antibiotic selection.pdf

8/9/2019 ANTIBIOTIC SELECTION.pdf

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ANTIBIOTIC SELECTION ANTIBIOTIC SELECTION

ByBy

Prof. ABDEL FATTAH ABDEL SATTARProf. ABDEL FATTAH ABDEL SATTAR

HEAD OF ANESTHESIA & PAIN RELIEFHEAD OF ANESTHESIA & PAIN RELIEF

DEPARTMENTDEPARTMENT

NATIONAL CANCER INSTITUTENATIONAL CANCER INSTITUTE

CAIRO UNIVERSTIYCAIRO UNIVERSTIY

20072007


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Topics:

Introduction.

Antibiotic Review.

Principles of Antibiotic choice.

Surgical Prophylaxis -- antimicrobial use


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ANTIBIOTICS REVIEW ANTIBIOTICS REVIEW

Since the development of Sulphonamides inSince the development of Sulphonamides in1930 and Penicillin in 1940, numerous effective1930 and Penicillin in 1940, numerous effective

antibacterial, antifungal and recently antiviralantibacterial, antifungal and recently antiviralagents have become available.agents have become available.

TheThe similaritiessimilarities of many of these antibiotics areof many of these antibiotics aremore striking than their differencesmore striking than their differences..

The newest antibiotic is often not the bestThe newest antibiotic is often not the best

choice.choice. Therefore obtaining culture in conjunction withTherefore obtaining culture in conjunction with

susceptibility testing is imperative.susceptibility testing is imperative.


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The empiric use of antibiotics is the normThe empiric use of antibiotics is the norm

rather than exception.rather than exception. The physician should be familiar with theThe physician should be familiar with the

suspected organismssuspected organisms for bothfor both communitycommunity

andand hospital acquired infectionhospital acquired infection..

Choice will consider Choice will consider ::

The nature of the infectionThe nature of the infection (What organisms(What organismsare most likely involved) .are most likely involved) .

Understanding of different antibioticsUnderstanding of different antibiotics(spectrum and limitations)(spectrum and limitations)

The patient factorsThe patient factors (renal or hepatic(renal or hepatic

dysfunction are common in ICU patient) .dysfunction are common in ICU patient) .


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The selection of specific antibioticsThe selection of specific antibiotics

depends on:depends on:1.1.

The presumed site of infectionThe presumed site of infection

(see table 1(see table 1below).below).

Table 1: Frequency of Source of InfectionTable 1: Frequency of Source of Infection

Respiratory TractRespiratory Tract

25%25%

Abdominal / Pelvic Abdominal / Pelvic

25%25%BacteremiaBacteremia

15%15%

Urinary TractUrinary Tract

10%10%

SkinSkin

5%5%IV Catheter IV Catheter

5%5%

Other sourceOther source

15%15%


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22--

Gram's stain results .Gram's stain results .

33--

Suspected or known organismsSuspected or known organisms

44--

Resistance patterns of the commonResistance patterns of the common

hospital microbial flora.hospital microbial flora.55--

PatientPatient’’s immune status (especiallys immune status (especially

neutropenia and immunosuppressiveneutropenia and immunosuppressivedrugs), allergies, renal dysfunction, anddrugs), allergies, renal dysfunction, and

hepatic dysfunction.hepatic dysfunction.

66--

Antibiotic availability, hospital resistance Antibiotic availability, hospital resistance

patterns, and clinical variables of patientpatterns, and clinical variables of patient

to be treatedto be treated


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CLASSIFICATION & PATHOGENICITY CLASSIFICATION & PATHOGENICITY

OF MICROBESOF MICROBES11--BACTERIABACTERIA::

* Gram* Gram--stained: positive, negative.stained: positive, negative.* Acid fast bacilli: Mycobacterium(TB,Leprae).* Acid fast bacilli: Mycobacterium(TB,Leprae).* Spirochetes: Treponema (Syphilis),* Spirochetes: Treponema (Syphilis),Leptospira, Borrelia(Relapsing Fever).Leptospira, Borrelia(Relapsing Fever).

22-- Viruses Viruses::

DNA & RNA containing viruses.DNA & RNA containing viruses.

33--FungiFungi::

* Filamentous: Tinea, Aspergillus.* Filamentous: Tinea, Aspergillus.** True Yeast: Cryptococcus neoformans.True Yeast: Cryptococcus neoformans.* Yeast like: Candida albicans.* Yeast like: Candida albicans.

44--

ProtozoaProtozoa

::Toxoplasmosis,Leishmaniasis,Toxoplasmosis,Leishmaniasis,Trichomonas.Trichomonas.


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GRAMGRAM--STAINED BACTERIAL PATHOGENSSTAINED BACTERIAL PATHOGENS

GramGram--

positive cocci (Aerobic):positive cocci (Aerobic):* Staphylococcus:S.aureus, albus(epidermis).* Staphylococcus:S.aureus, albus(epidermis).

* Streptococcus:S.pneumoniae, S.pyogenes* Streptococcus:S.pneumoniae, S.pyogenesS.viridian's, S.faecalis(enterococci).S.viridian's, S.faecalis(enterococci).

GramGram--positive cocci(Anaerobic):positive cocci(Anaerobic):

putridus

GramGram--positive bacilli(Aerobic):positive bacilli(Aerobic):* Non* Non--poring: Corynobacterium(c.dipht.),poring: Corynobacterium(c.dipht.),Listeria (L.monocytogens)..B.Anthrax(Spor).Listeria (L.monocytogens)..B.Anthrax(Spor).

GramGram--

positive bacilli(Anaerobic):positive bacilli(Anaerobic):* Sporing:* Sporing: Clostridium tetani,welchiiClostridium tetani,welchii..* Non* Non--sporing: propionibacter(p.acnes)sporing: propionibacter(p.acnes)

Actinomycetes(A.israelii). Actinomycetes(A.israelii).


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GramGram--negative cocci (Aerobic):negative cocci (Aerobic):

**

Nersseria: N.meningitidis, N.gonorrhoae.Nersseria: N.meningitidis, N.gonorrhoae.GramGram--negative cocci (Anaerobic):negative cocci (Anaerobic):

Gram negative bacilli (Aerobic):Gram negative bacilli (Aerobic):

(a) Enterobacteria: E.coli, K.aerogenes,(a) Enterobacteria: E.coli, K.aerogenes,Proteus S.typhi, Sh.sonnei, Serrattia.Proteus S.typhi, Sh.sonnei, Serrattia.

(b) Pseudomonas: P.aeruginosa.(b) Pseudomonas: P.aeruginosa.( c)Parvobacteria: Haemophilus( H.influenza)( c)Parvobacteria: Haemophilus( H.influenza)Brucella(B.abortus), Bordetella(B.pertussis).Brucella(B.abortus), Bordetella(B.pertussis).

(d) Vibrios(V.cholerae).(d) Vibrios(V.cholerae).(e) Legionella: L.pneumoehila.(e) Legionella: L.pneumoehila.

GramGram--negative bacilli (Anaerobic)negative bacilli (Anaerobic)

* Bacteroides(B.fragelis).* Bacteroides(B.fragelis).


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InIn intensive care units approximately 25% ofintensive care units approximately 25% of

infections are confirmedinfections are confirmed gram negativegram negative,,25%25% gram positivegram positive, 20%, 20% mixed grammixed gram

positive/gram negativepositive/gram negative, and 3%, and 3% fungafungal.l.

Of the gram negative organismsOf the gram negative organisms, the, the

organisms in order of likelihood areorganisms in order of likelihood are e.colie.coli(25%),(25%), klebsiellla/citrobacter klebsiellla/citrobacter (20%),(20%),

pseudomonaspseudomonas (15%),(15%), enterobacter enterobacter (10%)(10%)andand proteusproteus (5%); the remaining 25% is(5%); the remaining 25% is

made up of dozens of differentmade up of dozens of different bacteriaebacteriae..


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Of the gram positive infectionsOf the gram positive infections, by far, by far

the most common isthe most common is staphylococcusstaphylococcusaureusaureus (35%), followed by(35%), followed by enterococcusenterococcus

(20%),(20%), coagulasecoagulase negative staphylococcusnegative staphylococcus

(15%) and(15%) and streptococcusstreptococcus pneumoniaepneumoniae

(10%). The vast majority of(10%). The vast majority of fungalfungal

infections areinfections are candidalcandidal..


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ORGANISMS & SITE of INFECTIONORGANISMS & SITE of INFECTION

** S.aureusS.aureus skin,soft tissue,bone,IV linesskin,soft tissue,bone,IV lines..

** Strept(A).Strept(A).

skin,soft tissue,fascial infectionskin,soft tissue,fascial infection** EnterococciEnterococci Biliary,urinaryBiliary,urinary, colonic infection, colonic infection

** Pseudomonas aerugPseudomonas aerug..

lung, skin infectionlung, skin infection** KlebsiellaKlebsiella Infection around biliary TractInfection around biliary Tract

** ProteusProteus Urosepsis.Urosepsis.

** E.coliE.coli Intraabdominal pelvic or urinaryIntraabdominal pelvic or urinary

** ClostridiumClostridium skin,soft t., biliary, colonicskin,soft t., biliary, colonic


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PENICILLINSPENICILLINS

Penicillins have predictable activity againstPenicillins have predictable activity against

gram+ve coccigram+ve cocci →→(Streptococci).(Streptococci).

Ampicillin Ampicillin && Amoxycillin Amoxycillin →→some gramsome gram--ve bacillive bacilli

MethicillinMethicillin ((StaphcillinStaphcillin)) →→ StaphStaph albusalbus..

Piperacillin, Ticracillin, Mezlocillin and AzlocillinPiperacillin, Ticracillin, Mezlocillin and Azlocillin

→→ Anti Anti--pseudomonas penicillins.pseudomonas penicillins.

They should be used in combination with anThey should be used in combination with an

aminoglycoside or agent with antiaminoglycoside or agent with anti-- gramgram--Ve.Ve.

They have no anti gramThey have no anti gram--veve activity.activity.


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CEPHALOSPORINSCEPHALOSPORINS●●11stst

generationgeneration→→

active against gram+ve.active against gram+ve.e.g.:Cephalexine.g.:Cephalexin

((KeflexKeflex), Cephardine (), Cephardine (Velosef Velosef ))

●●33₫ ₫ generationgeneration→→

active against gramactive against gram--ve.ve.e.g.:e.g.: CefotaximeCefotaxime

((ClaforanClaforan), Cefoperazine), Cefoperazine((Cefobid),Cefobid),

Cefotriaxone (Cefotriaxone (RociphenRociphen),),

Ceftazidime (Ceftazidime (FortumFortum))

●●22₫ ₫ generationgeneration→→

mixed activity.mixed activity.

e.g.: Cefuroxime (e.g.: Cefuroxime (Zinnat).Zinnat).44thth

generationgeneration: gram: gram--ve(p.auregve(p.aureg.) +.) +strept.+staphstrept.+staph+limited activity against anaerobes.+limited activity against anaerobes.

e.g.; Cefipime (e.g.; Cefipime (MaxipimeMaxipime))

P i illi S l F dP i illi St t l F t d


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Penicillin Structural Features andPenicillin Structural Features and

Requirements for Antibacterial ActivityRequirements for Antibacterial Activity

PenicillinsPenicillins

have similar structures: ahave similar structures: a

thiazolidinethiazolidine

ring (A)ring (A) atachedatached

to ato a ßß--

lactamlactam

ring (B).ring (B).

SubstituentsSubstituents

are attached to the aminoare attached to the aminogroup (R). Moieties A and B togethergroup (R). Moieties A and B together

constitute the 6constitute the 6--aminopennicillanicaminopennicillanic

acid nucleus required foracid nucleus required for

antibacterial activity.antibacterial activity.

Cleaving theCleaving the ßß--lactamlactam

ring byring by

penicillinasespenicillinases

((ßß--lactamaseslactamases) results) results

in loss of antibacterial properties.in loss of antibacterial properties.

PenicillinsPenicillins

may also be inactivated bymay also be inactivated by

amidasesamidases..

Static figure (left top): Nitrogen atomsStatic figure (left top): Nitrogen atoms

are red, sulfur light blueare red, sulfur light blue--green andgreen and

oxygen atoms are green.oxygen atoms are green.

3D interactive figure (left, bottom) atoms3D interactive figure (left, bottom) atoms

areare identifiedidentified


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BETABETA--LACTAMASE INHIBITORSLACTAMASE INHIBITORS

BetaBeta--LactamasesLactamases are bacterial enzymes thatare bacterial enzymes thatinactivateinactivate betabeta--lactams antibioticslactams antibiotics ((PenicillinsPenicillins &&cephalosporinscephalosporins).).

BetaBeta-- lactamase inhibitors bind to the enzymeslactamase inhibitors bind to the enzymespreventing them from inactivating antibiotics.preventing them from inactivating antibiotics.

e.g. Sulbactam + ampicillin =e.g. Sulbactam + ampicillin = Unasyn.Unasyn.Clavulanate +amoxycillin =Clavulanate +amoxycillin = Augmentin. Augmentin.

Tazobactam +piperacillin =Tazobactam +piperacillin = Tazocin.Tazocin. They are active against betaThey are active against beta--lactamases oflactamases of

nisseria gonorrhea, K.pneumonia, H.influenza,nisseria gonorrhea, K.pneumonia, H.influenza,s.aureuss.aureus m.cattaralis but less to Pseudomonasm.cattaralis but less to Pseudomonas


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CARBAPENEBSCARBAPENEBS

Imipenem & MeropnemImipenem & MeropnemThey are active against mostThey are active against most aerobicaerobic

andand

anaerobicanaerobic

gram +vegram +ve

&& gramgram – –veve

organismsorganisms.. Imipenem (Imipenem (TienemTienem))→→ Cilastatin sodium toCilastatin sodium to

prevent renal metabolism &prevent renal metabolism &↓↓ nephrotoxicitynephrotoxicitybut have CNS adverse effect (seizuresbut have CNS adverse effect (seizures).).

Meropenem (Meropenem (MeronemMeronem))→→ nono cilastatincilastatin

↓↓

epileptogenic &epileptogenic &↓↓Renal degradation.Renal degradation.↑↑activity against aerobic gramactivity against aerobic gram – –ve bacillive bacilli..


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MONOBACTAMS & AMINOGLYCOSIDESMONOBACTAMS & AMINOGLYCOSIDES

Aztreonam Aztreonam

(( A Azactamzactam):):

Extremely effective againstExtremely effective against aerobic gramaerobic gram--vevebacillibacilli including P.aeuroginosa.including P.aeuroginosa.

Narrow spectrumNarrow spectrum →↓→↓emergence ofemergence of resistantresistantbacteria.bacteria.

Aminoglycosides Aminoglycosides::

Gentamicin, AmikacinGentamicin, Amikacin

Have great activity againstHave great activity against gramgram--ve bacilli.ve bacilli.

Post antibiotic effectPost antibiotic effect→→ ↑↑dose interval.dose interval.

Nephrotoxicity and Ototoxcicity.Nephrotoxicity and Ototoxcicity.


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MACROLIDESMACROLIDES

ErythromycinErythromycin

AzithromycinAzithromycin ClarithromycinClarithromycin

All have activity against Clamydia pneumoniae, All have activity against Clamydia pneumoniae,Mycoplasma pneumoniae & Ligionella spices.Mycoplasma pneumoniae & Ligionella spices.

The latter two have greater activity against H.infleunzaThe latter two have greater activity against H.infleunza

& nontuberculus mycobacterium.& nontuberculus mycobacterium. Used in critically ill patients suspected of havingUsed in critically ill patients suspected of having

Atypical pneumonias.Atypical pneumonias.


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QUINOLONESQUINOLONES

They bind to bacterial DNA, prevent replicationThey bind to bacterial DNA, prevent replication

Excellent bioavailabilityExcellent bioavailability

((effective orally as IVeffective orally as IV).).

Ciprofloxacin,Ciprofloxacin, OfloxacinOfloxacin , , NorfloxacinNorfloxacin::

Active against gram Active against gram--ve (ve (antianti--pseudpseud.) &Staph..) &Staph.

Limited activity against anaerobes &Limited activity against anaerobes & StreptStrept..

LevofloxacinLevofloxacin , Moxifloxacin,Garifloxacin , Moxifloxacin,Garifloxacin::

↑↑activity against Anaerobic&Strept.pneumon.activity against Anaerobic&Strept.pneumon.

activity against atypical Pneumon(Ligionella).activity against atypical Pneumon(Ligionella).


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VANCOMYCIN VANCOMYCIN

•• TricyclicTricyclic glycopeptideglycopeptide

active against:active against:BB lactamlactam

resistant Gram +ve (MRSA &resistant Gram +ve (MRSA &

enterocoocienterocooci

))..

•• No activity for GramNo activity for Gram --ve.ve.

* Used in pts. with implanted heart prosthesis, dental* Used in pts. with implanted heart prosthesis, dental

prophylaxis, Enterococcal endocarditisprophylaxis, Enterococcal endocarditis(combination with aminoglycosides ).(combination with aminoglycosides ).

* Oral :Antibiotic induced* Oral :Antibiotic induced colitis(C.difficillecolitis(C.difficille).).

*PO: 0.25g/12h. IV :0.5g/12h.(Renal excretion)*PO: 0.25g/12h. IV :0.5g/12h.(Renal excretion)*Side effects: Serious(*Side effects: Serious(ototoxicityototoxicity, neutropenia, neutropeniaNephrotoxicityNephrotoxicity,, rashsrashs, hypotension if rapid IV), hypotension if rapid IV)


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LINEZOLIDSLINEZOLIDS

Oxazolidinones group :Oxazolidinones group :

They have a novel mechanismThey have a novel mechanism →→blockblockbacterial protein synthesis at the ribosomebacterial protein synthesis at the ribosomeat a very early stage.at a very early stage.

So, it does not share crossSo, it does not share cross--resistance withresistance withother antimicrobial agentsother antimicrobial agents

SpectrumSpectrum→→ Identical to VancomycinIdentical to Vancomycin..

Major indicationMajor indication →→ VancomycinVancomycinresistanceresistance..

Excellent oral bioavailability.Excellent oral bioavailability.


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TRIAZOLESTRIAZOLES

They are fungistatic drugs.They are fungistatic drugs.

Fluconazole (Fluconazole (DiflucanDiflucan):):

High volume of distribution.High volume of distribution. Active against Active against Candida albicansCandida albicans,C,C tropicalistropicalis,,

Cryptococcus neoformans.Cryptococcus neoformans. 80% excreted unchanged in urine80% excreted unchanged in urine→→ no needno need

to adjust for renal insufficiency.to adjust for renal insufficiency.

Itraconazole (Itraconazole (ItrapexItrapex , , ItranoxItranox):):

Greater activity againstGreater activity against aspergillusaspergillus,,

Blastoyces dermatidis & HistoplasaBlastoyces dermatidis & Histoplasa capsulatcapsulat..


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AMPHOTERICIN B AMPHOTERICIN B

Empirical therapy in febrile patient withEmpirical therapy in febrile patient with

neutropenia.neutropenia. StandardStandard fungicidalfungicidal drug for treatment of severedrug for treatment of severe

mycoses.mycoses.

Adverse effect Adverse effect→→ nephrotoxicitynephrotoxicity.. 3 new formula3 new formula→→ ↓↓ nephrotoxicity:nephrotoxicity:

-- Amphotericin B Lipid complex. Amphotericin B Lipid complex.-- Amphotericin B colloidal dispersion. Amphotericin B colloidal dispersion.

--Liposomal Amphotericin B.Liposomal Amphotericin B.


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PneumoniaPneumonia


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KlebsiellaKlebsiella

pneumoniae pneumoniae

ProteusProteus


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PneumoniaPneumonia


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Treatment for Ambulatory Patients: Treatment for Ambulatory Patients:

Oral macrolide ( erythromycin, azithromycin(Zythromax), or clarithromycin(Biaxin)), doxycycline (Vibramycin, Doryx), or

fluoroquinones with good anti-pneumococcalactivity (levofloxacin (Levaquin), grepafloxacin,trovafloxacin)

Older patients or patients with underlying

disease: recommendation -- levofloxacin

(Levaquin)- grepafloxaci - trovafloxacin

C itCommunity i d b t i lacquired bacterial


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CommunityCommunity--acquired bacterialacquired bacterial

pneumoniapneumonia Most frequent cause: StreptococcusMost frequent cause: Streptococcus pneumoniaepneumoniae

((pneumococcipneumococci))

Other pathogens:Other pathogens: HaemophilusHaemophilus influenzaeinfluenzae

StaphylococcusStaphylococcus aureusaureus

KlebsiellaKlebsiella pneumoniaepneumoniae

occasionally: other gramoccasionally: other gram--negative bacilli and anaerobicnegative bacilli and anaerobicmouth organismsmouth organisms

""Atypical" pathogensAtypical" pathogens:: LegionellaLegionella MycoplasmaMycoplasma pneumoniaepneumoniae ChlamydiaChlamydia pneumoniaepneumoniae

respiratory viruses tuberculosisrespiratory viruses tuberculosis

PneumocystisPneumocystis cariniicarinii

Treatment: In Hospitalized PatientsTreatment: In Hospitalized Patients

http://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htmhttp://www.pharmacology2000.com/Antibacterial/strep_pneumoniae1.htm


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Treatment: In Hospitalized Patients Treatment: In Hospitalized Patients

Pending culture results and susceptibility testing:Pending culture results and susceptibility testing:

ReasonableReasonable firstfirst--choicechoice:: cefotaximecefotaxime oror

ceftriaxoneceftriaxone CefotaximeCefotaxime ((ClaforanClaforan),), ceftriaxoneceftriaxone

((RocephinRocephin

),),

VancomycinVancomycin ((VancocinVancocin): high resistance): high resistance

VancomycinVancomycin ((VancocinVancocin) and cephalosporin:) and cephalosporin:

severe illnesssevere illness---- not responding to a betanot responding to a beta--

lactamlactam..


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Treatment: In Hospitalized Patients Treatment: In Hospitalized Patients--

A A macrolidemacrolide ((erythromycinerythromycin,, azithromycinazithromycin

((ZythromaxZythromax), or), or clarithromycinclarithromycin ((BiaxinBiaxin))

added toadded to

aa fluoroquinonefluoroquinone (good activity against S.(good activity against S.

pneumoniaepneumoniae ---- levofloxacinlevofloxacin ((LevaquinLevaquin),),grepafloxacingrepafloxacin andand trovafloxacintrovafloxacin) can be) can be

used to coverused to cover LegionellaLegionella,, MycoplasmaMycoplasma,,

chlamydiachlamydia..

IfIf aspiration pneumoniaaspiration pneumonia is a concern:is a concern:

clindamycinclindamycin ((CleocinCleocin) or) or metronidazolemetronidazole ((FlagylFlagyl))may be addedmay be added


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Treatment for hospitalTreatment for hospital--acquiredacquired


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Treatment for hospital Treatment for hospital acquiredacquired

bacterial pneumoniabacterial pneumonia Most often cause byMost often cause by gramgram--negative bacilli:negative bacilli:


Enterobacter Enterobacter

SerratiaSerratia Acinetobacter Acinetobacter AND AND

Pseudomonas aeruginosaPseudomonas aeruginosa

StaphylococcusStaphylococcus aureusaureus ((gram + positivegram + positive))

Treatment for hospitalTreatment for hospital acquiredacquired


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Treatment for hospital Treatment for hospital--acquiredacquired

bacterial pneumoniabacterial pneumonia The initial treatment: thirdThe initial treatment: third--generationgeneration

cephalosporin :cephalosporin :

cefotaximecefotaxime

((ClaforanClaforan

))

ceftizoximeceftizoxime ((CefizoxCefizox)) ceftriaxoneceftriaxone ((RocephinRocephin))

ceftazidimeceftazidime ((FortaxFortax,, TaxidimeTaxidime,, Tazicef Tazicef ))

Or:Or: cefepimecefepime ((MaxipimeMaxipime))

ticarcillinticarcillin ((Ticar Ticar )/)/ clavulanicclavulanic acidacid

piperacillinpiperacillin ((Pipracil)/tazobactamPipracil)/tazobactam

meropenemmeropenem ((MerremMerrem IV)IV)

imipenemimipenem

TT f h i l di d


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bacterial pneumoniabacterial pneumonia ConsideringConsidering thirdthird--generationgeneration cephalosporinscephalosporins::

CefotaximeCefotaxime ((ClaforanClaforan),), ceftizoximeceftizoxime ((CefizoxCefizox),),andand ceftriaxoneceftriaxone ((RocephinRocephin)} limited activity)} limited activity

against Pseudomonasagainst Pseudomonas

CeftazidimeCeftazidime ((FortaxFortax,, TaxidimeTaxidime,, Tazicef Tazicef )} more)} more

activity against staphylococci and other gramactivity against staphylococci and other gram--

positivepositive coccicocci..

with or without thewith or without the aminoglycosideaminoglycoside

{{tobramycintobramycin ((NebcinNebcin), gentamicin), gentamicin

(Garamycin), or(Garamycin), or amikacinamikacin (( Amikin Amikin)})}

Treatment for hospitalTreatment for hospital--acquiredacquired


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bacterial pneumoniabacterial pneumonia In the intensive care unitIn the intensive care unit ---- nosocomialnosocomial

pneumonia due to highly resistant grampneumonia due to highly resistant gram--

negative bacteria and Pseudomonasnegative bacteria and Pseudomonasaeruginosa:aeruginosa:

Good first choicesGood first choices---- imipenemimipenem


plusplus aminoglycosideaminoglycoside

addadd vancomycinvancomycin ((VancocinVancocin) in hospitals) in hospitals

wherewhere methicillinmethicillin ((StaphcillinStaphcillin))--resistantresistantstaphylococci (MRSA) are commonstaphylococci (MRSA) are common


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GenitourinaryGenitourinary

Urinary tract infection (UTI)Urinary tract infection (UTI)


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y ( )y ( )

Acute, uncomplicated UTIAcute, uncomplicated UTI ttrimethoprimrimethoprim--sulfamethoxazolesulfamethoxazole ((BactrimBactrim))

(3(3--day course of treatment)day course of treatment) Alternative: Alternative: fluoroquinonefluoroquinone (three(three--day courseday course

of treatment)of treatment)

Alternative (longer treatment): Alternative (longer treatment): oral cephalosporinoral cephalosporin

amoxicillinamoxicillin (( Amoxil Amoxil PolymoxPolymox)(many)(many

urinary pathogensurinary pathogens ---- resistance toresistance toamoxicillin)amoxicillin)

fosfomycinfosfomycin ((MonurolMonurol)(single)(single dosedose ) )



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RepeatedRepeated UTIsUTIs

or UTI occurring in theor UTI occurring in thehospitalhospital

may be due to antibioticmay be due to antibiotic--resistant gramresistant gram--negative bacillinegative bacilli

Treatment:Treatment:

fluoroquinonefluoroquinoneoral amoxicillinoral amoxicillin ((AmoxiAmoxi))

Polymox)/clavulanicPolymox)/clavulanic acidacid

oral thirdoral third--generation cephalosporingeneration cephalosporin((cefiximecefixime ((SupraxSuprax),), cefpodoximecefpodoxime((VantinVantin),), ceftibutenceftibuten) or) or idanylidanyl ester ofester of

carbenicillincarbenicillin



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in patients hospitalized with UTI:in patients hospitalized with UTI:

thirdthird--generation cephalosporingeneration cephalosporin

ticarcillinticarcillin ((Ticar Ticar )/)/clavulanicclavulanic acidacid

piperacillinpiperacillin ((PipracilPipracil)/)/ttazobactamazobactam

imipenemimipenem (occasionally in(occasionally in

combination withcombination with aminoglycosideaminoglycoside))

S iS i


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SepsisSepsis

SepsisSepsis


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SepsisSepsis

Initial treatmentInitial treatment LifeLife--threatening sepsis and adults:threatening sepsis and adults:

Third or fourth generation cephalosporinThird or fourth generation cephalosporin

cefotaximecefotaxime ((ClaforanClaforan)) ceftizoximeceftizoxime ((CefizoxCefizox))

ceftriaxoneceftriaxone ((RocephinRocephin))

cefepimecefepime ((MaxipimeMaxipime))

ticarcillinticarcillin ((Ticar)/clavulanicTicar)/clavulanic acidacid

piperacillinpiperacillin ((Pipracil)/tazobactamPipracil)/tazobactam imipenemimipenem oror meropenemmeropenem ((MerremMerrem IV)IV)

{{eacheach together withtogether with aminoglycosideaminoglycoside

[[gentamicingentamicin ((GaramycinGaramycin),), tobramycintobramycin((NebcinNebcin), or), or amikacinamikacin ((AmikinAmikin)]})]}

S iS i


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SepsisSepsis

IfIf methicillinmethicillin--resistant staphylococci isresistant staphylococci is

a considerationa consideration::

vancomycinvancomycin ((VancocinVancocin) alone or) alone or

vancomycinvancomycin ((VancocinVancocin) with) with gentamicingentamicin

((GaramycinGaramycin) and/or) and/or rifampinrifampin ((RimactaneRimactane)) If bacterialIf bacterial endocarditisisendocarditisis is a considerationis a consideration

(prior to pathogen identification):(prior to pathogen identification):

vancomycinvancomycin ((VancocinVancocin) plus) plus gentamicingentamicin((GaramycinGaramycin))

SepsisSepsis


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SepsisSepsis

Treatment of intraTreatment of intra--abdominal or pelvic infection (abdominal or pelvic infection (likelylikely

to involve anaerobes):to involve anaerobes):

ticarcillinticarcillin ((Ticar)/clavulanicTicar)/clavulanic acid)acid)ampicillinampicillin ((PrincipenPrincipen,, Omnipen)/sulbactamOmnipen)/sulbactam))

piperacillinpiperacillin ((Pipracil)/tazobactamPipracil)/tazobactam))

imipenemimipenem

meropenemmeropenem

cefoxitincefoxitin ((MefoxinMefoxin) or) or cefotetancefotetan ((CefotanCefotan))

{each with or without an{each with or without an aminoglycosideaminoglycoside,,

metronidazolemetronidazole ((FlagylFlagyl) OR) OR

clindamycinclindamycin ((CleocinCleocin) with an) with an aminoglycosideaminoglycoside

S iS i


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SepsisSepsis

gramgram--negative bacilli:negative bacilli:Third or fourth generationThird or fourth generation cephalosporinscephalosporins

cefotaximecefotaxime ((ClaforanClaforan))

ceftizoximeceftizoxime ((CefizoxCefizox))

cefoperazonecefoperazone ((CefobidCefobid)) ceftriaxoneceftriaxone ((RocephinRocephin))

cefepimecefepime ((MaxipimeMaxipime))

ceftazidimeceftazidime (plus activity against gram(plus activity against gram--positivepositive coccicocci))

imipenemimipenem,, meropenemmeropenem ((MerremMerrem IV),IV),

aztreonamaztreonam (( Azactan Azactan ) )

S iS p i


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SepsisSepsis

CephalosporinsCephalosporins (other than(other than cefoperazonecefoperazone

((CefobidCefobid),), cefepimecefepime ((MaxipimeMaxipime), and), and

ceftazidimeceftazidime ((FortaxFortax,, TaxidimeTaxidime,, Tazicef Tazicef )):)):limited efficacy against Pseudomonaslimited efficacy against Pseudomonas

aeruginosaaeruginosa

Pseudomonas aeruginosaPseudomonas aeruginosa::

effectively treated witheffectively treated with imipenemimipenem,, meropenemmeropenem

((MerremMerrem IV), andIV), and aztreonamaztreonam (( Azactan Azactan).). Aztreonam Aztreonam (( Azactan Azactan): poor activity against): poor activity against

gramgram--positive organisms and anaerobespositive organisms and anaerobes

SepsisSepsis-- Special CasesSpecial Cases


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pp

pp

NeutropenicNeutropenic

patients with suspected bacteremia patients with suspected bacteremia ceftazidimeceftazidime ((FortaxFortax,, TaxidimeTaxidime,, Tazicef Tazicef ))

imipenemimipenem


cefepimecefepime ((MaxipimeMaxipime) (in more seriously ill) (in more seriously ill

patients,patients, add anadd an aminoglycosideaminoglycosideamikacinamikacin (( Amikin Amikin) and) and ceftriaxoneceftriaxone ((RocephinRocephin))

(single daily doses)(single daily doses)

piperacillinpiperacillin ((Pipracil)/tazobactamPipracil)/tazobactam plusplus amikacinamikacin Addition of Addition of vancomycinvancomycin ((VancocinVancocin)): in: in neutropenicneutropenic

cancer patients with bacteremia due tocancer patients with bacteremia due to methicillinmethicillin

((StaphcillinStaphcillin))--resistant staphylococci & some strains ofresistant staphylococci & some strains ofviridansviridans

A 69 year old female, with no past medical


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history, is admitted from home with pleuritic

chest pain, shortness of breath, pyrexia and

tachycardia

Presumed diagnosisPresumed diagnosis

::

community acquired pneumonia incommunity acquired pneumonia in

anan immunocompetentimmunocompetent hosthost..

The most likely organisms areThe most likely organisms are


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The most likely organisms areThe most likely organisms are

pneumococcipneumococci,, MycoplasmaMycoplasma andandLegionellaLegionella..

The patient requires coverage for bothThe patient requires coverage for bothgram positivegram positive andand atypical organisms.atypical organisms.

Cephalosporin iv +Cephalosporin iv +

macrolidemacrolide

popo

or or

fluroquinolonefluroquinolone

Cefuroxime/CeftriaxoneCefuroxime/Ceftriaxone iv +iv +azithromycinazithromycin popo oror levofloxacinlevofloxacin


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An 85 year old female is admitted An 85 year old female is admitted

unconscious and hypotensive from aunconscious and hypotensive from a

nursing home.nursing home.

She has a fever and aShe has a fever and a leucocytosisleucocytosis andand

her urine is foul smelling.her urine is foul smelling.

Presumed diagnosisPresumed diagnosis – – urinary tracturinary tract

infection.infection.

The most common organisms causing urinaryThe most common organisms causing urinary


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g g y

tract infections aretract infections are EnterobacteriacaeEnterobacteriacae andand

enterococcienterococci,, and the treatment isand the treatment is ciprofloxacin orciprofloxacin or

ampicillinampicillin andand gentamycingentamycin..

In this case, however, the patient has beenIn this case, however, the patient has beenadmitted from a nursing home and pseudomonasadmitted from a nursing home and pseudomonas

is a strong possibility.is a strong possibility.

Twin therapyTwin therapy is often requiredis often required,,

Anti Anti--pseudomonalpseudomonal quinolonequinolone oror aminoglycosideaminoglycoside

plus antiplus anti--pseudomonalpseudomonal penicillin orpenicillin or

cephalosporin.cephalosporin.

Ciprofloxacin /Ciprofloxacin /gentamycin/amikacingentamycin/amikacin

plusplus piperacillinpiperacillin

oror ceftazidimeceftazidime


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An 62 year old male presents with

abdominal pain, hypotension,tachycardia, tachypnea, hypothermia

and neutropenia.

Presumed diagnosis –

perforateddiverticulum

and fecal peritonitis

This patient requires surgical source control andThis patient requires surgical source control and


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This patient requires surgical source control andThis patient requires surgical source control and

antibiotics. The most likely infecting organismsantibiotics. The most likely infecting organismsareare EnterobacteriaceaeEnterobacteriaceae,, enteococcienteococci, S., S.

pneumoniaepneumoniae and anaerobesand anaerobes..

Broad spectrum treatment is required, withoutBroad spectrum treatment is required, withoutcover for pseudomonascover for pseudomonas..

PenicllinPenicllin+ beta+ beta LactamLactam inhibitor orinhibitor orampicillin+aminoglycoside+antiampicillin+aminoglycoside+anti--anaerobicanaerobic agentagent

Ampicillin+Sulbactam Ampicillin+Sulbactam oror

Piperacillin+TazobactamPiperacillin+Tazobactam oror ampicillinampicillin ++gentamycin/aztreonamgentamycin/aztreonam ++metronidazolemetronidazole oror

imipenemimipenem

A 48 year old intellectually subnormalA 48 year old intellectually subnormal


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y yy y

lady is admitted with red hotlady is admitted with red hot induratedindurated skin over her left buttockskin over her left buttock..

Presumed diagnosisPresumed diagnosis – – cellulitiscellulitis The most likely organisms are streptococciThe most likely organisms are streptococci

and staphylococci, ifand staphylococci, if community acquiredcommunity acquired

thenthen cloxicillincloxicillin is adequate,is adequate, again this patient was institutionalized, andagain this patient was institutionalized, and

must be treated as hospital acquired:must be treated as hospital acquired:

VancomycinVancomycin

++ gentamycingentamycin..

The patient becomes progressivelyThe patient becomes progressively stuperosestuperose andand

hypotensivehypotensive as the day goes on She isas the day goes on She is intubatedintubated


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hypotensivehypotensive

as the day goes on. She isas the day goes on. She is intubatedintubated

and CT of her pelvis reveals gas in the muscles andand CT of her pelvis reveals gas in the muscles and

along thealong the fascialfascial

planes of her left buttockplanes of her left buttock..

Confirmed diagnosisConfirmed diagnosis – – necrotizingnecrotizing fasciitisfasciitis

This patient requires immediate surgicalThis patient requires immediate surgical

intervention andintervention and

debridementdebridement

of necrotic tissue.of necrotic tissue.

The infection has probably arisen from anThe infection has probably arisen from an ischioischio--

rectal abscess and isrectal abscess and is polymicrobialpolymicrobial in nature:in nature:

Streptococci, Staphylococci,Streptococci, Staphylococci, BacteroidesBacteroides,,Clostridium (1).Clostridium (1).

Penicillin (high dose) or ciprofloxacin (ifPenicillin (high dose) or ciprofloxacin (if

penicllinpenicllin allergic) +allergic) + clindamycinclindamycin

On the 8th day following admission, this patient isextubated. Four hours later she becomes severely


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dyspneic

and hypoxemic. She is reintubated

and

chest x-ray reveals a new infiltrate in her left base..

Presumed diagnosisPresumed diagnosis – – aspirationaspiration pneumonitispneumonitis

In most cases, aspiration events are sterile, andIn most cases, aspiration events are sterile, andantimicrobials are unnecessary . In the case ofantimicrobials are unnecessary . In the case ofpatients already in intensive care, however,patients already in intensive care, however,

nasopharyngeal colonization withnasopharyngeal colonization with gram negativegram negativeorganismsorganisms has occurred, and aspiration of infectedhas occurred, and aspiration of infectedmaterial should be presumed, Although it has beenmaterial should be presumed, Although it has beenconventional toconventional to treat these patients with antitreat these patients with anti--anaerobeanaerobecoveragecoverage,, it is unlikely that this is necessary.it is unlikely that this is necessary.

Add Add ampicillin+sulbactamampicillin+sulbactam oror piperacillin+tazobactampiperacillin+tazobactam

..

A 75 year old male presents withA 75 year old male presents with


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A 75 year old male presents with A 75 year old male presents with

hypotension, pyrexia andhypotension, pyrexia and leucocytosisleucocytosis ..

Presumed diagnosisPresumed diagnosis -- sepsis, cause unknownsepsis, cause unknown

Broad spectrum coverage is required, toBroad spectrum coverage is required, to

covercover gram positivesgram positives,, gram negativesgram negativesandand pseudomonaspseudomonas

Suggested modalities are:Suggested modalities are:

CombiningCombining either either

ti dti d ll h l i (h l i ( ft idift idi ))


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antipseudomonaantipseudomonall

cephalosporin (cephalosporin (ceftazidineceftazidine))oror antipseudomonalantipseudomonal

penicillin (penicillin (piperacillinpiperacillin

++azobactamazobactam) (particularly if anaerobes are) (particularly if anaerobes are

suspected) with either ansuspected) with either an aminoglycosideaminoglycoside ((gentamycingentamycin

oror amikacinamikacin) or a) or afluoroquinolonefluoroquinolone

(ciprofloxacin(ciprofloxacin).).

If anIf an antipseudomonalantipseudomonal

cephalosporin is used andcephalosporin is used andanaerobes are a possible cause, theanaerobes are a possible cause, theaddition ofaddition of metronidazolemetronidazole

oror clindamycinclindamycin

should be consideredshould be considered..Piperacillin+Tazobactam/ImipenemPiperacillin+Tazobactam/Imipenem

++GentamycinGentamycin /Ciprofloxacin /Ciprofloxacin

PROPHYLACTIC ANTIBIOTICSPROPHYLACTIC ANTIBIOTICS


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Surgical ProphylaxisSurgical Prophylaxis

antimicrobial useantimicrobial use


http://www.dental.mu.edu/oralpath/spresent/leukemia/img018.jpg


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The prophylactic antibiotics must be inThe prophylactic antibiotics must be inplace alreadyplace already before the bacteria land inbefore the bacteria land in

the woundthe wound

. For prevention of the

. For prevention of thepostoperative infection,postoperative infection,

The antibiotics are usually injected someThe antibiotics are usually injected some

30 minutes before the start of the30 minutes before the start of theoperationoperation..

In this way the levels of the antibiotic inIn this way the levels of the antibiotic inthe blood will attain concentrations that willthe blood will attain concentrations that willkill occasional bacteria that may land in thekill occasional bacteria that may land in the

operation wound.operation wound.


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Studies demonstrated that for Studies demonstrated that for prophylaxis againstprophylaxis against

postoperative wound infectionpostoperative wound infection administeringadministering


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postoperative wound infection,postoperative wound infection, administeringadministering

antibiotics during only one day after the operationantibiotics during only one day after the operationhas been equally effective as a two day or longerhas been equally effective as a two day or longer

antibiotic prophylactic regime.antibiotic prophylactic regime.

For occasions later on, when you need antibioticFor occasions later on, when you need antibiotic

protection during dental surgery and like,protection during dental surgery and like, usuallyusually

one dose of antibiotics before the dental and otherone dose of antibiotics before the dental and othersurgery is sufficient.surgery is sufficient.

use the antibiotics only when really necessaryuse the antibiotics only when really necessary, and, andthen use them onlythen use them only during the shortest intervalduring the shortest interval

possible.possible.

Choice of agents (principles)Choice of agents (principles)


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g (p p )g (p p )

need not eradicate every potential pathogenneed not eradicate every potential pathogen

Effective agent exampleEffective agent example ---- cefazolincefazolin (( Ancef Ancef ,,DefzolDefzol))

long serum half long serum half --lifelife

vancomycinvancomycin ((VancocinVancocin))

routine use ofroutine use of vancomycinvancomycin ((VancocinVancocin) for) for

prophylaxisprophylaxis---- discouraged since it promotesdiscouraged since it promotesvancomycinvancomycin ((VancocinVancocin))--resistant strains.resistant strains.

Colorectal surgery & appendectomyColorectal surgery & appendectomy


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g y pp yg y pp y

cefoxitincefoxitin ((MefoxinMefoxin) or) or cefotetancefotetan ((CefotanCefotan))preferred due to enhanced activity relative topreferred due to enhanced activity relative tocefazolincefazolin (( Ancef Ancef ,, DefzolDefzol) a) against anaerobesgainst anaerobes

(bowel), e.g.(bowel), e.g. BacteriodesBacteriodes fragilisfragilis Agents not recommendedAgents not recommended

ThirdThird--generationgeneration cephalosporinscephalosporins

((cefotaximecefotaxime ((ClaforanClaforan),), ceftriaxoneceftriaxone((RocephinRocephin),), cefoperazonecefoperazone ((CefobidCefobid),),ceftazidimeceftazidime ((FortaxFortax,, TaxidimeTaxidime,, Tazicef Tazicef ), or), or

ceftizoximeceftizoxime ((CefizoxCefizox)) FourthFourth--generationgeneration cephalosporinscephalosporins: e.g.: e.g.

cefepimecefepime ((MaxipimeMaxipime ))

Choice of agents (principles)Choice of agents (principles)


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g (p p )g (p p )

Rationale:Rationale:

expense, some are less activeexpense, some are less activecefazolincefazolin (( Ancef Ancef ,, DefzolDefzol) (against) (againststaphylococci)staphylococci)

nonnon--optimal spectrum of actionoptimal spectrum of action(includes activity against organisms not(includes activity against organisms notcommonly encountered in electedcommonly encountered in elected

surgerysurgery widespread for prophylaxis encourageswidespread for prophylaxis encourages

emergence of resistanceemergence of resistance

Gastrointestinal diseasesGastrointestinal diseases


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Antibiotic prophylaxisAntibiotic prophylaxis recommended for esophageal surgery withrecommended for esophageal surgery with

obstructionobstruction ---- obstruction increases infection riskobstruction increases infection risk

factors that promote high infection risk afterfactors that promote high infection risk aftergastroduodenalgastroduodenal surgery:surgery:

reduced gastric acidity and gastrointestinalreduced gastric acidity and gastrointestinalmotilitymotility – –

reduction may occur because of:reduction may occur because of: obstruction hemorrhageobstruction hemorrhage

gastric ulcer malignancygastric ulcer malignancy

treatment with Htreatment with H22 blocker {ranitidine (Zantac)}blocker {ranitidine (Zantac)}or proton pump, inhibitors {e.g.or proton pump, inhibitors {e.g. omeprazoleomeprazole((PrilosecPrilosec)})}

morbid obesitymorbid obesity



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Antibiotic prophylaxisAntibiotic prophylaxis not indicatednot indicated for:for: routineroutine gastroesophagealgastroesophageal endoscopyendoscopy

(may be used for high(may be used for high--risk patientsrisk patients

undergoing esophageal dilatation orundergoing esophageal dilatation orsclerotherapysclerotherapy ofof variciesvaricies ). ).



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y



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Probable pathogens:Probable pathogens:

enteric gramenteric gram--negative bacilli,negative bacilli,

enterococcienterococci

ProphylaxisProphylaxis

highhigh--risk only (risk only (urinate cultureurinate culturepositive/unavailable; preoperativepositive/unavailable; preoperative

catheter,catheter, transrectaltransrectal prostaticprostatic biopsy)biopsy) ----

ciprofloxacinciprofloxacin ((CiproCipro)) {PO or IV}{PO or IV}

Head & Neck SurgeryHead & Neck Surgery


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Incision through oral/pharyngeal mucosaIncision through oral/pharyngeal mucosa..


Anaerobes, Anaerobes, enteric gramenteric gram--negative bacilli,negative bacilli,

StaphylococcusStaphylococcus aureusaureus


clindamycinclindamycin (Cleocin) + gentamicin

(Garamycin) reduce the high incidence of wound infectionreduce the high incidence of wound infection

following head/neck operations which utilizefollowing head/neck operations which utilize

incisions through oral or pharyngeal mucosalincisions through oral or pharyngeal mucosal

NeurosurgeryNeurosurgery


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CraniotomyCraniotomy

Probable pathogens:Probable pathogens: StaphylococcusStaphylococcus aureusaureus,


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Probable pathogens:Probable pathogens: StaphylococcusStaphylococcus aureusaureus,,

StaphylococcusStaphylococcus epidermidisepidermidis

ProphylaxisProphylaxis:: cefazolincefazolin

(( Ancef Ancef ,, DefzolDefzol) or) or vancomycinvancomycin

((VancocinVancocin) (IV)) (IV)Antibacterial prophylaxisAntibacterial prophylaxis

cerebrospinal fluid shuntcerebrospinal fluid shunt: conflicting research results: conflicting research results

CraniotomyCraniotomy:: antistaphylococcalantistaphylococcal antibioticantibiotic ---- reducedreducedinfection incidenceinfection incidence

Spinal surgerySpinal surgery: antibiotics not effective in reducing the: antibiotics not effective in reducing the

already low postoperative infection rate followingalready low postoperative infection rate followingconventional lumbarconventional lumbar discectomydiscectomy..

Questionable effectiveness (not yet demonstrated inQuestionable effectiveness (not yet demonstrated in

controlled clinical trials) for spinal fusion, prolonged spinecontrolled clinical trials) for spinal fusion, prolonged spinesurgery, or insertion of foreign materialsurgery, or insertion of foreign material

OphthalmicOphthalmic


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OphthalmicOphthalmic


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Probable pathogens:Probable pathogens: StaphylococcusStaphylococcus epidermidisepidermidis,,StaphylococcusStaphylococcus aureusaureus, streptococci, enteric gram, streptococci, enteric gram--negative bacilli, Pseudomonasnegative bacilli, Pseudomonas

ProphylaxisProphylaxis::

gentamicingentamicin

(Garamycin),(Garamycin), tobramycintobramycin

((NebcinNebcin),), ciprofloxacinciprofloxacin

((CiproCipro),), ofloxacinofloxacin

((FloxinFloxin), or), orneomycinneomycin--gramicidingramicidin--polymixinpolymixin

B;B; cefazolincefazolin

(( Ancef Ancef ,,DefzolDefzol))

Most ophthalmologist use antibioticMost ophthalmologist use antibiotic eyedropseyedrops forforprophylaxis in view of the potential for extremely seriousprophylaxis in view of the potential for extremely seriouspostoperativepostoperative endophthalmitis.{limitedendophthalmitis.{limited data to supportdata to supporteffectiveness of prophylactic antimicrobials}effectiveness of prophylactic antimicrobials}

No evidence for the rational basis for use ofNo evidence for the rational basis for use ofprophylactic antibiotics when procedures do notprophylactic antibiotics when procedures do not

invade the globeinvade the globe

OrthopedicOrthopedic


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OrthopedicOrthopedic


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Total joint replacement, internal fracture fixationTotal joint replacement, internal fracture fixation Probable pathogens:Probable pathogens: StaphylococcusStaphylococcus aureusaureus,,

StaphylococcusStaphylococcus epidermidisepidermidis

ProphylaxisProphylaxis cefazolincefazolin

(( Ancef Ancef ,, DefzolDefzol) or) or vancomycinvancomycin((VancocinVancocin) (IV)) (IV)

Rationale for Prophylaxis:Rationale for Prophylaxis:

antistaphylococcalantistaphylococcal agents decrease incidence of early &agents decrease incidence of early &late infection following joint replacementlate infection following joint replacement

decrease infection rate in compound/open fractures anddecrease infection rate in compound/open fractures and

when hip & other fractures are managed with internalwhen hip & other fractures are managed with internalfixation using nails, plates, screws, or wiresfixation using nails, plates, screws, or wires

For diagnostic & operative arthroscopic surgeryFor diagnostic & operative arthroscopic surgery ----antibody prophylaxis is not justifiedantibody prophylaxis is not justified

Vascular Vascular


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Vascular VascularArterial surgery (involving: a prosthesis,


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Arterial surgery (involving: a prosthesis,Arterial surgery (involving: a prosthesis,

abdominal aorta, or groin incisionabdominal aorta, or groin incision))

Probable pathogenProbable pathogen:: StaphylococcusStaphylococcus aureusaureus,,StaphylococcusStaphylococcus epidermidisepidermidis, enteric gram, enteric gram--negative bacillinegative bacilli

ProphylaxisProphylaxis:: cefazolincefazolin

(( Ancef Ancef ,, DefzolDefzol) or) orvancomycinvancomycin

((VancocinVancocin))

A lower extremity amputation for ischemiaA lower extremity amputation for ischemiaProbable pathogen:Probable pathogen: StaphylococcusStaphylococcus aureusaureus,,

StaphylococcusStaphylococcus epidermidisepidermidis, enteric gram, enteric gram--

negative bacilli, clostridianegative bacilli, clostridiaProphylaxisProphylaxis::

cefazolincefazolin

(( Ancef Ancef ,, DefzolDefzol))----or or

cefoxitincefoxitin ((MefoxinMefoxin) for better anaerobic coverage) for better anaerobic coverage----oror vancomycinvancomycin

((VancocinVancocin ) )

Vascular Vascular


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Rationale for prophylaxisRationale for prophylaxis:: CephalosporinCephalosporin: reduced likelihood of postoperative: reduced likelihood of postoperative

infection incidences following arterial reconstructiveinfection incidences following arterial reconstructive

surgery on the abdominal aorta, vascular limbsurgery on the abdominal aorta, vascular limboperations involving groin incisions, and loweroperations involving groin incisions, and lower

extremity amputation for ischemiaextremity amputation for ischemia

Recommended:Recommended: for any vascular prosthetic material implantation (e.g.for any vascular prosthetic material implantation (e.g.

grafts supportinggrafts supporting hemodialysishemodialysis))

Not indicated for carotidNot indicated for carotid endarterectomyendarterectomy or brachialor brachialartery repair (assuming no prosthetic materialartery repair (assuming no prosthetic material

involvedinvolved ) )

Cardiac SurgeryCardiac Surgery


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Cardiac SurgeryCardiac Surgery


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Prosthetic valve, coronary bypass, other openProsthetic valve, coronary bypass, other open--heartheartprocedures, pacemaker/defibrillator implantationprocedures, pacemaker/defibrillator implantation

Probable pathogenProbable pathogen:: ---- StaphylococcusStaphylococcusepidermidisepidermidis, Staphylococcus, Staphylococcus aureusaureus,,CorynebacteriumCorynebacterium, enteric gram, enteric gram--negative bacillinegative bacilli

Antibacterial drug:Antibacterial drug: cefazolincefazolin (( Ancef Ancef ,, DefzolDefzol),), cefuroximecefuroxime

((Zinacef Zinacef ,, CeftinCeftin))---- IVIV

VancomycinVancomycin,, IVIV((VancocinVancocin) (if above agents) (if above agentsare ineffective or contraindicated)are ineffective or contraindicated)

Antibacterial drug pre Antibacterial drug pre--treatment reducestreatment reducesinfection incidence after cardiac surgery;infection incidence after cardiac surgery;

Thoracic ( Thoracic (noncardiacnoncardiac

))


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Probable pathogens:Probable pathogens: StaphylococcusStaphylococcus aureusaureus,,StaphylococcusStaphylococcus epidermidisepidermidis, streptococci, enteric, streptococci, entericgramgram--negative bacillinegative bacilli

TreatmentTreatment::

cefazolincefazolin (( Ancef Ancef ,, DefzolDefzol) or) or

cefuroximecefuroxime

((Zinacef Zinacef ,, CeftinCeftin) or) or vancomycinvancomycin ((VancocinVancocin))Rationale for ProphylaxisRationale for Prophylaxis::

commonly used for routine pulmonary surgery;commonly used for routine pulmonary surgery; limitedlimited

research supportresearch support insertion of chest tubes following closedinsertion of chest tubes following closed--tubetube

thoracostomythoracostomy following chest trauma:following chest trauma: cephalosporincephalosporin(multiple doses) can prevent infection(multiple doses) can prevent infection

single preoperativesingle preoperative cefazolincefazolin (( Ancef Ancef ,, DefzolDefzol) dose) dose(pulmonary resection): decrease in the incidence of(pulmonary resection): decrease in the incidence ofwound infectionwound infection ---- no decrease in incidence ofno decrease in incidence ofpneumonia orpneumonia or empyemaempyema

Gynecologic & ObstetricGynecologic & Obstetric


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Antibacterial prophylaxis:Antibacterial prophylaxis: reduces infection incidence following vaginalreduces infection incidence following vaginal

hysterectomy & abdominal hysterectomyhysterectomy & abdominal hysterectomy

(probably)(probably) PerioperativePerioperative/preoperative antibiotics:/preoperative antibiotics:

prevention of infection when givenprevention of infection when given::

following cord clamping in emergencyfollowing cord clamping in emergencycesarean sectioncesarean section

highhigh--risk situations {active Labor, prematurerisk situations {active Labor, premature

membranemembrane rupture,after rupture,after midmid--trimestertrimesterabortion}abortion}

Possibly substantial protective effect ofPossibly substantial protective effect ofperioperativeperioperative antibiotics in all womenantibiotics in all womenundergoing therapeutic abortionsundergoing therapeutic abortions


V i l bd i l hV i l bd i l h


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Vaginal or abdominal hysterectomyVaginal or abdominal hysterectomy Probable pathogens:Probable pathogens: Enteric gramEnteric gram--negatives,negatives,

anaerobes,anaerobes, enterococcienterococci, Group B strep, Group B strep


cefazolincefazolin

(( Ancef Ancef ,, DefzolDefzol) or) or cefotetancefotetan ((CefotanCefotan) or ) or

cefoxitincefoxitin

((MefoxinMefoxin)(IV)(IV))

Cesarean sectionCesarean section Probable pathogens:Probable pathogens: Enteric gramEnteric gram--negatives,negatives,

anaerobes,anaerobes, enterococcienterococci, Group B strep, Group B strep

ProphylaxisProphylaxis::

highhigh--risk {active labor or prematurerisk {active labor or prematuremembrane rupturemembrane rupture};};

cefazolincefazolin (( Ancef Ancef ,, DefzolDefzol)) ---- IV after cord clampingIV after cord clamping


Ab tiAb ti


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AbortionAbortion Probable pathogensProbable pathogens:: Enteric gramEnteric gram--negatives,negatives,

anaerobes,anaerobes, enterococcienterococci, Group B strep, Group B strepProphylaxisProphylaxis::

first trimester first trimester , high, high--risk {patients withrisk {patients withprevious pelvic inflammatory disease,previous pelvic inflammatory disease,

previous gonorrhea or multiple sex partners)previous gonorrhea or multiple sex partners)

----

aqueous penicillin Vaqueous penicillin V

((PenPen--VeeVee

KK,,VeetidsVeetids) or ) or

doxycyclinedoxycycline ((VibramycinVibramycin,, DoryxDoryx ))



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Medical ProphylaxisMedical Prophylaxis

antimicrobial useantimicrobial use

PREVENTION of ENDOCARDITISPREVENTION of ENDOCARDITIS


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Heart valve lesions or prosthetic valve.Heart valve lesions or prosthetic valve.

(A)(A)Dental procedure under No orDental procedure under No or L.AnasthL.Anasth..::Pt.Pt. HavnHavn’’tt

endocarditisendocarditis

AmoxycillinAmoxycillin(3g PO)(3g PO) 1h before operation1h before operation

ClindamycinClindamycin (600mg PO)(600mg PO) Penicill.AllergyPenicill.Allergy

Pt. WithPt. With endocarcitisendocarcitis

( AS under GA ):( AS under GA ):

AmoxycillinAmoxycillin(1g IV)(1g IV) ++ GentamicinGentamicin(120mg)(120mg)

VancomycinVancomycin(1g IV)(1g IV) Allergy to Penicillin Allergy to Penicillin

OrOr ClindamycinClindamycin(300mg IV)(300mg IV) Over 10Over 10 minmin..

PROPHYLACTIC ANTIBIOTICPROPHYLACTIC ANTIBIOTIC

((B)B)D t l d d GAD t l d d GA


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((B)B)Dental procedure under GADental procedure under GA

::Pt.Pt. HavnHavn’’tt

endocarditis :endocarditis :

AmoxycillinAmoxycillin (1g IV at induction) or (1g IV at induction) or (3g PO 4h before induction)(3g PO 4h before induction)

Pt. With endocarditis( At risk) :Pt. With endocarditis( At risk) :

AmoxycillinAmoxycillin(1g )(1g )++ GentamicinGentamicin(120mg)(120mg) atatinduction or 15 min.before induction.induction or 15 min.before induction.

OrOr VancomycinVancomycin 1g1g ++ GentamicinGentamicin(120mg)(120mg) OrOr ClindamycinClindamycin 300mg IV300mg IV over 10 min (15over 10 min (15

min before induction)min before induction)..



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MENINGITISMENINGITIS

((meningococcalmeningococcal--N.menigitidisN.menigitidis))

* For close contacts(children& adults).* For close contacts(children& adults).

RifampicinRifampicin(600mg)(600mg) /12h/2days/12h/2days..

oror CiprofloxacinCiprofloxacin (500mg)(500mg) Single doseSingle dose

oror CeftriaxoneCeftriaxone(250mg)(250mg) Single dose.Single dose.

Empiric treat. Of suspectedEmpiric treat. Of suspected bact.meningitbact.meningit..

**Penicillin GPenicillin G

IV:2IV:2

--MU immediatelyMU immediately

.

.

ANTIBIOTIC PROPHYLAXISANTIBIOTIC PROPHYLAXIS

RHEUMATIC FEVER:RHEUMATIC FEVER:


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RHEUMATIC FEVER:RHEUMATIC FEVER: BenzathineBenzathine penicillinpenicillin (IM)(IM) monthlymonthly oror

Penicillin V Penicillin V ( PO)( PO) twice dailytwice daily** oror SulphadiazineSulphadiazine

(PO)(PO) 1g/day1g/day

**

During childhood & early teenage .During childhood & early teenage .GAS GANGERENE (L.L.Amputation) :GAS GANGERENE (L.L.Amputation) :

* Penicillin G* Penicillin G 300300--600mg(500000600mg(500000--1000000U)/ 6h/5 days .1000000U)/ 6h/5 days .

**MetronidazoleMetronidazole(Allergy to Penicillin)(Allergy to Penicillin)500 mg/8h.500 mg/8h.


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Head & Neck SurgeryHead & Neck Surgery


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QUINUPRISTIN/DAFLOPRISTINQUINUPRISTIN/DAFLOPRISTIN


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A formulation of two bacteriostatic agents A formulation of two bacteriostatic agentswhen combined are bactericidal.when combined are bactericidal.

MechanismMechanism→→ inhibit protein synthesis at theinhibit protein synthesis at the505 ribosome.505 ribosome.

Spectrum: Similar to Vancomycin i.e. ActiveSpectrum: Similar to Vancomycin i.e. Activeagainst Streptococci, S.aureus andagainst Streptococci, S.aureus andcoagulasecoagulase – –negative Staph.negative Staph.

Used in treatment ofUsed in treatment of VancomycinVancomycin – –resistant cases.resistant cases.

KlebsiellaKlebsiella pneumoniaepneumoniae ProteusProteus


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pneumoniae pneumoniae

ProteusProteus

SepsisSepsis--

Special CasesSpecial Cases

Resistant gramResistant gram-negative bacillinegative bacilli


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Resistant gramResistant gram--negative bacillinegative bacilli

GramGram--negative bacilli resistant to:negative bacilli resistant to:

aminoglycosidesaminoglycosides thirdthird--generationgeneration cephalosporinscephalosporins

aztreonamaztreonam ((AzactanAzactan)) These bacilli susceptible to:These bacilli susceptible to:

imipenemimipenem

meropenemmeropenem ((MerremMerrem IVIV))

ciprofloxacinciprofloxacin ((CiproCipro))

SepsisSepsis--

Special CasesSpecial Cases

Pseudomonas aeruginosa strains resistantPseudomonas aeruginosa strains resistanti i (G i )


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Pseudomonas aeruginosa strains resistantPseudomonas aeruginosa strains resistantgentamicin (Garamycin)gentamicin (Garamycin)

Susceptible to:Susceptible to:

amikacinamikacin (( Amikin Amikin))

ceftazidimeceftazidime ((FortaxFortax,, TaxidimeTaxidime,, Tazicef Tazicef ))

cefepimecefepime ((MaxipimeMaxipime)) imipenemimipenem meropenemmeropenem ((MerremMerrem IV)IV)

ciprofloxacinciprofloxacin ((CiproCipro)) trovafloxacintrovafloxacin

aztreonamaztreonam

possiblypossibly tobramycintobramycin ((NebcinNebcin) or) or netilmicinnetilmicin

((NetromycinNetromycin



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Esophageal/Esophageal/gastroduodenalgastroduodenal


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Esophageal/Esophageal/gastroduodenalgastroduodenalProbable pathogens:Probable pathogens:


gramgram--positivepositive coccicocci

Treatment: (highTreatment: (high--risk only,risk only, i.e. esophageali.e. esophagealobstruction, decreased gastricobstruction, decreased gastric

acidity/gastrointestinal motility, morbidacidity/gastrointestinal motility, morbid

obesityobesity))

CefazolinCefazolin (( Ancef Ancef ,, DefzolDefzol) () (IVIV))


BiliBili t tt t


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BiliaryBiliary

tracttractProbable pathogens:Probable pathogens:


enterococcienterococci, clostridia, clostridia

Treatment: (highTreatment: (high--riskrisk only,only,i.ei.e. age > 70,. age > 70,acuteacute cholecystitischolecystitis, non, non--functioningfunctioninggallbladder, obstructive jaundice orgallbladder, obstructive jaundice or

common duct stonescommon duct stones)) CefazolinCefazolin (( Ancef Ancef ,, DefzolDefzol)) IVIV


A d f d


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Appendectomy, nonAppendectomy, non--perforatedperforated



anaerobes,anaerobes, enterococcienterococci


CefoxitinCefoxitin ((MefoxinMefoxin))

SepsisSepsis

Factors in selecting appropriate drugs toFactors in selecting appropriate drugs to


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manage sepsis syndromemanage sepsis syndrome::

source of infectionsource of infection

gram staingram stain

immune statusimmune status bacterial resistance patterns in the communitybacterial resistance patterns in the community

and hospitaland hospital

SepsisSepsis



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manage sepsis syndromemanage sepsis syndrome::

source of infectionsource of infection

gram staingram stain

immune statusimmune status bacterial resistance patterns in the communitybacterial resistance patterns in the community

and hospitaland hospital

ANTIBIOTIC SELECTION ANTIBIOTIC SELECTION


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ByBy

Prof. ABDEL FATTAH ABDEL SATTARProf. ABDEL FATTAH ABDEL SATTAR

HEAD OF ANESTHESIA & PAIN RELIEFHEAD OF ANESTHESIA & PAIN RELIEF

DEPARTMENTDEPARTMENTNATIONAL CANCER INSTITUTENATIONAL CANCER INSTITUTE

CAIRO UNIVERSTIYCAIRO UNIVERSTIY20072007

A 43 year old lady with short bowel syndromeA 43 year old lady with short bowel syndrome

following surgery forfollowing surgery for CrohnCrohn’’ss

disease, ondisease, on

home TPN, is admitted with hypoxemia,home TPN, is admitted with hypoxemia,tachycardia pyrexia and neutropeniatachycardia pyrexia and neutropenia


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, yp ,, yp ,tachycardia, pyrexia and neutropenia.tachycardia, pyrexia and neutropenia.

PresumedPresumed diagnosisdiagnosis

--

infected intravenousinfected intravenous

catheter (line sepsiscatheter (line sepsis).).

A 54 year old male develops a fever,A 54 year old male develops a fever,leucocytosisleucocytosis

and inflammation around hisand inflammation around his

midlinemidline sternotomysternotomy

site 5 days aftersite 5 days after

undergoing coronary bypass surgery.undergoing coronary bypass surgery. Presumed diagnosisPresumed diagnosis – –

wound infection,wound infection,

possiblepossible mediastinitismediastinitis..

There is a strong possibility of infection in both ofThere is a strong possibility of infection in both ofthese cases withthese cases with staphylococci,staphylococci, coagulasecoagulase--positivepositive or negative.or negative.

VancomycinVancomycin should be added to for exampleshould be added to for example


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VancomycinVancomycin should be added to, for example,should be added to, for example,piperacillin+azobactampiperacillin+azobactam..

Once the infecting organisms have been isolated,Once the infecting organisms have been isolated,thethe spectrum of antimicrobials should bespectrum of antimicrobials should benarrowednarrowed

(if(if methacillinmethacillin resistantresistant staphstaph aureusaureus – –MRSAMRSA-- isisisolated, theisolated, the piperacillinpiperacillin++ azobactamazobactam should beshould bediscontinued).discontinued).

VancomycinVancomycin

++ Piperacillin+TazobactamPiperacillin+Tazobactam

ororCiprofloxacinCiprofloxacin

The lady withThe lady with CrohnCrohn’’ss disease and presumed linedisease and presumed linesepsis does not respond to line removal and thesepsis does not respond to line removal and theantibiotic regimen above, blood cultures comeantibiotic regimen above, blood cultures comeback positive forback positive for unspeciatedunspeciated candidacandida. Confirmed. Confirmeddi idi i f l if l i


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diagnosisdiagnosis – – fungal sepsis.fungal sepsis.The options areThe options are

1) start high dose1) start high dose fluconazolefluconazole and if there is noand if there is noresponse move over to the more toxic agent,response move over to the more toxic agent,amphoteracinamphoteracin,,

2) start2) start amphoteracinamphoteracin immediately. In this patientimmediately. In this patient’’sscase, she is severely ill, and has depletedcase, she is severely ill, and has depletedphysiologic reserve and may well bephysiologic reserve and may well be

immunocompromisedimmunocompromised (steroids), I would start(steroids), I would startamphoteracinamphoteracin B. If there is a question of renalB. If there is a question of renalinsufficiency, I would prescribe the less toxicinsufficiency, I would prescribe the less toxiccolloidal orcolloidal or liposomalliposomal form.form.

A 17 year old female presents with a 2 hour history of A 17 year old female presents with a 2 hour history of

confusion, pyrexia, headacheconfusion, pyrexia, headacheand aand a purpuricpurpuric rashrash..


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and aand a purpuric purpuric rash rash ..

This patient has This patient has meningococcal septicemiameningococcal septicemia untiluntil

otherwise proven.otherwise proven. The most likely alternative organisms are The most likely alternative organisms are

pneumococci pneumococci, H., H. InfluenzaeInfluenzae andand,, rarely,rarely,

EnterobacteriaceaeEnterobacteriaceae andand ListeriaListeria.. Third generation cephalosporin Third generation cephalosporin ++ vancomycin vancomycin (if(if

penicillin resistant S.penicillin resistant S. pneumoniaepneumoniae suspected) +suspected) +

ampicillinampicillin (if(if ListeriaListeria suspected)suspected) ..

CefotaximeCefotaxime

++ Vancomycin Vancomycin


Esophageal/Esophageal/gastroduodenalgastroduodenal


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p gp g ggProbable pathogens:Probable pathogens:

enteric gramenteric gram--negative bacilli,negative bacilli,gramgram--positivepositive coccicocci

Treatment: (highTreatment: (high--risk only,risk only, i.e. esophageali.e. esophagealobstruction, decreased gastricobstruction, decreased gastric

acidity/gastrointestinal motility, morbidacidity/gastrointestinal motility, morbid

obesityobesity))

cefazolincefazolin (( Ancef Ancef ,, DefzolDefzol) () (IVIV))


BiliaryBiliary tracttract


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BiliaryBiliary

tracttractProbable pathogens:Probable pathogens:


enterococcienterococci, clostridia, clostridia

Treatment: (highTreatment: (high--riskrisk only,only,i.ei.e. age > 70,. age > 70,acuteacute cholecystitischolecystitis, non, non--functioningfunctioninggallbladder, obstructive jaundice orgallbladder, obstructive jaundice or

common duct stonescommon duct stones)) cefazolincefazolin (( Ancef Ancef ,, DefzolDefzol)) IVIV


Appendectomy nonAppendectomy non perforatedperforated


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Appendectomy, nonAppendectomy, non--perforatedperforated



anaerobes,anaerobes, enterococcienterococci


cefoxitincefoxitin ((MefoxinMefoxin)) LorcetLorcet ((hydrocodonehydrocodone/acetaminophen) (IV)/acetaminophen) (IV)

Thoracic ( Thoracic (noncardiacnoncardiac

)) Probable pathogens:Probable pathogens:

StaphylococcusStaphylococcus

aureusaureus

,,

StaphylococcusStaphylococcus epidermidisepidermidis, streptococci, enteric, streptococci, entericti b illiti b illi


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gramgram--negative bacillinegative bacilli

TreatmentTreatment:: cefazolincefazolin (( Ancef Ancef ,, DefzolDefzol) or) or cefuroximecefuroxime((Zinacef Zinacef ,, CeftinCeftin) or) or vancomycinvancomycin ((VancocinVancocin))

Rationale for ProphylaxisRationale for Prophylaxis::

commonly used for routine pulmonary surgery;commonly used for routine pulmonary surgery; limitedlimited

research supportresearch support insertion of chest tubes following closedinsertion of chest tubes following closed--tubetube

thoracostomythoracostomy following chest trauma:following chest trauma: cephalosporincephalosporin(multiple doses) can prevent infection(multiple doses) can prevent infection

single preoperativesingle preoperative cefazolincefazolin (( Ancef Ancef ,, DefzolDefzol) dose) dose(pulmonary resection): decrease in the incidence of(pulmonary resection): decrease in the incidence ofwound infectionwound infection ---- no decrease in incidence ofno decrease in incidence ofpneumonia orpneumonia or empyemaempyema


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Pneumococcal meningitisPneumococcal meningitis ::


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Pneumococcal meningitisPneumococcal meningitis ::

** CefotaximeCefotaxime

(Vancomycin if resistant).(Vancomycin if resistant). H.influenza meningitisH.influenza meningitis ::

**CefotaximeCefotaxime

or or

ChloramphenicolChloramphenicol

++RiphampicinRiphampicin

(4days before discharge)(4days before discharge)

Listeria meningitisListeria meningitis ::

**AmoxycillinAmoxycillin

++gentamicingentamicin

ORGANISMS & SITE of INFECTIONORGANISMS & SITE of INFECTION

** S.aureusS.aureus skin,soft tissue,bone,IV linesskin,soft tissue,bone,IV lines..


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**

Strept(A).Strept(A). skin,soft tissue,fascial infectionskin,soft tissue,fascial infection..

* Enterococci* Enterococci Biliary,urinary , colonicBiliary,urinary , colonicinfection.infection.

**

Pseudomonas aerugPseudomonas aerug.. lung, skin infectionlung, skin infection* Klebsiella* Klebsiella Infection around biliary T.Infection around biliary T.

* Proteus* Proteus Urosepsis.Urosepsis.* E.coli* E.coli Intraabdominal pelvic or urinaryIntraabdominal pelvic or urinary

* Clostridium* Clostridium skin,soft t., biliary, colonicskin,soft t., biliary, colonic

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