Lactams: Cephalosporins
3rd Generation

Cefotaxime & Ceftriaxone:

Use: Good for staph and non-enterococcal strep; broad
coverage of gram negative and oral anaerobes, CNS,
pulmonary, endovascular, GI infections (excluding gut
anaerobes), sinusitis, otitis, head & neck.

Limitations: does NOT cover Pseudomonas; ceftriaxone can
cause biliary sludging and limits its utility in treating biliary tree
infections

Ceftazidime:

Use: Good gram negative coverage including Pseudomonas;
febrile neutropenia CNS infections- good for Pseudomonas
meningitis

Limitations: reduced activity against the gram positives and oral
anaerobes.
4th Generation

Cefepime & Cefpirome:
 Use: Enterobacter, Citrobacter and Serratia;Pseudomonas;
gram positives; used in neutropenic fever and CNS infections.

20. Beta-Lactams: Carbapenems

Imepenem:

slightly more activity against gram positive
bacteria than meropenem or ertapenem

Ertapenem:

Good for aerobic gram negatives

poor coverage of pseudomonas ,E. faecalis,
nocardia

Meropenem:

Good for aerobic gram negatives

Doripenem:

Good for CNS coverage and pseudomonas

21. Beta-Lactams

Cautions:

Beta-lactam allergy can occur in up to
10%

5%-10% cross-sensitivity in penicillin,
cephalosporins, and carbapenems

Side effects:

diarrhea, nausea, rash

22. Quinolones:

Ciprofloxacin:

Use: Covers most aerobic gram negatives including
Pseudomonas.

penetrates CNS, prostate, lungs

Limited against staph

Non-ciprofloxacin quinolones: Ofloxacin, Levofloxacin,
Moxifloxacin: Gemifloxacin:

Use: Great for respiratory pathogens, most enteric gram
negatives

Only levofloxacin covers pseudomonas

Covers some atypicals: Mycoplasma, Chlamydia, Legionella

Cautions:

Can cause Qt prolongation, tendon rupture, CNS toxicity

Do not use in patients with epilepsy or existing CNS lesions or
inflammation

Side effects:

Commonly causes C diff

23. Macrolides:
Erythromycin, Clarithromycin, Azithromycin

Use:
− Broad spectrum against gram positives
including strep, staph aureus (MSSA)
− Good for atypical oganism such as
Mycoplasma, Chlamydia, Legionella
− Covers N.gonorrhea, H flu, Legionella

Caution:
− can interact with statin to cause myopathy
− Can cause Qt prolongation

Side effects:
− GI upset

24. Clindamycin

Use:

Reasonable gram positive aerobic coverage
against strep and many staph including MRSA

Special role in treating strep in necrotizing
fascitits

Anaerobic coverage better then penicillin but
not as good as metronidazole

Caution:

can interact with neuromuscular blocking
agents and cyclosporine

Side effects:

Diarrhea, commonly causes C difficile—avoid
clindamycin if other good options exist.

25. Metronidazole

Use:

No aerobic activity

Does not stand alone for mixed infections

Good coverage of anaerobes

Can be used for C diff, parasites

Caution:

May require reduced dose in liver disease

Can increase effect of warfarin

Side effects:

Nausea, GI toxicity, antabuse reaction with
Etoh; headache, seizure, peripheral neuropathy
with prolonged therapy.

26. Other major antibiotic groups:
aminoglycosides
• Gentamicin, amikacin (tobramycin,
streptomycin)

Mainly active against gram negative bacteria

Mainly used to treat nosocomial infections

Limiting factors are nephrotoxicity (and
ototoxicity) and resistance

Also used in combination

27. How we give aminoglycosides

For serious nosocomial infections: “extended
interval” or once daily dosing

Rationale based on concentration- dependent
killing and post-antibiotic effect

Reduced risk of nephrotoxicity

In infective endocarditis use lower doses to
give synergy with penicillin

28. Colistin

belongs to the polymyxin group of antibiotics

used intravenously for otherwise panresistant
nosocomial infections, especially those due to
Pseudomonas and Acinetobacter spp

The most important side effect of intravenous
colistin is nephrotoxicity and neurotoxicity

29. Current major resistance problems:
hospital infections
• MRSA: current strains are often multiply-antibiotic
resistant
• VISA/GISA: intermediate resistance to glycopeptides
(thickened cell wall)
• VRSA/GRSA: highly resistant (transferable on
plasmids) from enterococci
• VRE: enterococci (multiply resis tant)

Broad spectrum beta lactam resistant (ESBL) Esch
coli, Klebsiella

Multiply antibiotic resistant enterobacteria:
Acinetobacter, Serratia

30. How to optimize antibiotic administration in critically illHow to optimize antibiotic administration in critically ill
patientpatient
 1)1) ββ-lactams-lactams

Active against most organisms recovered form ICU patientsActive against most organisms recovered form ICU patients

Drug levels are insufficient in patients with severe infectionsDrug levels are insufficient in patients with severe infections

Cefepime(2g taken every 12hr) concentrations were more than 70% aboveCefepime(2g taken every 12hr) concentrations were more than 70% above
target concetnrations in less than half of patients with sepsistarget concetnrations in less than half of patients with sepsis
 Cefepime (2g every 8hr), recentlyCefepime (2g every 8hr), recently

Lipman J, Gomersall CD, Gin T, et al. Continuous infusion ceftazidime in intensive care: aLipman J, Gomersall CD, Gin T, et al. Continuous infusion ceftazidime in intensive care: a
randomized controlled trial. J Antimicrob Chemother. 1999;43:309–11.randomized controlled trial. J Antimicrob Chemother. 1999;43:309–11.
YUMC

31. How to optimize antibiotic administration in critically illHow to optimize antibiotic administration in critically ill
patientpatient
 1)1) ββ-lactams-lactams

Piperacillin concentration, above therapeutic levels for most of the time intervalPiperacillin concentration, above therapeutic levels for most of the time interval
in patients with sepsisin patients with sepsis

Administration of piperacillin by continuous infusion, with a loading dose,Administration of piperacillin by continuous infusion, with a loading dose,
achieved superior pharmacodynamic targets compared with conventional bolusachieved superior pharmacodynamic targets compared with conventional bolus
dosing in septic patientsdosing in septic patients

Meropenem concentration, adequate inMeropenem concentration, adequate in mostmost of the studies in critically illof the studies in critically ill
patientspatients

But in severe infection, meropenem had adequate serum concentration for atBut in severe infection, meropenem had adequate serum concentration for at
least 50% of the time in patients with normal and impaired renal functionleast 50% of the time in patients with normal and impaired renal function
Kitzes-Cohen R, Farin D, Piva G, et al. Pharmacokinetics and pharmacodynamics ofKitzes-Cohen R, Farin D, Piva G, et al. Pharmacokinetics and pharmacodynamics of
meropenem in critically ill patients. Int J Antimicrob Agents. 2002;19:105–10meropenem in critically ill patients. Int J Antimicrob Agents. 2002;19:105–10..
YUMC

32. How to optimize antibiotic administration in critically illHow to optimize antibiotic administration in critically ill
patientpatient

Dose adjustments are necessary to optimize drug concentrationsDose adjustments are necessary to optimize drug concentrations

Early phase of sepsis, broad-spectrumEarly phase of sepsis, broad-spectrum ββ-lactams should be administered more-lactams should be administered more
frequently or in doses larger than suggested in non septic patients with afrequently or in doses larger than suggested in non septic patients with a
dramatic increased of therapy costsdramatic increased of therapy costs

Continous infusion or extendedContinous infusion or extended ββ-lactam infusion are required to optimize-lactam infusion are required to optimize
pathogen exposure to bactericidal concentrations of these drugspathogen exposure to bactericidal concentrations of these drugs

Roberts JA, Lipman J: Pharmacokinetic issues for antibiotics in The critically ill patients.Roberts JA, Lipman J: Pharmacokinetic issues for antibiotics in The critically ill patients.
Crit Care Med 2009, 37:840–851Crit Care Med 2009, 37:840–851
YUMC

33. How to optimize antibiotic administration in critically illHow to optimize antibiotic administration in critically ill
patientpatient
 2) Vancomycin2) Vancomycin

Higher than recommended doses of vancomycin were necessary to optimizeHigher than recommended doses of vancomycin were necessary to optimize
drug concentrations and rescue patients from septic shockdrug concentrations and rescue patients from septic shock

Administration of the conventional dose of vancomycin(15mg/kg of BW everyAdministration of the conventional dose of vancomycin(15mg/kg of BW every
12hr) would probably fail to achieve therapeutic drug concentraions in the12hr) would probably fail to achieve therapeutic drug concentraions in the
majority of critically ill patientsmajority of critically ill patients
 Continuous infusion with 30mg/kg daily dosage has been proposed to optimize PDContinuous infusion with 30mg/kg daily dosage has been proposed to optimize PD
vancomycinvancomycin

Continuous infusion, faster time to achieve target drug concentrations, lowerContinuous infusion, faster time to achieve target drug concentrations, lower
daily dose, reduced therapy costs than intermittent dosedaily dose, reduced therapy costs than intermittent dose
YUMC

34. Duration of antibiotic therapyDuration of antibiotic therapy
 The optimal duration of antibiotic therapy forThe optimal duration of antibiotic therapy for
bacteremia is unknown.bacteremia is unknown.
 There appears to be some evidence thatThere appears to be some evidence that
would suggest that there is no significantwould suggest that there is no significant
difference in mortality, clinical anddifference in mortality, clinical and
microbiological cure between shorter durationsmicrobiological cure between shorter durations
i.e. 5 – 7 days versus 8 -21 days in critically illi.e. 5 – 7 days versus 8 -21 days in critically ill
patients with bacteremia.patients with bacteremia.

35. Strategies to optimize the use of antimicrobials in theStrategies to optimize the use of antimicrobials in the
ICUICU
 1) De-escalation therapy1) De-escalation therapy
 2) Antibacterial cycling2) Antibacterial cycling
 3) Pre-emptive therapy3) Pre-emptive therapy
 4) Use of pharmacokinetic/pharmacodynamic parameters4) Use of pharmacokinetic/pharmacodynamic parameters
for dose adjustmenfor dose adjustmentt
YUMC

36. De-escalation therapyDe-escalation therapy
 Initial administration of broad spectrum empirical treatmentInitial administration of broad spectrum empirical treatment
 Rapid adjustment of antibacterial treatment once the causative pathogenRapid adjustment of antibacterial treatment once the causative pathogen
has been identifiedhas been identified
 ObjectiveObjective

Lower morbidity and mortality by an early achievement of an appropriateLower morbidity and mortality by an early achievement of an appropriate
empirical treatmentempirical treatment

Limit the appearance of bacterial resistance by a reduced antibacterial pressureLimit the appearance of bacterial resistance by a reduced antibacterial pressure
YUMC

37. De-escalation therapyDe-escalation therapy
 Applicability of this strategy, failedApplicability of this strategy, failed

Absence of microbiological resultsAbsence of microbiological results

Isolation of multi-resistant pathogens preventing de-escalationIsolation of multi-resistant pathogens preventing de-escalation

Reluctance of some clinicians to change antibacterials in patients with aReluctance of some clinicians to change antibacterials in patients with a
favorable clinical course despite persistence of severity of illnessfavorable clinical course despite persistence of severity of illness
 Despite limitations, antibacterial de-escalation therapy has beenDespite limitations, antibacterial de-escalation therapy has been
recommendedrecommended
YUMC

38. Antibacterial cyclingAntibacterial cycling
 The scheduled rotation of one class of antibacterialsThe scheduled rotation of one class of antibacterials

One or more different classes with comparable spectra of activityOne or more different classes with comparable spectra of activity

Different mechanisms of resistanceDifferent mechanisms of resistance
 Some weeks and a few monthsSome weeks and a few months
 ObjectiveObjective

Reduce the appearance of resistances by replacing the antibacterial before theyReduce the appearance of resistances by replacing the antibacterial before they
occur and preserving its activity to be re-introduced in the hospital in a later cycleoccur and preserving its activity to be re-introduced in the hospital in a later cycle
YUMC

39. Pre-emptive therapyPre-emptive therapy
 The administration of antimicrobials in certain patients at very high risk ofThe administration of antimicrobials in certain patients at very high risk of
opportunistic infectionsopportunistic infections before the onset of clinical signs of infectionbefore the onset of clinical signs of infection

Developed in hematological patients and/or transplant recipients based on theDeveloped in hematological patients and/or transplant recipients based on the
use of serological tests that advanced the diagnosis of some infectionsuse of serological tests that advanced the diagnosis of some infections

CMV, aspergillosisCMV, aspergillosis

In critical illness patients to patients at high risk of candidemia or invasiveIn critical illness patients to patients at high risk of candidemia or invasive
candidiasiscandidiasis
: In the absence of serological test to establish an early diagnosis of invasive: In the absence of serological test to establish an early diagnosis of invasive
candidiasis, different scores based on clinical and/or microbiological datacandidiasis, different scores based on clinical and/or microbiological data
YUMC

40. Optimize Duration of Antibiotic Therapy
•
Avoid automatic 10-14-day course of therapy
•
New evidence for duration of therapy
– Uncomplicated urinary tract infection: 3-5 days
– Community-acquired pneumonia: 3-7 days
– Ventilator-associated pneumonia: 8 days
– CR-BSI Coagulase-negative staphylococci: 5-7 days
– Acute Hem Osteomyelitis in children-21 days
– Meningococcal meningitis-7 days
– Uncomplicated secondary peritonitis with source control: 4-7 days

41. •Nosocomial infection is an
infection that is not
present or incubating
when a patient is
admitted to a hospital

42. TYPES OF NCI BY SITE
1. Urinary tract infections (UTI)
2. Surgical wound infections (SWI)
3. Lower respiratory infections (LRI)
4. Blood stream infections (BSI)

43. CONSEQUENCES OF
NOSOCOMIAL INFECTIONS
1. Prolongation of hospital stay:
Varies by site, greatest with pneumonias and
wound infections
2. Additional morbidity
3. Mortality increases - in order - LRI, BSI, UTI
4. Long-term physical &neurological
consequences
5. Direct patient costs increased-
Escalation of the cost of care

44. UTI
• Contribute to one third of NCI s
• 80% due to catheter
• 5-10% due to urinary tract manipulation
• Prolongs hospital stay by 1-2 days

45. BACTERIURIA
• PERIURETHRAL COLONIZATION
WITH POTENTIAL PATHOGENS
INCREASES BU BY THREE FOLD
• LATE CATHETERIZATION
INCREASES BU

46. SURGICAL WOUND INFECTIONS
Incidence varies from 1.5 to 13 per 100
operations.
It can be classified as
1- Superficial incisional SWI
2-Deep incisional SWI and
3-Organ/Space SWI.

47. LOWER RESPIRATORY INFECTIONS
MOSTLY SEEN IN ICU
RISK FACTORS
1. TRACHEOSTOMY,
2. ENDOTRACHEAL INTUBATION, VENTILATOR,
3. CONTAMINATED AEROSOLS, BAD EQIPPMENT,
4. CONDENSATE IN VENTILATOR TUBING,
5. ANTIBIOTICS,
6. SURGERY,
7. OLD AGE ,
8. COPD,
9. IMMUNO SUPPRESSION

48. RISK FACTORS FOR
DIARRHEAS
1. BY CLOSTRIDIUM DIFFICILE
2. OLD AGE
3. SEVERE UNDERLYING DISEASE
4. HOSPITALISATION FOR >1 WEEK
5. LONG STAY IN ICU
6. PRIOR ANTIBIOTICS

49. BLOOD STREAM INFECTIONS
(BSI)
• PRIMARY = ISOLATION OF BACTERIAL
BLOOD PATHOGEN IN THE ABSENCE OF
INFECTION AT ANOTHER SITE
• SECONDARY = WHEN BACTERIAARE
ISOLATED FROM THE BLOOD DURING
AN INFECTION WITH THE SAME
ORGANISM AT ANOTHER SITE i.e. UTI,
SWI OR LRI

50. BACTEREMIA (BSI)
BSI ARE INCREASING PRIMARILY DUE TO
INCREASE IN INFECTIONS WITH GM+VE
BACTERIA & FUNGI
MOST COMMON IN NEONATES IN HIGH
RISK NURSERIES
MORTALITY RATE FOR NOSOCOMIAL
BACTEREMIA IS HIGHER THAN FOR
COMMUNITY ACQUIRED BACTEREMIA

51. Case 1
 F/74, DM on oral hypoglycemic drugs
 Presented with fever and malaise, cough with sputum,
tachypnea; chest X-ray revealed bilateral infiltrates
 Travel history, occupation, contact and clustering non-
remarkable
 Received a course of amoxicillin for urinary tract infection
10 weeks ago
 Diagnosis: Community-acquired pneumonia
 Question
 What is the empirical treatment for CAP?

52. Community-acquired pneumonia (CAP)
 Microbiology
 “Typical” organisms
 Streptococcus pneumoniae
 Haemophilus influenzae
 Moraxella catarrhalis
 “Atypical” organisms
 Chlamydia pneumoniae
 Mycoplasma pneumoniae
 Legionella pneumophilia
 Empirical therapy
 Beta-lactams to cover typical organisms
 Doxycycline / macrolides to cover atypical organisms
 Respiratory fluoroquinolones (levo, moxi) for beta-lactam
allergy

53. Community-acquired pneumonia (CAP)
 Empirical therapy (as per IMPACT)
 CAP, out-patient
 Augmentin/Unasyn PO ± macrolide PO
 Amoxicillin PO + clarithromycin / azithromycin PO
 CAP, hospitalized in general ward
 Augmentin / Unasyn IV/PO ± macrolide
 Cefotaxime / ceftriaxone IV ± macrolide
 CAP, hospitalized in ICU for serious disease
 Add cover to Gram-negative enterics
 Tazocin / cefotaxime / ceftriaxone IV + macrolide
 Cefepime IV + macrolide

54. Community-acquired pneumonia (CAP)
 Empirical therapy
 Modifying factors
 Allergy to beta-lactams
 Fluoroquinolone (levofloxacin / moxifloxacin)
 Aspiration likely: anaerobes should be covered
 Augmentin / Unasyn / Tazocin already provide coverage
 Cephalosporins (except Sulperazon) is inactive
 Moxifloxacin
 Bronchiectasis: Pseudomonas cover essential
 Tazocin / Timentin / cefepime + macrolide
 Fluoroquinolone + aminoglycoside

55. Case 2
M/56
Presented with skin redness, warmth,
swelling, tenderness on his right lower limb,
a pocket of fluid palpated
Diagnosis: cellulitis with pus formation
Question
Empirical treatment?

56. Skin and soft tissue infection
Cellulitis
Microbiology
Staphylococcus, Streptococci
Streptococci more likely when cellulitis is
well demarcated and there are no pockets
of pus or evidence of vein thrombosis

57. Staphylococcus aureus
 If susceptible, penicillinase-resistant penicillins are the
drugs of choice for methicillin-susceptible Staphylococcus
aureus (MSSA)
 Drug of choice
 Cloxacillin, flucloxacillin
 Cefazolin, cephalexin (penicillin allergic but tolerate cephs)
 With beta-lactamase inhibitor
 As two-agent combination in Augmentin, Unasyn
 Erythromycin, clindamycin (if penicillin allergic)
 The above antibiotics also have good activity vs.
Streptococci

58. Case 3
 M/59
 Presented with 2-day history of right upper quadrant pain,
fever, jaundice
 Emesis x 2 past 24 hours, dark color urine
 Elevated LFT
 Radiologic finding: dilated common bile duct, no increase
in gallbladder size
 Diagnosis: acute cholangitis
 Question
 What is the empirical therapy?

59. Acute cholangitis/cholecystitis
Microbiology
Gram negative enterics
 E. coli, Klebsiella spp., Proteus spp.
Anerobes
 Bacteriodes fragilis, Clostridium spp.
Enterococcus

60. Acute cholangitis/cholecystitis
Adequate drainage is essential
Empirical treatment complementary to
drainage
Augmentin/Unasyn ± aminoglycoside
Cefuroxime + metronidazole
Ciprofloxacin (if beta-lactam allergic)