Carbapenems Aminoglycosides

Urinary tract Third-generation cephalosporin (ceftriaxone) OR Fluoroquinolone (levofloxacin or ciprofloxacin) Antipseudomonal penicillin OR Antipseudomonal cephalosporin OR Antipseudomonal carbapenem plus aminoglycoside... 

Treatment for septic patients with hospital-acquired, ventilator-acquired, and health care-associated pneumonia is dependent on risk factors for multi-drug resistant (MDR) organisms (Fig. 79-2). Recommended treatment for patients with no MDR risk factors are third-generation cephalosporins, fluoroquinolones, ampicillin-sulbactam, or ertapenem (see Table 79-3).35 Recommended treatment for patients with MDR risk factors are P-lactam/p-lactamase inhibitors (piperacillin-tazobactam), antipseudomonal cephalosporin, or carbapenem, plus an aminoglycoside, plus vancomycin or linezolid (see Table 79-3).35 If an aminoglycoside is undesirable, a antipseudomonal fluoroquinolone may be utilized with a P-lactam/p-lactamase inhibitor. 

Nosocomial pneumonia Gram-negative bacilli (such as K pneumoniae, Enterobacter spp.. Pseudomonas aeruginosa), 5. aureus Pi peraci 11 i n-tazo bacta rr carbapenem,e or extended-speclrum cephalosporin plus aminoglycoside, fluoroquinolone ... 

Broad spectrum therapy is started on an empirical basis. Intra-abdominal infections can be treated by ampicillin (or amoxycillin) or clindamycin combined with aminoglycosides, penicillin-beta-lacta-mase inhibitors such as amoxycillin-clavulanic acid or a second or third generation cephalosporin combined with metronidazole are good alternatives. In patients with impaired immunity and/or prior use of antibiotics, i.e. when it is reasonable to expect resistant pathogens, a broad spectrum penicillin plus beta-lactamase inhibitor or a carbapenem can be used empirically in monotherapy. In septic patients, the rapidly bactericidal action of aminoglycosides is useful. Aminoglycosides should preferentially not be given for more than 3-5 days. 

Piperadllin-tazobactarrt carbapenem, or extended-spectrum cephalosponnP plus aminoglycoside, fluoroquinolone ... 

Pazufloxacin is an injectable quinolone antibiotic with bactericidal effect against cephalosporin-resistant, carbapenem-resistant, and aminoglycoside-resistant strains of bacteria. 

Alcoholism Aspiration Pneumococcus, K. pneumoniae, S. aureus, H. influenzae, possibly mouth anaerobes Ticarcillin-clavulanate, piperacillin-tazobactam, plus aminoglycoside carbapenem, fluoroquinolone ... 

Antimicrobial regimens for secondary intraabdominal infections should include coverage for enteric gram-negative bacilli and anaerobes. Antimicrobials that may be used for the treatment of secondary intraabdominal infections include (a) a /3-lactam// -lactamase inhibitor combination, (b) a carbapenem, (c) quinolone plus metronidazole, or an aminoglycoside plus clindamycin (or metronidazole). 

At least four different types of empirical parenteral antibiotic regimens are in use (1) monotherapy with an antipseudomonal cephalosporin (cefepime or ceftazidime) or antipseudomonal car-bapenem (imipenem-cilastatin or meropenem), (2) combination therapy with an aminoglycoside plus an antipseudomonal penicillin (piperacillin-tazobactam or ticarciUin-clavulate), an antipseudomonal cephalosporin, or an antipseudomonal carbapenem, (3) vancomycin plus an antipseudomonal cephalosporin or antipseudomonal carbapenem, with or without an aminoglycoside, and (4) a fluoroquinolone (ciprofloxacin or levofloxacin) in combination with an... 

In patients who have had a severe reaction to a penicillin, it is inadvisable to administer a cephalosporin or a carbapenem such as meropenem. Aztreonam has no significant activity against gram-positive cocci, so the logical treatment in this case is vancomycin, often with an aminoglycoside for synergistic activity against enterococci. The answer is (E). 

The use of piperacillin is reported to be a risk factor for aminoglycoside-associated nephrotoxicity. A reduction in serum aminoglycoside levels can occur if aminoglycosides and penicillins are given together to patients with severe renal impairment. No pharmacokinetic interaction of importance appears to occur with intravenous aminoglycoside and penicillins in those with normal renal function or between aminoglycosides and carbapenems. The serum levels of oral phenoxymethylpenicillin can be halved by oral neomycin. 

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