ssg hospital vadodara

1. ANTIBIOTICS AND THEIR
USES
BY DR.NISHANT SINGH SINSINWAR
R2MEF

2. Introduction to Antimicrobials
ANTIMICROBIALS ARE CHEMICALS THAT INHIBIT THE GROWTH OR KILL
MICROORGANISMS. THEY CAN BE CLASSIFIED INTO BACTERICIDAL AND
BACTERIOSTATIC DRUGS.
BACTERICIDAL ANTIBIOTICS: ANTIBIOTICS THAT WORK BY KILLING
MICROORGANISMS DO IT BY INTERFERING WITH THE STRUCTURE OF THE CELL
WALL OF THE BACTERIUM OR PARASITE.EXAMPLE: PENICILLINS, CEPHALOSPORINS,
FLUOROQUINOLONES, GLYCOPEPTIDES, MONOBACTAMS, CARBAPENEMS
BACTERIOSTATIC ANTIBIOTICS: ANTIBIOTICS THAT WORK BY INHIBITING THE
GROWTH OF ORGANISMS
EXAMPLES: TETRACYCLINES, SULPHONAMIDES, MACROLIDES, CHLORAMPHENICOL,
TRIMETHOPRIM

4. PENICILLINS
PENICILLINS: AQUEOUS AND BENZATHINE PENICILLIN
COVERAGE: STREPTOCOCCI, BASIC ANAEROBES, SYPHILIS (TREPONEMA PALLIDUM)
AMINOPENICILLINS: AMPICILLIN, AMOXICILLIN
COVERAGE: DRUG OF CHOICE FOR ENTEROCOCCI, STREPTOCOCCI, BASIC ANAEROBES, LISTERIA.
ANTI-STAPHYLOCOCCAL PENICILLINS AKA PENICILLINASE-RESISTANT PENICILLIN: CLOXACILLIN,
DICLOXACILLIN,METHICILLIN,OXACILLIN
COVERAGE: METHICILLIN SENSITIVE STAPHYLOCOCCUS AUREUS (MSSA)
PENICILLIN/BLI (BETA LACTAMASE INHIBITOR) COMBINATIONS: AMOXICILLIN-CLAVULANIC ACID,
PIPERACILLIN-TAZOBACTAM
COVERAGE: STREPTOCOCCI, ENTEROCOCCI, MSSA, GRAM NEGATIVES (MORE WITH PIP/TAZ, WHICH ALSO
HAS ANTI-PSEUDOMONAL ACTIVITY), ANAEROBES (INCLUDING BACTEROIDES FRAGILIS)

5. Side effects
1. Neurotoxic
2. A/w Hypersensitivity Reaction ( All B- lactams shows “cross allergy” except
Aztreonam)
3. Jarish Harxheimer Reaction ( due to treponema toxin )
4. Ampicillin worsen Rashes ( C/I in infectious mononucleosis)

6. Cephalosporins
1ST GEN: CEPHALEXIN,CEPHAZOLIN,CEFADROXIL
COVERAGE: STREPTOCOCCI, MSSA, PROTEUS, KLEBSIELLA, E.COLI
2ND GEN: CEFUROXIME, CEFOXITIN, CEFMETAZOLE
COVERAGE: STREPTOCOCCI, MSSA, HAEMOPHILUS INFLUENZAE, NEISSSERIA, PROTEUS, E. COLI, KLEBSIELLA
3RD GEN: CEFTRIAXONE (IV), CEFTAZIDIME (IV), CEFIXIME, CEFOTAXIME, CEFPODOXIME
COVERAGE: STREPTOCOCCI (BETTER THAN 1ST OR 2ND GEN), MSSA (NOT AS GOOD AS 1ST OR 2ND GEN),
BROAD GRAM-NEGATIVE COVERAGE (CEFTAZIDIME EVEN HAS ANTI-PSEUDOMONAL ACTIVITY)
4TH GEN: CEFEPIME (IV) , CEFPIROME
COVERAGE: STREPTOCOCCI (BETTER THAN 1ST OR 2ND GEN), MSSA, BROAD GRAM-NEGATIVE COVERAGE
(BETTER THAN 3RD GEN) AND HAS PSEUDOMONAS ACTIVITY, ALSO ACTIVE AGAINST AMP-C PRODUCERS
“5TH” GEN: CEFTAROLINE (IV) , CEFTOBIPIROLE
COVERAGE: LIKE CEFTRIAXONE WITH MRSA COVERAGE
CEPHALOSPORIN COMBINATIONS: CEFOPERAZONE-SULBACTAM
COVERAGE: ADDITIONAL ACTIVITY ON MDR ACINETOBACTER SPP, PSEUDOMONAS SPP.
S

7.  SIDE EFFECTS OF CEPHALOSPORINS:
 1.Diarrhoea
 2. Nephrotoxic
 3. Bleeding (hypoprothrombinemia)

8. Carbapenems:
 Imipenem v/s Meropenem:
 Imipenem – metabolized by dehydropeptidase inhibitor so administered
with Cilastatin
 Coverage: MSSA, GAS and Pneumococci, anaerobes, gram negative
organisms,
 Extended spectrum b lactamase resistant- Carbepenem
 S/E – Seizures
 Monobactams:
 Aztreonam:
Use in penicillin allergic cases ,only in Gram – bacteria , pseudomonas

9. GLYCOPEPTIDES
 Binds to D-alanyl D-alanine( gram+ bacteria cell wall)
 Effective for Gram + bacterias only
1.Vancomycin
2. Teicoplanin
3. Telavancin
4. Dalbavancin
5. Oritavancin
Vancomycin – orally inactive, t half – 6hrs , dose – 500mg * 4times a day
Doc – MRSA and drug induced colitis (pseudomembranous colitis)
S/E: Rashes (maculo popular)
Red Man syndrome
Nephrotoxic
Ototoxic

10. MRSA INFECTION
 DOC – 1.Vancomycin (1st line)
 Other drugs effective for mrsa –2. Teicoplanin(1st line)
 If Resistant –
 3. Linezolid
 4. Quinupristin/ Dalfepristin (Streptogramins)
 5. Daptomycin S/E- Rhabdomyolysis
 6. Mupirocin(2% oint.) – DOC – Eradication of nasal carriers of staph aureus.

11. ANTIFUNGALS
 Based on mechanism of action systemic antifungals can be divided into three
groups.
 Acting on cell wall: Echinocandins (Caspofungin, Anidulafungin, Micafungin)
 Acting on cell membrane: Azoles (Fluconazole, Itraconazole, Voriconazole,
posaconazole), Polyenes (Amphotericin B)
 Inhibiting protein synthesis: 5 Flucytosine

12. ANTIVIRAL AGENTS
 Agents for treatment of HSV and VZV
 Acyclovir is selectively activated in HSV or VZV-infected cells to acyclovir diphosphate and
triphosphate by cellular enzymes which are a potent, irreversible inhibitor of the DNA polymerases of
HSV types 1 and 2 and VZV.
 Valacyclovir is a prodrug and is converted to acyclovir in vivo.
 Famciclovir is an oral prodrug of the antiviral agent penciclovir. Penciclovir exerts its antiviral effects
by inhibiting DNA polymerase, in a similar manner to that of acyclovir.
 Agents for treatment of CMV
 Ganciclovir triphosphate inhibits CMV DNA polymerase and is incorporated into CMV DNA,
eventually terminating elongation and replication. In HSVand VZV-infected cells, ganciclovir is
phosphorylated by virus-encoded thymidine kinases.

13. Community acquired pneumonia
 Community acquired pneumonia should be suspected in patient presenting with fever, cough with expectoration,
shortness of breath and bronchial breath sounds or crepitations on auscultation.
 Note: No pathogen is identified in majority of the cases.
 Chest X-Ray- presence of lobar consolidation/ interstitial infiltrates and/or cavitations.
 Confirmation of diagnosis- gram staining and culture of sputum sample.
 Treatment
 The severity of CAP and requirement of in-patient care can be ascertained by simple scores such as CURB-65 score.
One point each is awarded if the patient has Confusion, BUN> 20mg/dl, Respiratory rate>30/min, SBP<90mm of Hg or
DBP <60 mm of Hg and Age >65 years. A CURB-65 score of ≥ 2 requires inpatient care.
 Early initiation of empirical antibiotics is the key to the treatment of CAP as it prevents complications and decreases
morbidity & mortality. Pathogen directed therapy should be started as soon as microbiological diagnosis is available
to decrease antimicrobial resistance.
 Etiology: Streptococcus pneumoniae, Haemophilus influenza, Moraxella catarrhalis, Mycoplasma pneumoniae,
Chlamydia pneumoniae

14.  Empirical Treatment:
 Inpatient (CURB-65 ≥ 2)
 [Inj. Ceftriaxone 1 g IV BD or Inj. Amoxicillin-clavulanic acid 1.2 g IV TDS] PLUS Azithromycin 500 mg (IV/PO) OD for 5 days
 Outpatient (CURB-65 ≤ 1)
 Tab Amoxicillin-clavulanic acid 625 mg TDS PLUS Tab Azithromycin 500 mg OD for 5 days
 When risk factors of Pseudomonas are present: (COPD, bronchiectasis, broad-spectrum antibiotics for at least 7 days in the past month,
corticosteroid therapy & malnutrition)
 Replace Ceftriaxone with any of the following:
 Piperacillin/Tazobactam 4.5 gm iv QID or Cefoperazone/Sulbactam 2- 3 gm iv BD (upto TDS in severe infections) or Cefepime 2gm iv TDS
Imipenem 500 mg QID or Meropenem 1g TDS
 Remarks:
 1. Once the etiology of CAP has been identified on the basis of reliable microbiological methods, antimicrobial therapy should be directed
that pathogen.
 2. Duration of antibiotic therapy may be extended if indicated clinically.
 3. Fluoroquinolones should be avoided in the treatment of community acquired pneumonia due to high burden of tuberculosis in India.
 4. Addition of empirical vancomycin: History of IV drug usage, post influenza pneumonia, severe CAP, associated skin and soft tissue
infection.

15.  The following criteria can be used for diagnosing severe pneumonia: (either major criterion or 3 or
more minor criteria)
 Major criteria:
 Invasive mechanical ventilation
 Septic shock with the need for vasopressors
 Minor criteria:
 Respiratory rate ≥ 30/min
 P/F ratio < 250
 Multilobar infiltrates
 Confusion/disorientation
 BUN ≥ 20mg/dl
 WBC < 4000/mm3
 Thrombocytopenia
 Core temperature < 36°C
 Hypotension requiring aggressive fluid resuscitation

16. HAP AND VAP
 Hospital Acquired Pneumonia (HAP) occurs after more than 48 hours of admission and was apparently not incubating at the time of admission.
 Ventilator Associated Pneumonia (VAP) develops after more than 48 hours of mechanical ventilation.
 When a patient is hospitalized/on mechanical ventilation for > 48 hrs develops new or progressive infiltrates on a chest radiograph and has at least 2 of the following
features:
 fever> 100°4F;
 leucocytosis (>12000/µl) or leucopenia (<4000/ µl);
 altered mental status with no other recognizable cause in the elderly;
 new onset purulent sputum or change in sputum character;
 worsening gas exchange (i.e. increased FiO2 requirement);
 new onset or worsening cough or dyspnea; rales or bronchial breathing.
 HAP
 Respiratory samples obtained by spontaneous expectoration, sputum induction or nasotracheal suctioning and are subjected to semiquantitative cultures. Culture
growth is to be considered significant if ≥ 105 CFU/ml.
 VAP
 Respiratory specimens are obtained by Endotracheal aspiration or bronchoalveolar lavage (BAL).
 Culture growth is considered to be significant if ≥ 105 CFU/ml for tracheal aspirate and ≥103 CFU/ml for BAL.
 Treatment
 Empiric antibiotic therapy should be initiated after sending the cultures

17.  A) Empiric (VAP/HAP):
 Preferred:
 Cefoperazone –Sulbactam (3g IV BD) Or Imipenem-Cilastatin (0.5-1gm IV QID)
 Or Meropenem (1 g IV TDS)Or Piperacillin-Tazobactam (4.5 g IV QID)
 plus
 Amikacin (15–20 mg/kg IV OD)
 Alternative:
 Colistin (9MU IV stat followed by 4.5 MU IV BD)
 Or
 Polymyxin B (20000-25000U/kg loading f/b 25000 U/kg/day in two divided doses)
 (To be used in combination with carbapenems/ BL-BLI inhibitors)
 B) Culture proven VAP/HAP:
 -Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa: Choose any one according to culture sensitivity from: Piperacillin-Tazobactam (4.5 g IV
Cefoperazone –Sulbactam (3g IV BD), Imipenem-Cilastatin (500 mg IV QID), Meropenem (1 g IV TDS), Colistin (9MU IV stat followed by 4.5 MU IV BD), Polymyxin B
25000U/kg loading f/b 25000 U/kg/day in two divided doses)
 -MRSA:
 Preferred: Inj. Vancomycin (1g IV BD) or Inj. Linezolid (600 mg IV BD)
 Alternative: Inj.Teicoplanin (400mg IV BD for 3 doses followed by 400mg IV OD)

18.  Special Remarks:
 Levofloxacin (750 mg IV q24h) may be used as an alternative to amikacin as a second anti-pseudomonal agent.
 Nebulized Colistin at a dose of 2.25 to 4.5 MU twice daily or 3 MU thrice daily can be used along with IV Colistin.
 Colistin and Polymyxin B should be used only when there is resistance to all the other tested antibiotics.
 If a patient with suspected VAP has septic shock and rapidly deteriorating status, empiric MRSA coverage can be
added.
 The choice between vancomycin and linezolid to be guided by patient-specific factors (blood cell counts, renal
functions, concomitant nephrotoxic agents)
 De-escalation should be done once the culture reports are available.
 Recommended duration of therapy: 7 days if there is good clinical response or longer if clinically indicated
(immunodeficiency, empyema, lung abscess, cavitation, necrotising pneumonia, etc).
 HAP/VAP due to P. aeruginosa who remain in septic shock/ at high risk for poor outcome when the results of
antibiotic susceptibility testing are known, combination therapy using 2 antibiotics to which the isolates susceptible
rather than monotherapy is preferred.
 Clinical picture and procalcitonin levels may be used to guide discontinuation of antibiotics.

19.  C) Aspergillus Pneumonia:
 Preferred: Voriconazole (6 mg/kg IV every 12 h for 1 d, followed by 4 mg/kg IV
every 12 h; oral therapy can be used at 200–300 mg every 12 h)
 Alternative: Liposomal AmB (3–5 mg/kg/day IV)
 Special Remarks:
 -Therapeutic Drug Monitoring (TDM) should be done in patients receiving
voriconazole (Range: 1-5 mg/L)

20. Empyema Thoracis
 Empyema is collection of pus in the pleural space. It is divided into three stages: exudative, fibrinopurulent and organizing.
 Failure of a community or healthcare associated pneumonia to respond to antibiotic therapy (20- 40% cases of pneumonia have a
parapneumonic effusion, and 5-10% of these parapneumonic effusions may progress to empyema).
 Imaging:
 1) CXR (PA view): at least 175ml is required
 2) USG: Complex septated, complex non-septated and echogenic pleural effusions
 3) CT Scan: Parietal pleural thickening (86%), pleural enhancement (96%) and Split Pleura sign (68%). High attenuation of the
extrapleural adipose tissue in the chest wall.
 Pleural Fluid Analysis: Pus or positive gram stain/culture is diagnostic of empyema.
 Other diagnostic clues: pH<7.2, raised LDH, low glucose and high protein levels.
 Note: Tuberculosis needs to be ruled out in all cases (ZN stain, geneXpert, Liquid cultures, ADA levels)
 Etiology:
 Most common causes of non-tubercular empyema: Streptococcus pneumoniae followed by Staphylococcus aureus, Klebsiella
pneumoniae, Haemophilus influenzae type b and Enterococcus sp.
 Anaerobic causes are rare: Peptostreptococci, Bacteroides sp.
 Post procedure/ hospital acquired: MRSA and Gram-negative bacilli.

21.  Treatment
 Image guided pleural drain must be put for all patients and large bore catheters should be preferred.
 Tube thoracostomy should be combined with close CT or USG follow up to confirm adequacy of
drainage. Persistence of any undrained fluid should prompt additional drains or more aggressive
management.
 Intrapleural fibrinolytics should NOT be used ROUTINELY for complicated pleural effusions and early
empyema.

22. GENITO URINARY DISEASE
 Acute uncomplicated cystitis (females):
 Infection of lower urinary tract without structural or functional abnormality.
 When to suspect: Urinary symptoms (dysuria, burning sensation during micturition, supra-pubic
pain, urinary frequency and urgency)
 How to confirm: Laboratory tests including culture are usually not required for confirmation.
 Etiology: Enterobacteriaceae, Enterococci
 Preferred: Nitrofurantoin monohydrate/macrocrystals 100 mg PO BD for 5 days or Fosfomycin (3
gm) sachet single dose
 Alternative: Amoxicillin clavulunate 1g BD or Cefixime 400 mg BD for 5-7 days
 Remarks: Fluoroquinolone- less preferred (TB endemic area/ Resistance)
 Demonstrate culture negativity during treatment in pregnant individuals

23.  Acute uncomplicated cystitis (males):
 Urinary symptoms in the absence of fever or other features suggestive of pyelonephritis or prostatitis
 Urinalysis for evaluation of pyuria is a valuable laboratory diagnostic test for UTI. Pyuria is present in almost all men with
acute cystitis; its absence strongly suggests an alternative diagnosis. Urine culture — A midstream urine culture is
recommended to confirm the diagnosis of UTI in men
 Etiology: Enterobacteriaceae, Enterococci
 Preferred: Ciprofloxacin 500mg BD or Levofloxacin 750 mg OD for 7 days
 Alternative: Nitrofurantoin monohydrate/macrocrystals 100 mg PO BD for 7 days
 OR Fosfomycin (3 gm) sachet every other day for upto 3 doses
 Remarks:
 Enterococcus not covered in empiric regimen
 If sexually active, rule out gonococcal and chlamydial infection
 If recurrent infection: rule out prostatitis
 Fosfomycin and nitrofurantoin are not effective in prostatitis because of poor penetration

24.  Acute Pyelonephritis :
 Infections of Upper urinary tract (renal parenchyma and renal pelvis)
 Fever (high grade with chills and rigors), urinary symptoms, low backache, costovertebral
and tenderness of costovertebral angle
 Urine (routine and culture) and blood culture should be done before start of treatment.
Imaging (USG/CT Scan) to rule out abscess formation which will require drainage.
 Etiology: Enterobacteriaceae, Staphyloccus spp.
 Preferred: Piperacillin tazobactam 4.5 gm QID or Ertapenem 1 g IV OD for 10-14 days
 Alternative: Imipenem 500 mg QID or Meropenem 1g TDS for 10-14 days

25.  Complicated UTI / Catheter related :
 Complicated UTI: Infection in patients with structural or functional abnormality of genitourinary tract and/or impaired host
defence (Vesicoureteric reflux, Renal insufficiency and transplantation, diabetes mellitus and immunodeficiency or critically ill
patients)
 Fever (high grade with chills and rigors), urinary symptoms in the presence of above-mentioned risk factors
 Urine (routine and culture) and blood culture should be done before start of treatment
 Catheter associated UTI: Infection acquired in health care setting in whom it was not present or incubating at the time of
admission and > 48 hours after catheterization.
 New onset or worsening of fever, rigors, altered mental status with no other identified cause.
 Urine (routine and culture) and blood culture should be done before start of treatment
 Etiology: Enterobacteriaceae, Enterococci, Pseudomonas spp., Acinetobacter spp., Staphylococcus spp.
 Preferred: Meropenem 1g TDS Or Imipenem 500 mg QID for 14 days
 Alternative: Piperacillin tazobactam 4.5 gm QID for 14 days

26.  Bacterial prostatitis (acute and chronic):
 Acute bacterial prostatitis (ABP): Associated with severe prostatitis symptoms, systemic infection and acute bacterial UTI.
 Urinary symptoms associated with fever, genitourinary pain and/ or pelvic pain. Sexual dysfunction/ ejaculatory
may be present. Duration of symptoms <2 weeks
 Urine analysis and culture. Trans-rectal prostatic ultrasonography (TRUS) or computed tomography scan is indicated in
patient refractory to initial therapy. Pelvic ultrasound (or bladder scan) is indicated in ABP patients with severe obstructive
symptoms, poor bladder emptying or physical examination findings of possible urinary retention.
 Chronic bacterial prostatitis:
 same as acute bacterial prostatitis. Duration of symptoms> 2 weeks
 Localization cultures of the lower urinary tract . Imaging (similar to that of ABP).
 Etiology: Enterobacteriaceae
 Preferred: Ciprofloxacin 500mg BD or Levofloxacin 750 mg OD for up to 6 weeks
 Alternative: TMP-SMX DS BD for up to 6 weeks

27.  Asymptomatic bacteriuria :
 Asymptomatic bacteriuria is defined as isolation of a specified quantitative count of
bacteria (>105) in an appropriately collected urine specimen obtained from a person
without symptoms or signs suggestive of urinary infection.
 Indications to treat: Pregnancy, before urological procedures, post renal transplant
 Preferred: Nitrofurantoin monohydrate/macrocrystals 100 mg PO BD for 3-7 days
 Alternative: Amoxicillin clavulunate 1g BD or Cefixime 400 mg BD for 3-7 days
 Note: Nitrofurantoin avoided in third trimester of pregnancy due to risk of hemolytic
anemia in the newborn.

28. SEPSIS
 Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to
infection. The organ dysfunction is represented by an acute increase in the Sequential [Sepsis-related]
Organ Failure Assessment (SOFA) score of 2 points or more (with the baseline assumed to be 0 in
patients without any known preexisting organ dysfunction).
 Septic shock is a subset of sepsis in which particularly profound circulatory, cellular, and metabolic
abnormalities are associated with a greater risk of mortality than with sepsis alone. Clinically they are
identified by a vasopressor requirement to maintain mean arterial pressure of ≥ 65 mmHg and serum
lactate level greater than 2 mmol/L (>18mg/dL) in absence of hypovolemia.
 Adult patients with suspected infection can be quickly screened for likelihood of having poor outcomes
typical of sepsis, if they have at least 2 of the following 3 clinical criteria: (qSOFA)
 1.Respiratory rate of 22/min or greater
 2.Altered mentation
 3.Systolic blood pressure of 100 mmHg or less.

29.  Diagnosis
 In patients with suspected sepsis or septic shock, appropriate routine microbiologic cultures (blood,
respiratory secretions, urine, cerebrospinal fluid, wounds, and other body fluids) should be obtained before
initiation of antimicrobial therapy from all potential sites of infection. If it is not logistically possible to obtain
cultures promptly (45 minutes), the appropriate antimicrobials should be administered.
 Management
 Sepsis management is simplified by using the “bundle” approach. The 1st hour of the patient with sepsis and
septic shock within the healthcare facility is the GOLDEN HOUR.
 Measure lactate level. Remeasure if initial lactate level > 2 mmol/L.
 Obtain blood cultures before administering antibiotics.
 Administer broad-spectrum antibiotics.
 Begin rapid administration of 30mL/kg crystalloid for hypotension or lactate level ≥ 4 mmol/L.
 Apply vasopressors if patient is hypotensive during or after fluid resuscitation to maintain MAP ≥ 65 mm Hg.

30.  Antimicrobial therapy :
 Intravenous antimicrobials must be initiated as soon as possible after recognition and within 1
hour for both sepsis and septic shock.In absence of a definitive diagnosis at presentation. Various
factors which must be taken into consideration for deciding the choice of empiric antimicrobial
therapy:
 Clinical syndrome/site of infection
 Severity of illness
 Concomitant underlying diseases, chronic organ failures, medications, indwelling devices
 Immunosuppression or other form of immunocompromise
 Recent infections, intake of antimicrobials within the previous 3 months
 Patient’s location (i.e., community, healthcare facility)

31.  Treatment (Empirical)
 Preferred
 Imipenem-Cilastatin (500 mg IV q6h) +/- Amikacin (15 mg/kg IV q24h) +/-
Vancomycin (15 mg/kg IV q8–12h) or Teicoplanin (400mg IV every 12h for 3 doses
followed by 400mg IV q24h)
 *If risk factors for candida are present, add Caspofungin 70 mg IV on day 1, then 50
mg IV q24h or Fluconazole 400 mg IV q24h
 Alternative:
 Meropenem 1gm IV q8h or Piperacillin-tazobactam 4.5 gm IV q6h Or Cefoperazone –
Sulbactam (3g IV q12h) +/- Amikacin (15 mg/kg IV q24h) +/- Vancomycin (15 mg/kg
IV q8–12h) or Teicoplanin (400mg IV every 12h for 3 doses followed by 400mg IV q24h)

32.  Remarks:
 The empiric broad-spectrum therapy with one or more antimicrobials should be a clinical decision based on factors
mentioned above
 Septic shock patient must receive empiric combination therapy.
 De-escalation of antimicrobials should be considered daily and at the earliest stage when the clinical situation permits/
once culture susceptibility reports are available.
 Treatment duration of 7 to 10 days is adequate for most cases.
 Longer courses appropriate in slow clinical response, undrainable foci of infection, bacteremia with S aureus, some fungal
and viral infections, or immunologic deficiencies.
 Measurement of procalcitonin levels can be used to support shortening the duration of antimicrobial therapy.
 Risk factors for invasive candida infections include immunocompromised status (neutropenia, chemotherapy, transplant,
diabetes mellitus, chronic liver failure, chronic renal failure), prolonged invasive vascular devices (hemodialysis catheters,
central venous catheters), total parenteral nutrition, necrotizing pancreatitis, recent major surgery (particularly abdominal),
prolonged administration of broad-spectrum antibiotics, prolonged hospital/ICU admission, recent fungal infection, and
multisite colonization.Triazoles are acceptable in hemodynamically stable, less ill patients who have not had previous
triazole exposure and are not known to be colonized with azole-resistant species.

33. SAFE ANTIBIOTICS IN CKD
 NO DOSE ADJUSTMENT IS REQUIRED
 1. Azithromycin
 2. clindamycin
 Doxycycline
 Erythromycin
 Penicillin vk

34.  NO DOSE ADJUSTEMENT IS REQUIRED
 Amoxycillin
 Amoxyclav
 clindamycin
 Clarithromycin
 Metronidazole
 Doxycyline
 Vancomycin
SAFE ANTIBIOTICS IN LIVER DISEASES

35. THANK YOU