antibiotics 101 for laboratory professionalsantibiotics 101 for laboratory professionals: part two...
TRANSCRIPT
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Antibiotics 101 forLaboratory Professionals:
Part Two
Erik MunsonClinical Microbiology
Wheaton Franciscan LaboratoryWauwatosa, Wisconsin
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OUTLINE
I. Trying to understand the choice
II. Selected classes of antimicrobials
III. Bacterium-specific examples of resistance
A. Streptococcus pneumoniae
B. Staphylococcus aureus
C. Klebsiella pneumoniae
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“D#*%it, Jim,I’m not a physician.”
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Skin and soft tissue infections
Necrotizing pneumonia
Otitis media
Osteomyelitis
Bacteremia
Endocarditis
Staphylococcus aureus
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-lactam
TWO BASIC SUBDIVISIONS
Non--lactam
Penicillins Cell wall synthesis
Glycopeptides Cell wall synthesisLincosamides Protein synthesisStreptograminsOxazolidinones
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PENICILLIN CLASSSubclass (if appropriate) Agent(s)
penicillin penicillin
aminopenicillinamoxicillinampicillin
carboxypenicillincarbenicillin
ticarcillinureidopenicillin piperacillin
penicillinase-stable penicillins
dicloxacillinmethicillinnafcillinoxacillin
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PENICILLIN CLASSParameter Description
Spectrum of activity
Penicillins: streptococci, anaerobes, Neisseria, agent of syphilis
Aminopenicillins: (similar to penicillin PLUS) Listeria, enterococci, Haemophilus, some enteric GNR
Carboxypenicillins: better enteric GNR coverage, some Pseudomonas aeruginosa, anaerobes
Ureidopenicillins: even better enteric GNR coverage, better Pseudomonas aeruginosa, anaerobes
Penicillinase-stable penicillins: Staph w/o mecA
Interesting stuff Despite “narrow” spectrum of activity, nafcillin with greater potency than broad spectrum vancomycin
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Higher treatment failure/mortality rates in MSSAbacteremic patients treated with vancomycin
than in those treated with nafcillin
Clin. Infect. Dis. 42(suppl 1): S51-S57; 2006
CONSERVATIVE EMPIRICAL RX??
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GLYCOPEPTIDE CLASSSubclass (if appropriate) Agent(s)
glycopeptide vancomycinlipoglycopeptide teicoplanin
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GLYCOPEPTIDE MECHANISM
cell membrane
cell wall(peptidoglycan)
Complexes withD-alanine-D-alanineresidues on cell wall
precursor
Inhibit peptidoglycansynthesis
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Parameter Description
Mechanism of actionInhibits peptidoglycan synthesis by complexing
with D-alanine-D-alanine residues
Activity rendered CidalRoute of administration IV (PO for C. difficile)
Distribution Well; CNS penetration at high dosesHalf-life 4-6 hours → q12h
Excretion Renal and biliary
Adverse effects Fever, chills, phlebitis at infusion site; red man syndrome with rapid/bolus infusion; kidneys (with AG)
GLYCOPEPTIDE CLASS
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Parameter Description
Spectrum of activity
Broad spectrum (Gram positive anaerobes, facultatives)MRSAClostridium difficileCorynebacterium jeikeium
Penicillin- or cephalosporin-allergic patients
Empiric therapy for sepsis
Aminoglycoside synergy
Interesting stuff Activity against just one Gram negative organism (Flavobacterium meningosepticum)
GLYCOPEPTIDE CLASS
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LINCOSAMIDE CLASSSubclass (if appropriate) Agent(s)
NONE clindamycin
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Reversible binding to 50S ribosomal subunit
Blocks translocation reaction of peptide elongation(no A to P)
LINCOSAMIDE CLASS
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Parameter Description
Mechanism of actionBind reversibly to 50S ribosomal subunits,
blocking the translocation reaction of polypeptide chain elongation
Activity rendered Static; can be cidalRoute of administration PO or IV
Distribution Well (including bone, placenta, intracellular); no CNSHalf-life 2.4 hours → q6h or q8h
Excretion Renal and biliary
Adverse effects Diarrhea in 20% of patients; association with Clostridium difficile; rash and fever
LINCOSAMIDE CLASS
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Parameter Description
Spectrum of activity
Gram positive facultative: Option for MRSANot Enterococcus spp.
S. pneumoniae (not CSF)
Anaerobes: Good for actinomycosis10-15% resistance in Bacteroides
10-20% resistance in C. perfringens
Babesia, Plasmodium, Toxoplasma, Pneumocystis
Interesting stuff ~40% resistance rate in -hemolytic streptococci; emerging problem in penicillin-allergic patients
LINCOSAMIDE CLASS
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STREPTOGRAMIN CLASSSubclass (if appropriate) Agent(s)
NONE quinupristin-dalfopristin
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Combination of two structurally-unrelatedcompounds (group A and group Bstreptogramins) acting in synergy
Synercid: 30% quinupristin70% dalfopristin
STREPTOGRAMIN CLASS
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STREPTOGRAMIN CLASS
Group A streptograminbinds to 50S subunit
of ribosome
Prevent peptide bondformation during chain
elongation step
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STREPTOGRAMIN CLASS
Conformation change ofribosome (group A)
increases affinity for group Bstreptogramins
Release of incompletepeptides from 50S subunit
of ribosome
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Parameter Description
Mechanism of action
streptogramin A: block translocation function of polypeptide chain elongation
streptogramin B: release of incomplete chain from ribosome
Activity rendered CidalRoute of administration IV
Distribution Well; intracellularHalf-life 1 hour → q8h
Excretion Biliary, renal
Adverse effects Arthralgias, myalgias (reversible upon discontinuation); cutaneous reactions; GI
STREPTOGRAMIN CLASS
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Parameter Description
Spectrum of activity
Vancomycin-resistant Enterococcus (E. faecium)
Staphylococci and streptococci (including species resistant to macrolides, -lactams, fluoroquinolones)
Agents of atypical pneumonia
Neisseria spp.
Most anaerobes
Interesting stuff Losing battle versus enterococci (VRE)
STREPTOGRAMIN CLASS
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Subclass (if appropriate) Agent(s)NONE linezolid
OXAZOLIDINONE CLASS
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OXAZOLIDINONE CLASS
30Ssubunit
Prevent formationof functional
initiation complex
Binds ribosomal RNAwithin 50S subunit ( ),distorting binding sitefor first transfer RNA
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Parameter Description
Mechanism of action1. Prevents initiation of protein synthesis
2. No cross-resistance with other protein synthesis inhibitors
Activity rendered StaticRoute of administration PO or IV
Distribution Well; CNS penetrationHalf-life 5 hours → q12h
Excretion Renal
Adverse effects Diarrhea, headache, nausea; prolonged use →neuropathy, myelosuppression (RBC, WBC, platelets)
OXAZOLIDINONE CLASS
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Parameter Description
Spectrum of activity
Vancomycin-resistant Enterococcus spp. (VRE)
Methicillin-resistant Staphylococcus aureus (MRSA)
Gram positive facultatives and mycobacteria
Gram positive anaerobes
Skin and soft tissue infections
Lower respiratory tract infections
Interesting stuff “Do we want GI mad at us or do we want heme/oncmad at us?? (quinupristin-dalfopristin vs. linezolid)”
OXAZOLIDINONE CLASS
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Mechanisms of Resistance
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29penicillin-binding protein
-lactam
-LACTAM RESISTANCEMediated by -lactamases
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30penicillin-binding protein
-lactam
-lactamase
-LACTAM RESISTANCE
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Predicts resistance to thefollowing -lactam agents:
penicillinampicillinamoxicillincarbenicillin
ticarcillinpiperacillin
-LACTAMASE-POSITIVE STAPHYLOCOCCI
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Penicillin
> 90% resistance rate
Nafcillin (tested by oxacillin)
Staphylococcus aureus THERAPY
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-LACTAM RESISTANCE
Mediated by penicillin-binding proteinsmecA (origin likely Staphylococcus sciuri)
transcribed, translated into PBP2a
mecA influenced by several regulatory genes
Constituent of SCCmec (staphylococcalcassette chormosome)
Mediated by -lactamases
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Organism
Increase in mecA ActivityOxacillin
(1 g/mL)Cefoxitin
(1 g/mL)
MRSA 1.1-fold 9.7-fold
METHICILLIN-RESISTANCE INDUCTION
J. Bacteriol. 183: 6862-6868; 2001
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Disk Diffusion AgentOxacillin
Cefoxitin
Sensitivity~81%
100%
Specificity~70%
100%
DETECTION OF MRSA
J. Clin. Microbiol. 43: 3818-3825; 2005
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Change categorical interpretation to“RESISTANT”, regardless of MIC,
for the following agents:
penicillinscephems
monobactams-lactam/-lactamase inhibitor combinations
carbapenems
CEFOXITIN-RESISTANT STAPHYLOCOCCI
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Penicillin
> 90% resistance rate
Nafcillin (tested by cefoxitin)
Variable resistance~60% in Milwaukee (mecA)
Vancomycin (MRSA and MSSA)
Staphylococcus aureus THERAPY
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GLYCOPEPTIDE RESISTANCE (INTRINSIC)
Large size limits ability to penetrate Gram negatives
Gram positive Gram negative
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GLYCOPEPTIDE RESISTANCE (ACQUIRED)
Mutational cell wall changes
Characterized by reduced susceptibility, not resistance
Characterized by thickened cell wallIncreased number of unlinked precursors
Abnormal septum formation
Antimicrobial Agents Chemother. 44: 2276-2285; 2000
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GLYCOPEPTIDE RESISTANCE (ACQUIRED)
Altered precursor formationResistance genes promote change in terminusof peptidoglycan precursor to alanine~lactate
1000-fold reduced affinity for vancomycin
vanA transposon (plasmid)vanB transposon (plasmid)
vanC chromosomalvanD chromosomalvanE chromosomalvanG chromosomal
Mutational cell wall changes
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Vancomycin-resistantStaphylococcus aureus (VRSA)
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VRSA IN MICHIGAN--2002
Chronic renal failure; diabetic foot ulcers
VRSA isolated from catheter exit site;VRE, VRSA, Klebsiella from ulcer
vanA sequenced from VRSASame as vanA from patient’s VRESame as vanA from VRE transposon
MMWR. 51: 565-567; 2002
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Staphylococci and -streptococci
msrA constitutive resistance (efflux)
ACROLIDE
INCOSAMIDE
TREPTOGRAMIN
erm gene cassette inducible resistancea.k.a. MLSB locus
LINCOSAMIDE RESISTANCE
Ribosome
methylation
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CE
msrA-mediatederythromycin resistance
erm-mediatederythromycin resistance
Inducible clindamycin resistance
ERYTHROMYCIN/CLINDAMYCIN TESTING
E C
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Organism Group
Percentage of Isolates with Inducible Clindamycin ResistanceNosocomial Outpatient Total
Coagulase-negative staph 51.4 46.2 49.2
MRSA 31.3 26.2 27.3MSSA 78.9 54.8 62.2
INDUCIBLE LINCOSAMIDE RESISTANCE
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Clindamycin Resistance in MRSA
0
5
10
15
20
25
30
35
40
45
50
55
60
65
2005 2006 2007 2008
Year
Perc
enta
ge R
esis
tanc
e
Nosocomial isolatesCommunity isolates
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STREPTOGRAMIN RESISTANCE
ATP-dependent efflux
Streptogramin acetyltransferases(modification of streptogramin binding site)
Several with unknown mechanism
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OXAZOLIDINONE RESISTANCE
Gene may have multiple copy number insome organisms → increased resistance
Point mutation in gene that confers portionof 50S subunit
First mutation promotes successivemutations
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Pneumonia
Peritonitis
Urinary tract infection
Skin and soft tissue
Bacteremia
Liver abscess
Klebsiella pneumoniae
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-lactam
TWO BASIC SUBDIVISIONS
Non--lactam
CephemsMonobactamsInhibitor combinationsPenems
Aminoglycosides Protein synthesisLipopeptides Cell membrane
Cell wall synthesis
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ARBITRARY CLASSIFICATIONS
ActivityNarrow spectrum
Expanded spectrum
Broad spectrum
Extended spectrum
GenerationFirst
Second
Third
Fourth
GP
GN
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OFFICIAL BREAKDOWNSubclass (if appropriate) Agent(s)
cephalosporin Icefazolin
cephalexincephalosporin II cefuroxime
cephamycin (“cephalosporin II”)cefoxitincefotetan
cephalosporin III
ceftriaxoneceftazidimecefotaxime
cefdinircefoperazone
cephalosporin IVcefepime
ceftobiprole
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CEPHEM CLASSParameter Description
Mechanism of action
1. Bind to bacterial penicillin-binding proteins (PBP), interfering with cell wall synthesis
2. Can trigger membrane-associated autolyticenzymes that destroy cell wall
Activity rendered CidalRoute of administration PO or IV; e.g., cephalexin vs. cefazolin
Distribution Well; CNS penetrationHalf-life 0.5 to 8 hours → q6h or q24h
Excretion Mostly renal; cefoperazone with great biliary
Adverse effects Allergic skin rash, drug fever, diarrhea; creatinine, transaminases; leukopenia, thrombocytopenia
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CEPHEM CLASSMicrobe(s) I II Cephamycin III IV
Streptococcus spp. +++ +++ +++ +++ ++MSSA +++ +++ +++ + +MRSA NO NO NO NO (NO)
Enterococcus spp. NO NO NO NO NOHaemophilus spp. + +++ +++ +++ +++Enterics (basic) + ++ ++ +++ +++
Enterics (resistant) NO + (++) +++ +++Pseudomonas spp. NO NO NO +++ +++
Anaerobes ++ ++ +++ ++ ++Bacteroides fragilis NO NO +++ NO NO
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CEPHEM CLASSParameter Description
Spectrum of activity
cefazolin: MSSA, streptococcicefuroxime: Haemophilus, S. pneumoniaecefoxitin/cefotetan: Anaerobesceftriaxone: Resistant enterics, N. gonorrhoeaeceftazidime/cefepime: Resistant enterics, Pseudoceftobiprole: MRSA (allegedly)
Interesting stuffCross-reaction in 3-7% of penicillin-allergic patients
Hypoprothrombinemia and bleeding tendencies associated with cefotetan, cefoperazone
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MONOBACTAM CLASSSubclass (if appropriate) Agent(s)
NONE aztreonam
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Parameter Description
Mechanism of actionBinds to penicillin-binding protein 3, interfering
with cell wall synthesis
Activity rendered CidalRoute of administration IV
Distribution Well; CNS penetrationHalf-life 1.7 hours → q8h
Excretion Renal and biliary
Adverse effects Nausea, diarrhea, rash, eosinophilia; mild/transient elevation of transaminases, creatinine
MONOBACTAM CLASS
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Parameter Description
Spectrum of activity
Aerobic Gram-negative bacteriaEnterobacteriaceae (including resistant genera)Haemophilus spp.Neisseria spp.
Aminoglycoside synergy
No utility for: AnaerobesGram-positive bacteriaAcinetobacter, Stenotrophomonas
Interesting stuff Alternative -lactam agent for Gram-negative infections in penicillin- or cephem-allergic patients
MONOBACTAM CLASS
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Subclass (if appropriate) Agent(s)NONE amoxicillin-clavulanic acid
ampicillin-sulbactampiperacillin-tazobactam
-LACTAM/-LACTAMASE INHIBITORS
Clavulanic acid, sulbactam, tazobactam1. Alone have poor intrinsic antibacterial activity
2. Irreversibly complex with -lactamase → loss of enzyme activity
3. Can lower MIC up to 20-fold when combined with -lactam agent
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62penicillin-binding protein
-lactam
-lactamase
-LACTAMASE
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63penicillin-binding protein
-lactam
-lactamase
-LACTAMASE INHIBITOR
TAZOBACTAM
???
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Parameter Description
Mechanism of action Forms irreversible complex with -lactamase
Activity rendered CidalRoute of administration PO
Distribution Well; no CNS penetrationHalf-life 1 hour → q8h or q12h
Excretion Renal, biliary
Adverse effects Nausea, vomiting, diarrhea in 5-10% of patients; allergic skin reactions
AMOXICILLIN-CLAVULANIC ACID
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Parameter Description
Mechanism of action Forms irreversible complex with -lactamase
Activity rendered CidalRoute of administration IV
Distribution Well; CNS penetrationHalf-life 1 hour → q6h
Excretion Renal
Adverse effects Nausea, diarrhea, rash; transient eosinophilia, transaminase elevation
AMPICILLIN-SULBACTAM
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Parameter Description
Spectrum of activity
Effective versus: anaerobes, Haemophilus influenzaeNeisseria sp., Moraxella catarrhalisMSSA, enterics to variable extent
Piperacillin-tazobactam with greatest potency
Not effective versus MRSA
Interesting stuff An antimicrobial susceptibility testing diagnostic tool for microbiologists (stay tuned)
-LACTAM/-LACTAMASE INHIBITORS
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PENEM CLASSSubclass (if appropriate) Agent(s)
penem faropenem
carbapenem
imipenemertapenemmeropenemdoripenem
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Parameter Description
Mechanism of actionBind to penicillin-binding proteins 1 and 2, causing
cell elongation and eventual lysis
Activity rendered CidalRoute of administration IV
Distribution Well; imipenem, meropenem with CNS penetrationHalf-life 1-4 hrs → q8h or q24h
Excretion Renal
Adverse effects Nausea, vomiting, diarrhea 5%; drug fever, rash, urticaria 3%; seizures 1%; other reversible effects
PENEM CLASS
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Parameter Description
Spectrum of activity
Gram-positives (including penicillin-resist S. pneumo)
Gram-negatives (including -lactam- and aminoglycoside-resistant enterics, ESBL)
Not effective versus MRSA, vancomycin-resistantEnterococcus spp., Stenotrophomonas maltophilia
Most potent -lactam versus anaerobes
Interesting stuffWidest spectrum of antibacterial activity of currently-available antimicrobials; imipenem administered with
cilastatin (a dehydropeptidase I inhibitor)
PENEM CLASS
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AMINOGLYCOSIDE CLASSSubclass (if appropriate) Agent(s)
NONE
gentamicintobramycinamikacin
streptomycinkanamycin
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Irreversible binding to30S ribosomal subunit;ribosomes unavailablefor protein synthesis
Misreading of geneticcode; resultant productionof nonsense proteins
AMINOGLYCOSIDE CLASS
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Parameter Description
Mechanism of action
1. Bind irreversibly to 30S ribosomal subunits; ribosomes unavailable for protein synthesis
2. Cause misreading of genetic code; nonsense proteins
Activity rendered CidalRoute of administration IV
Distribution Extracellular; no CNSHalf-life 2-3 hours → q24h
Excretion Renal
Adverse effects Nephrotoxicity (variable and reversible); auditory, vestibular toxicity (irreversible in 3-5% of patients)
AMINOGLYCOSIDE CLASS
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Parameter Description
Spectrum of activity
Synergy w/ -lactam/vancomycin vs. Gram-positives
Streptomycin: Mycobacterium tuberculosisSuspected agents of bioterrorism
Gentamicin < tobramycin < amikacin (important vs. Pseudomonas, Acinetobacter)
NO anaerobes; NO Gram-positive monotherapy
Interesting stuff Energy-dependent uptake; can be facilitated by vancomycin or -lactam therapy (synergy)
AMINOGLYCOSIDE CLASS
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Subclass (if appropriate) Agent(s)polymyxin polymyxin B
polymyxin E (colistin)
LIPOPEPTIDE CLASS
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Parameter Description
Mechanism of action
1. Bind to phosphorylated head groups of lipid A, disrupting cell membranes and losing osmolarity
2. Disruption of biofilm formation
Activity rendered CidalRoute of administration IV
Distribution Well; except CNS, pleural fluid, synovial fluidHalf-life ~3 hrs (colistin) ~7 hrs polymyxin B → q8h or q12h
Excretion Renal
Adverse effects Neurotoxicity (parasthesia, dizzy, vertigo, ataxia, slurred speech, confusion); nephrotoxicity (20%)
POLYMYXIN SUBCLASS
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Parameter Description
Spectrum of activity
Only Gram-negative bacilli (especially Pseudomonas aeruginosa)
Synergy with trimethoprim-sulfamethoxazole for serious infections caused by resistant Serratia spp., P. aeruginosa, S. maltophilia, Burkholderia cepacia
Pan-resistant Gram negative bacilli
Interesting stuff “We’re going back to 40 years ago!?!?”
POLYMYXIN SUBCLASS
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Mechanisms of Resistance
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1950s Chromosomal-derived-lactamases in Gram-negatives
KEY DATES IN CEPHEM RESISTANCE
1940s First -lactamase identified (E. coli)
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1960s First plasmid-derived -lactamasefound in E. coli (TEM-1)
Pseudomonas aeruginosaHaemophilus influenzaeNeisseria gonorrhoeaeOther Enterobacteriaceae
KEY DATES IN CEPHEM RESISTANCE
Chromosomal -lactamase foundin Klebsiella pneumoniae (SHV-1)
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70s,80s Extended-spectrum beta-lactams
ceftazidime cefotaximeceftriaxone aztreonam
KEY DATES IN CEPHEM RESISTANCE
1985 Plasmid-derived SHV-2 -lactamaseisolated from Klebsiella in Germany
Hydrolyzed new extended-spectrumbeta-lactam antimicrobials
Extended-Spectrum Beta-Lactamase
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Cephalosporin
ESBL
OBLIGATORY CARTOON
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Cephalosporin
ESBL-lactamase inhibitor
OBLIGATORY CARTOON
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K. pneumoniae bacteremia (18.7% ESBL)
32 patients administered cephalosporinwithin five days of ESBL detection
Outcome
FailureMortality
Susceptible
54%14%
Intermediate
100%50%
Overall
59%19%
THERAPEUTIC BENEFIT
J. Clin. Microbiol. 39: 2206-2212; 2001
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Single French ICU patient
TEM-24 ESBL
2. TEM-3 plasmid DNA3. TEM-24 plasmid DNA4. TEM-5 plasmid DNA5. Proteus mirabilis TEM-246. Providencia rettgeri TEM-247. Klebsiella pneumoniae TEM-248. Enterobacter aerogenes TEM-24
TEM-specific probe
EPIDEMIOLOGICAL BENEFIT
Antimicrob. Agents Chemother. 43: 2069-2073; 1999
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Gold standard: enzyme detection
Phenotypic methods; screening drugs
aztreonamceftazidime
cefpodoxime
DETECTION OF ESBL
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Disk diffusionDouble-diskpotentiation
amoxicillin-clavulanic acidceftazidime
ceftazidime +clavulanic acid
ceftazidime
Etest
ceftazidime +clavulanic acid
ceftazidime
DETECTION OF ESBL--“Method 1”
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ESBL
MIC
1 2 3 4Cephem
non-ESBL
MIC
1 2 3 4Cephem
DETECTION OF ESBL--“Method 2”
Antibiogram profiles
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PENEM RESISTANCE
Alteration of porin channels in bacterial cellwall, reducing permeability
Carbapenemase production
Serine carbapenemases (class A -lactamase)Metallo--lactamase (class B -lactamase)OXA-type -lactamase (class D -lactamase)
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89Infect. Control Hosp. Epidemiol. 29: 1107-1109; 2008
Klebsiella pneumoniae CARBAPENEMASE(KPC)
K. pneumoniaecarbapenem
resistance rate:
1% in 20008% in 2008
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90Infect. Control Hosp. Epidemiol. 29: 1107-1109; 2008
Klebsiella pneumoniae CARBAPENEMASEConfers resistance to all -lactams and all-lactam/-lactamase inhibitor combinations
blaKPC located on plasmids
Plasmids carrying blaKPC contain genesconferring resistance to aminoglycosidesand fluoroquinolones
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PREVALENCE OF KPC
New York City hospital with endemicity
KPC-producing organisms accounted for26% of K. pneumoniae bloodstream infection
KPC-producing organisms:
59% susceptible to gentamicin52% susceptible to tetracycline90% susceptible to polymyxin B
Infect. Control Hosp. Epidemiol. 29: 1099-1106; 2008
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MODIFIED HODGE TEST
Carbapenemdisk
Lawn of E. coliATCC 25922
KPC-producingorganism
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AMINOGLYCOSIDE RESISTANCEInactivation via modifying enzymes
Modify specific amino or hydroxyl groups on AG;Results in lower affinity for ribosome
acetyltransferases (AAC)nucleotidyltransferases (ANT)phosphotransferases (APH)
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AMINOGLYCOSIDE RESISTANCEInactivation via modifying enzymes
Modify specific amino or hydroxyl groups on AG;Results in lower affinity for ribosome
Modification of ribosomeMutations → changes in proteins and 16S rRNAEnzymatic methylation of rRNA
Decreased uptakeElectron potential (anaerobes, facultatives)Divalent cations (competition)Efflux
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POLYMYXIN RESISTANCE
Decreased uptakeEffluxCell wall of some organisms prevents uptake
Modification of phosphate groups of lipid A
Lipopolysaccharide modificationsAlteration of fatty acid content of lipid AAddition of amino, carboxyl groups
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THE ENDStuff we’ve donepenicillins penicillins (methicillin) cephemsmacrolides glycopeptides monobactamstetracyclines lincosamides -lactam/-lactamase inhibitorsfolate pathway inhibitors streptogramins penemsquinolones oxazolidinones aminoglycosides
lipopeptides
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THE END
See you at the Dells
Stuff we’ve donepenicillins penicillins (methicillin) cephemsmacrolides glycopeptides monobactamstetracyclines lincosamides -lactam/-lactamase inhibitorsfolate pathway inhibitors streptogramins penemsquinolones oxazolidinones aminoglycosides
lipopeptides