Piperacillin Aminoglycosides

When used for intraabdominal infection, aminoglycosides should be combined with agents that are effective against the majority of B. fragilis. Clindamycin or metronidazole is the agent of first choice, but others, such as antianaerobic cephalosporins (e.g., cefoxitin, cefotetan, or ceftizoxime), piperacillin, mezlocillin, and combinations of extended-spectrum penicillins... 

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. 

Optimal antibiotic therapies for gram-negative bacillary meningitis have not been fully defined. Meningitis caused by Pseudomonas aeruginosa is initially treated with ceftazidime or cefepime, piperacillin + tazobactam, or meropenem plus an aminoglycoside, usually tobramycin. 

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

Pseudomonas aeruginosa Bacteremia pneumonia Ceftazidime or piperacillin + an aminoglycoside Aztreonam cefepime ciprofloxacin imipenem meropenem... 

An aminoglycoside plus a cephalosporin, mezlocillin, or piperacillin, is effective against sensitive strains of Klebsiella. 

As long as there is no positive bacteriological result from the bile (or blood), antibiotics are administered on empirical and plausible principles. In this case, mezlocillin or piperacillin is initially recommended, 3x2 (-4 or -5) g/day, i.v. (55) These antibiotics are effective against virtually all bacteria in acute cholangitis, since they can reach high biliary concentrations. Once the course of disease has entered a more severe stage, an additional dose of tobramycin, for example, is indicated (e.g. 3 x 80 mg/day, i.v.). A septic clinical picture requires a course of triple therapy with ureidopenicillin + aminoglycoside (see above) + metronidazole (3 x 500 mg/ day, i.v.). 

Adam D, Haneder J. Studies on the inactivation of aminoglycoside antibiotics by acylureidopeniciUins and piperacillin. Infection 1981 9 182. 

Piperacillin protected against aminoglycoside nephrotoxicity without reducing its blood concentration this was possibly a protective effect of co-administered mineral salts (249). 

Indications Neuromuscular blockade, endotracheal intubation Category Non-depolarizing neuromuscular blocker Half-life initial 2 minutes terminal 20 minutes Clinically important, potentially hazardous interactions with amikacin, aminoglycosides, anesthetics, antibiotics, gentamicin, halothane, kanamycin, neomycin, piperacillin, streptomycin, tobramycin... 

Clinically important, potentially hazardous interactions with aminoglycosides, clindamycin, cyclopropane, enflurane, halothane, isoflurane, methoxyflurane, piperacillin, rocuronium... 

Clinically important, potentially hazardous interactions with acitretin, aldesleukin, aminoglycosides, amiodarone, amoxicillin, ampicillin, aspirin, bacampicillin, bismuth, carbenicillin, chloroquine, cisplatin, cloxacillin, co-trimoxazole, dapsone, demeclocycline, dexamethasone, diclofenac, dicloxacillin, etodolac, etoricoxib, etretinate, fenoprofen, flurbiprofen, folic acid antagonists, haloperidol, hydrocortisone, ibuprofen, indomethacin, influenza vaccines, ketoprofen, ketorolac, lithium, magnesium trisalicylate, meclofenamate, mefenamic acid, methicillin, mezlocillin, minocycline, nabumetone, nafcillin, naproxen, NSAIDs, omeprazole, oxacillin, oxaprozin, oxytetracycline, paromomycin, penicillin G, penicillin V, penicillins, phenylbutazone, piperacillin, piroxicam, polypeptide antibiotics, prednisolone, prednisone, probenecid, procarbazine, rofecoxib, salicylates, salsalate, sapropterin, sulfadiazine, sulfamethoxazole, sulfapyridine, sulfasalazine, sulfisoxazole, sulindac, tazobactum, tenoxicam, tetracycline, ticarcillin, tolmetin, trimethoprim, vaccines... 

Early clinical trials showed no benefit from antibiotic prophylaxis, but studies were flawed, as they included patients with all degrees of disease severity and did not have a sufficient number of patients with severe necrotizing AP. " In addition, the studies utilized ampicillin, which does not penetrate well into pancreatic tissue." Imipenem-cilastatin, metronidazole, cefotaxime, piperacillin, mezlocillin, ofloxacin, and ciprofloxacin all achieve satisfactory bactericidal tissue concentrations, whereas aminoglycosides have poor penetration." " However, the importance of antibiotic penetration into pancreatic tissue has been debated, as it is the peripancreatic retroperitoneal necrotic fat and debris, not the pancreas itself, that becomes infected. 

It is incumbent on health professionals to avoid toxic drugs whenever possible. Antibiotics associated with CNS toxicities, usually when not dose-adjusted for renal function, include penicillins, cephalosporins, quinolones, and imipenem. Hematologic toxicities generally are manifested with prolonged use of nafcillin (neutropenia), piperacillin (platelet dysfunction), cefotetan (hypoprothrombinemia), chloramphenicol (bone marrow suppression, both idiosyncratic and dose-related toxicity), and trimethoprim (megaloblastic anemia). Reversible nephrotoxicity classically is associated with aminoglycosides... 

Cefepime, ceftazidime, piperacillin-tazobactam, or ticarcillin-clavulanate plus aminoglycoside ... 

Nosocomial pneumonia Gram-negative bacilli (such as K. pneumoniae, Enterobacter spp.. Pseudomonas aeruginosa), S. aureus Piperacillin-tazobactam, carbapenem, or expanded spectrum cephalosporin plus aminoglycoside, fluoroquinolone ... 

Penicillins Ampicillin Amp ic ill in-sulbactam Ticarcillin-clavulanate Piperacillin Piperac il 1 i n-tazobactam These agents generally are equally effective for susceptible bacteria. The extended-spectrum penicillins are more active against P. aeruginosa and enterococci and often are preferred over cephalosporins. They are very useful in renally impaired patients or when an aminoglycoside is to be avoided. 

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... 

Gram-negative aerobic bacilli (Enterobacteriaceae, Pseudomonas aeruginosa, Hemophilus influenzae) Blood, urinary tract, pulmonary, abdomen Empiric Ceftazidime 1-2 g every 8 h - -Aminoglycoside, cefepime 1-2 g every 12h- -aminoglycoside piperacillin-tazobactam 3.375. 5 g every 4-6 h imipenem-cilastatin 0.25-0.5 g every 6 h aminoglycoside Def/n/f/ve According to culture and sensitivity results... 

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