Neurosurgery
Bugs and DrugsBacteria Review:Gram Positive cocci:Clusters: staph speciesPairs and Chains: Enterococcus and Streptococcus species (S. pneumonia are diplococcic)Anaerobes: Peptostreptococcus speciesGram Positive rods: B. anthracis, ListeriaAnaerobes: Clostridium speciesGram Negative rods: E. coli, Klebsiella, Proteus, Morganella, Salmonella, Shigella, Enterobacter, Vibrio, Stenotrophomonas, Pseudomonas, Proteus, AcinetobacterAnaerobes: Bacteroides, Fusobacterium, Prevotella Gram negative cocciDiplococci: Neisseria (gonorrhea and meningitides), MoraxellaCoccobaciili: Haemophilus species, Eikenella, Bordatella, Campylobacter species, Legionella, H. pyloriBacteria without cell wall: Mycoplasma, UreaplasmaDrugs:Beta LactamsPCNNatural PCNs: mostly gram + coverage – narrowest spectrum Pen G, Pen VKAntistaphylococcal PCNs: MSSA and susceptible S. epi only Oxacillin, Nafcillin, Dicloxacillin AminoPCNs: mostly gram + coverageAmpicillin/Amoxicillin Beta-lactam/Beta-lactamase inhibitor combos: Ampicillin-sulbactam, piperacillin-tazobactam,, amoxicillin-clavulanate, ticaracillin-clavulanateCephalosporins: Increasing gram – coverage with 4th gen having pseudomonal coverage1st Gen: cefazolin, cephalexin2nd Gen: cefuroximeCephamycins: Cefoxitin, cefotetan Anaerobe coverage 3rd Gen: ceftriaxone, cefixime, cefpodoxime, cefuroxime4th Gen: cefepime“5th Gen”: ceftarolineCarbapenems: gram -/+, anaerobesErtapenem, meropenem, imipenem/cilastin, doripenemMonobactam: gram – coverageAztreonamAminoglycosides: gram negative coverage; levels requiredPeak levels measured 30 mins after termination of infusion Peaks represent efficacy Trough levelsTroughs monitored to avoid toxicity Ordered 30 mins prior to 3rd dose Target concentrations Gentamicin and tobramycin Traditional dosingMild to moderate infectionsPeak = 6 to 8 mcg/mLTrough <2 mcg/mLSevere infections Peak = >8 mcg/mLTrough = <2 mcg/mLOnce-daily dosingDraw random level 6-12 hours after initial infusion and assess with UHS nomogram found on clinical intranetMacrolides: gram +, mycoplasmaAzithromycin, clarithromycinFluoroquinolones: broad spectrum coverage + mycoplasmaMoxi (anaerobes), levo, cipro Lincosamides: gram +, anaerobesClindamycinOxazolidinones: gram + including MRSALinezolidNo dosage adjustment needed in renal impairmentIV = PO (100% oral bioavailability)Sulfonamides: mostly gram +, some gram -, anaerobesTMP-SMX (Bactrim)Vancomycin: MRSA, MRSE, c-diff (oral only)Order trough 30 mins prior to 4th dose Oral Vancomycin indicated for C. difficileTroughs not needed – not systemically absorbedAntifungals:Amphotericin, Fluconazole, Micafungin, VoriconazolePolymyxins: Multi-drug Resistant organisms Pseudomonas, Acinetobacter, E. coli, Stenotrophomonas, Klebisiella, legionellaColisitinTreatment Strategies for Common Infections:Community Acquired Pneumonia:Most common etiologies: strep pneumo, MSSA, H. flu, MoraxellaFor patients in the ICU: 2nd/3rd generation cephalosporin, beta-lactam/beta-lactamase inhibitor combo + macrolide or respiratory FQ (moxi/levo)HCAP, VAP, HAP: need broad spectrum coverage: gram +, gram -, possibly pseudomonas and MRSACefepime + vancomycin, Piperacillin/Tazo + vanc, Meropenem + vancMDR PNA: patients with a h/o resistant organisms, current hospitalization >5 days, significant drug resistance in unit/communityBroad coverage as above in HCAP + addition of FQ, aminoglycoside or ColistinUTI: most common organisms E.coli followed by pseudomonas, proteus, klebsiella, enterobacterStarting with broad gram negative coverage (3rd generation cephalosporin) unless concern for MDR organisms. Narrow with culture results ................
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