• Beta-lactams (cell wall synthesis inhibitors)
• Sulfonamides 
• Fluroquinolones
• Macrolides
• Aminoglycosides
• Tetracyclines 

• Penicllins (PenG, Augmentin, Cloxacillin, Deloxacillin, Pepercillin, Ticarcillin)
• Cephalosporins (Ceftriaxone, Cefotaxime) 
• Carbapenems 
• Vancocymin (for methcillin reisistant Staph)
• Linezolide (for methicillin and vancomycin resistant staph

Part of the sulfonamides

TMP-SMZ

It is Co-trimoxazole 

Folate synthesis + reduction inhibition 

Levoflloxacin 

Moxifloxacin

Gemifloxacin 

Azithromycin 

Clarithromycin 

Erythromycin 

Clindamycin 

Anaerobic infections 

(Macrolide)

Gentamycin

Streptomcyin 

Trimethoprim/sulfamethoxazole (TMP-SMX)

Itraconazole 

Fluconazole 

Amphotericin B 

Oseltamivir

Zanamivir

Amantadine 

Rimantadine 

Ribavirin

1. Isoniazid***
2. Rifampin***
3. Ethambutol***
4. Pyrazinamide***
5. Ribabutin/Rifapentine

***Pneumonia is an inflammatory condition***

• Can be caused by: Bacteria, viruses (influenza virus A; respiratory syncytial virus (RSV) in infants and young children), fungi (histoplasmosis, blastomycosis, pneumocystis carinii pneumonia)  

1. Community acquired (CAP 
2. Hospital acquired pneumonia 

1. Emperical 
2. Non-emperical (after ID on bacterial agent) 

1. Formulate clinical diagnosis 
2. Obtain specimens for lab 
3. Fomulate microbiological diagnosis 
4. Determine necessity for empirical treatment
5. Institute therapy (if you don't know the cause, use broad spec)

• Narrow spectrum 
• Broad spectrum 

• Anti-staphylococcal pencillin (these ONLY inhibit specific types

• Ampicillin
• Tetracycline

• S. pneumoniae
• H. influenzae
• S. aureus
• Gram (-) bacilli 
• Respiratory viruses 

Ceftraiazone 

Do NOT use benzylpencillin 

1. Streptococcus pneumoniae
2. Haemophilus influenzae 
3. Moraxella catarrhalis 

Symptoms of bacterial pneumonia

Physical exam findings

• Fever 
• Productive cough 
• Pleuritic chest pain 

Physical exam findings:

• Purulent sputum 
• Rales over involved lobe/segment 
• Increased tactile fremitus, bronchial breathing, E-to-A change if consolidation has occured
• Decreased tactile fremitus/dullness on chest percussion from pleural effusion (due to H. influenza usually) or empyema 

• Mild CAP:  Treated in an ambulatory settling (treat as out patients in the clinic) 
• Moderate-Severe CAP:  Hospitalized 
• Severe CAP w/ventilation requirement:  ICU

Can use emperical therapy in 3 different settings:

1. Ambulatory (mild) 
2. Hospitalization (moderate-severe)
3. ICU (severe w/ventilation requirement)  

***For young + healthy (17-50 yrs), requirement mostly oral w/single dose***

Oral Macrolides:

• PenG + Mycoplasm spectrum
• Azithromycin or clarithromycin or erythromycin 

Drugs of choice:

• Amoxicillin 
• 3rd generation cephalosporin

***Clindamycin***

Because this will cover anaerobes

Empiric treatment of CAP for ambulatory patients when they are at risk for drug resistant S. pneumonaie

(Ages 17-50)

Oral fluoroquinolones:

• Choice one with good anti-pneumooccal activity
• Levofloxacin or moxifloxacin 

***Oral treatment with fluoroquinolone***

(mostly oral)

Oral cephalosporins are less useful than in the past b/c pneumococcal resistance and lack of activity against atypical pathogens

***These patients are going to use IV preferred over oral treatment***

Use an IV or oral fluroquinolone:

• Use one with good activity against S. pneumoniae 
• Levofloxacin or moxifloxacin can be used alone

***Clindamycin can be added to beta-lactams for oral anaerobes***

Metronidazole can also be used for anaerobes 

***IV-treatment w/combination drugs is a MUST***

Use IV beta-lactam + IV-fluroquinolone:

• IV-ceftriaxone (3rd) or cefotaxime (3rd) or ampicillin/sulbactam 
• PLUS!!! IV-Fluroquinolone (levofloxacin or moxifloxacin) 

In general, improve gram negative coverage:

• Anti-pseduomonal penicillin + penicillinase inhibitor + macrolide or fluroquinolone combination is used 
• This covers atypical organisms (mycoplasm or chlamydia) 

***Gentamycin (gentamicin)***

This can be added to IV-beta lactam + IV-fluroquinolone treatment 

Therapy when bacterial infection is IDed

Emperical treatment of pneumococcal pneumonia (strep pneumonia)

Sensitive vs intermediate vs high reistance 

Sensitive strain:

• Pen-G or Pen-V or amoxillin or macrolide 

Intermediate degress of resistance:

• Ceftriaxone (3rd), cefotaxime (3rd) or high IV-dose of Pen-G
• IV-fluoroquinolone (levofloxacin) 

High degree of resistance (IV use needed):

• Fluoroquinolone + (vancomycin or linezolid) 

Emperical therapy for special CAP 

Drug-resistant S. pneumoniae 

Ceftriaxone (3rd) or cefotaxime (3rd) or...

Levofloxacin or moxifloxacin or...

Vancomycin in severely ill patients 

Emperical therapy for special circumstances of CAP

Community acquired MRSA

Vancomycin 

or linezolid 

Susceptibility testing and resistance patterns w/in the region guide the therapy 

Treat initially with: (drugs that have broad gram-negative)

• Pipericillin/tazobactam 
• Ticarcillin/clavulanate
• Carbapenem 

Treatment with:

• Ticarcillin/clavulanate
• Pipercillin/tazobactam 
• Carbapenem 

PLUS:

• aminoglycoside (gentamicin, tobramycin, amikacianan) 

HAP

Penicillin allergi patients 

***Patients that cannot take pipercillin or ticarcillin***

• Ciprofloxacin or...
• Aztreonam + clindamycin or...
• Vancomycin

• Ciprofloxacin or...
• Aztreonam + clindamycin or...
• Vancomycin 

***Addition of vancomycin***

This is when you have methicillin resistant S. aureus 

**HAP**

• Cefepime (4th) or...
• Imipenem or...
• Meropenem (carbapenems)...

***PLUS aminoglycoside***

This is a good first choice medication

Treatment of S. pneumoniae 

Sensitive 

Intermediate 

High resistance 

Sensitive organisms:

• Pen-G or...
• Pen-V or...
• Amoxicillin 

Intermediate resistance:

• High dose Pen-G IV or...
• Ceftriaxone (3rd) or...
• Cefotaxime (3rd) 

High-resistance:

•  Vancomycin 
• Ceftriaxone (3rd) or cefotaxime (3rd) 
• Levofloxacin, gatifloxacin, or moxifloxacin 
• Acute agent that i used is going to be based on susceptibility testing 

Macrolide:

• Azithromycin; clarithromycin; or erythromycin 

Tetracycline:

• Doxycycline 

Macrolide:

• Azithromycin, clarithromycin, or erythromycin 

Tetracycline:

• Doxycycline 

**H. influenzae is a gram - rod**

• 2nd or 3rd generation cephalosporin 
• Amoxillin/clavulanate (augmentin) 

**This is a gram - rod**

• Azithromycin +/- rifampin 
• Fluroquinolone +/- rifampin 
• Erythromycin +/- rifampin 

• 3rd or 4th generation cephalosporin 
• In severly ill patients, add aminoglycoside to the 3rd or 4th generation cephalosporin 

• 3rd or 4th generation cephalosporin 
• For severely ill patients, add aminoglycoside (gentamicin, tobramycin, amikacin) 

**gram - cocci**

When methicillin-sensitive:

• Penicillinase-resistant penicillin 
• Oral-  cloxacillin or dicloxacillin is preferred 
• Parenteral-  nafcillin or oxacillin 

These will include bacteria like bacteroides, fusobacterium, peptostreptococcus

• Clindamycin or...
• Metronidazole 

**PCP is a fungus that is in AIDS patients**

Use trimethoprim/sulfamethoxazole 

• Still leading cause of death by infection in the world 
• Difficult to stain 
• Acid-fast stain is performed to detect this
• Grows slowly and so it is relatively resistant to antibiotics, you MUST TREAT FOR 2 YEARS
• Lipid-rich cell wall is impermeable to many agents
• This is an intracellular organism and so is inaccessible to many drugs 
• Many of these strains are resistant to drug therapy, requires mutliple drugs 

Isoniazid

Rifampin 

Ethambutol 

Pyrazinamide 

Rifabutin, Rifapentine 

Streptomycin 

Ethionamide

Aminosalicylic acid 

Capreomycin

Cycloserine 

1. Treatment of latent infection:  This is going to be diagnosed by a +PPD 
2. Treatment of active clinical TB:  Confirmed by X-ray 

INH for 9 months in a single dose 

Daily refampin alone for 4 months 

• Patients on immunosuppressants (TNF-alpha inhibitors)
• HIV 
• Patient receiving cancer chemo
• Infliximab
• Etanercept 
• Adalimumab 
• Person with close contact with recent TB patient 
• People with radiographic evidence of TB 
• Recent immigrants 

Isoniazid 

Rifampin 

Ethambutol 

Pyrazinamide 

**continuation phase***

INH + rifampin or...

Rifapentine for 4 months 

Isoniazid (INH) 

MOA 

Metabolism 

SE 

• MOA:  Inhibits mycolic acid formation in the outer membrane, which is unique to mycobacteria
• Metabolism:  Acetylated in the liver.  There are "fast" acetylators that have lower levels of active drug and "slow" acetylators that reach toxic levels fast
• SE:  Drug-induced hepatitis (elevated liver enzymes); peripheral neuritis (high dose); immunologic reactions (fever and skin rash); drug interactions 

Rifampin 

MOA 

SE 

• MOA:  Inhibits DNA-dependent RNA polymerase and it is a broad spectrum antibiotic 
• SE:  Can cause body secretions to turn orange (harmless); STRONGLY induces cytochrome P450 drug metabolzing enzymes which increases the elimination of other drug

Pyrazinamide 

MOA 

SE 

• MOA:  Unknown
• SE:  Hepatotoxicity (1-5%); nausea; vomiting 

Ethambutol 

MOA 

SE 

• MOA:  Inhibits mycolic acid synthesis 
• SE:  Can impair color vision; optic neuritis 

Streptomycin 

MOA 

SE 

• MOA:  This is injectable.  It is bacteriocidal.  Protein synthesis inhibition 
• SE:  Vestibular damage, hearing loss, renal complications 

Histoplasmosis

Cause of disease 

Symptoms 

Risk factors 

Signs of infection 

• Cause: Cave exploring to tennessee; bird + bat dropping in the soil of the cave might be the cause
• Symptoms:  Asymptomatic, mild pneumonia, calcified granuloma
• Risk factors:  Immunocompromised
• Signs:  Bilateral rash on patient's lower extremities 

Blastomycosis 

Cause

Symptoms 

Location 

• Cause:  Soil or rotten wood 
• Symptoms:  Fever, night sweats, weight loss, skin and lung granulomas 
• Location:  East Mississippi; Central america 

• DOC:  Amphotericin-B (DOC for systemic mycoses) 
• 2nd DOC:  Itrconazole or fluconazole 

• DOC:  Amphotericin B (DOC for systemic mycoses) 
• 2nd DOC:  Itrconazole or fluconazole 

Amphotericin B

MOA 

SE

ROA 

• MOA:  Binds ergosterol in fungal cells and increases membrane permeability 
• ROA:  Slow parenteral administration is necessary
• SE:  Febrile response + delayed nephrotoxicity 

Oseltamivir

Amantadine

Rimantidine 

Amantadine and rimantadine 

MOA 

Use

How to use

• MOA:  Inhibits uncoating of viral nucleic aicds.  Inhibits viral replication.  
• Use:  RNA viruses and prophylaxis of type-A influenza
• How to use:  Initiate trt w/in 48 hrs of initial symptoms 

Ribavirin 

MOA

Use

ROA

• MOA:  Synthetic guanosine analog that inhibits viral mRNA synthesis 
• Use:  Active against broad spectrum RNA + DNA viruses.  Used to treat RSV 
• ROA:  Aerosol, oral, IV 

• MOA:  Viral neuraminidase inhibitor.  Neuraminidase s essential for the release of the virus from the infected cells and for its spread throughout the respiratory tract.  Enzyme cleaves terminal sialic acid residues, and destroys the cellular receptors recongized by the viral hemaggluttinin.  Both act through competitive + reversible inhibition of the active site of influenze A and B viral neuramindase and have little affect on mammal cell enzymes 

• Approved for influenza in adults and children (>7 for zanamivir and >1 for oseltamivir) who are symptomatic for < 2 days
• Oseltamivir is also approved for prophylaxis of influenza in > 13 years of age 
• Oseltamivir (oral) is stock piled in case of a bird flu H5N1 pandemic 
• Zanamivir comes in powder inhaler form