1. Inappropriate combinations of antimicrobial agents Munzur Morshed, Pharm D. candidate 2011 Arnold & Marie Schwartz College of Pharmacy and Health Sciences North Shore- Long Island Jewish Health System Infectious Diseases-Advanced Pharmacy Practice

2. Bacterial Targets for Antimicrobials

4. Streptococcus Pneumonia.

5. Enterococcus Species

6. Pseudomonas aeruginosa

7. Enterobacter Species

8. Acinobacter Species

9. Klebsiella Pneumonia- Extended Spectrum Beta-Lactamase producing. - Carbapenem resistant (KPC) John Papadopoulos- Pharmacodynamic Principles of Antimicrobial Pharmacotherapy.

10. New Antimicrobials in the pipeline ?????? John Papadopoulos- Pharmacodynamic Principles of Antimicrobial Pharmacotherapy.

12. Prior use of the same antimicrobial

13. Prolonged administrations of antimicrobial

14. Hospital Stay-Length of stay and prior hospitalization

15. Use of invasive devices

16. Lack of patient compliance

17. Sub-Optimal antibiotic concentration in the critically-ill patients

19. Spectrum of Activity

20. Spectrum of Activity cont…

22. Penicillins- Ampicillin, Piperacillin, Nafcillin

23. Cephalosporins- Ceftazidime, Cefazolin, Cefoxitin

24. Carbapenems- Imipenem/Cilastatin (Primaxin), Meropenem

25. β-lactamase inhibitors- Tazobactam, Sulbactam/ Unasyn, Zosyn

27. Avoid use b/c of therapeutic Duplication

28. Same MOA and same class and same spectrum of activity

29. Clinical Trials-Zosyn more efficacious than Unasyn if empiric treatment is desired- Pseudomonal Coverage

30. Zosyn plus Primaxin/Meropenem or Unasyn plus Primaxin/ Meropenem

31. Combination of a Beta-Lactam and Carbapenem

32. Same class but different Sub-Class

33. Avoid use

34. Major Drug Interactions- Antagonistic Effect

35. Carbapenems inhibits the destruction of Beta-Lactamases

36. Carbapenems induces the production of Beta-Lactamases

37. Zosyn/Unasyn induces the destruction of the Beta-Lactamase producing organism

39. Combination of a cephalosporin and a Beta-Lactam

40. Same class but different Sub-Class

41. Ceftazadime- Third Generation; Cefoxitin- Second Generation

42. Ceftazadime SOA- serious gram (+) infections, DRSP, pseudomonas, nosocomial pneumonia.

43. Cefoxitin SOA- Anaerobes-Bacteroides Fragilis; gram (-) such as Proteus, Klebsiella, E-Coli

44. Avoid use

45. Both combo represents therapy duplication; similar spectrum of activity

46. Clinical Trial

47. Each antimicrobial in both combo’s are equally efficacious

48. Same spectrum of activity

49. Eradication rate of each antimicrobial in both combo for the corresponding pathogens are similar.

51. Combination of a cephalosporin and a carbapenem

52. Same class but different Sub-Class

53. Avoid use

54. Major Drug Interactions- Antagonistic effect

55. Carbapenems inhibits the destruction of Beta-Lactamases

56. Carbapenems induces the production of Beta-Lactamases

57. Ceftazadime/ Cefoxitin induces the destruction of the Beta-Lactamase producing organisms

58. Clinical Trials

59. Primaxin- enhanced efficacy in tx. of both gram (+) and gram (-) infections

61. Same class, but different sub-class

62. Naficillin- a penicillinase resistant penicillin

63. SOA- mostly gram (+)- staph, strep

64. Common therapy for skin and soft tissue infection, Endocarditis, Bacteremia

65. Cefazolin- 1 st generation cephalosporin.

66. Mainly gram (+) coverage- Staph, strep, NO enterococci

67. Partial Gram (-) coverage- E.Coli, Proteus, Klebsiella

68. Commonly used as surgical prophylaxis

69. Avoid use

70. Represents Therapy Duplication

72. Fluoroquinolone plus Macrolides cont… Avelox plus Erythromycin or Avelox plus Azithromycin Combination of a fluoroquinolone and a macrolide Avelox SOA- Pseudomonas, Strep. , Staph. Enterobacter Erythro./Azithro. SOA- Strep. , Moraxella Catarrahalis, Chlamydia pneumonia. Avoid use Major Drug Interactions- additive effect Causes QT interval prolongation-Life threatening ventricular arrhythmias

74. Combination of 1st and 2nd line agents

75. Clindamycin- has excellent bone penetration ability-osteomyelitis, dental surgery

76. MOA- binds to 50S ribosomal subunit of the bacteria and therefore interfering with protein synthesis

77. SOA- mostly gram (+)-Excellent MSSA, strep, bacteroides

78. BBW- colitis and excessive GI upset and diarrhea (C. Difficile associated)

79. Augmentin- beta –lactam/ beta-lactamse inhibitor combinations

80. Mainly gram (+) coverage- MSSA, Bacteroides, strep.

81. No pseudomonas coverage

82. Avoid use

83. The Beta-lactam’s are cross-sensitive with penicillin

84. Clindamycin is a substitute for patients who is unable to take the Beta-lactam’s

86. Metronidazole- Drug of choice for Mixed infections, Trichomonas, and alternative for C-Difficile

87. SOA- Bacteroides, streptococci, C-Difficile, Gardnerella Vaginalis

88. Avoid alcohol- Good for alcoholics( Disulfiram reaction- nausea, vomiting, tachycardia)

89. Clindamycin- has excellent bone penetration ability-osteomyelitis, dental surgery

90. MOA- binds to 50S ribosomal subunit of the bacteria and therefore interfering with protein synthesis

91. SOA- mostly gram (+)-Excellent MSSA, strep, bacteroides

92. BBW- colitis and excessive GI upset and diarrhea (C. Difficile associated)

93. Avoid use

94. Therapeutic Duplication

95. Metronidazole- alternative for clindamycin induced C-Diffcile associated diarrhea

97. Thank You!

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