clinical pharmacy and therapeutics 2 · • 1. pharmacotherapy (principles & practice), 3th ed,...

Clinical Pharmacy and Therapeutics 2

Course code: 0520520 Dr. Qutaiba Ahmed Ms Noor Batarseh

Course module description: •  This course focuses on aspects of clinical

therapeutic. Students will receive information about important areas in therapeutics, which includes the infections management, women health care, acne and Oncology.

•  Various clinical cases of different diseases will be discussed each to assess a patient’s condition, determine reasonable treatment alternatives, select appropriate therapy (pharmacological and non pharmacological therapy), and monitoring parameters and to justify those choices by utilizing knowledge and skills acquired in pharmacotherapy I.

•  These diseases include upper and lower respiratory infections, lower and upper urinary infections, meningitis, tuberculosis, women contraceptives, sexual transmit diseases, soft tissue infections, acne and Oncology (leukemia, lymphoma).

•  Pharmacotherapy, physiological approach, 10th , 2014, ISBN: , ISBN-10: 1259587487, ISBN-13: 978-1259587481

•  Applied therapeutics, 10th, 2013, ISBN: 978-1-60913-713-7

•  Data from updated and Appropriate guidelines

AllocationofMarks

Mark AssessmentInstruments

20marks Firstexamination

20marks Secondexamination

40marks Finalexamination:50marks

20 Research projects, Quizzes,

Homeworks

100marks Total

•  Students will be expected to give the same attention to these references as given to the Module textbook.

•  1. Pharmacotherapy (Principles & Practice), 3th ed, 2013, ISBN: 978-0-07-180423-3

•  2. Clinical pharmacy and therapeutics, 5th ed, 2012, ISBN 978-0-7020-4293-5

Antibiotics pharmacology and clinical uses

Dr. Qutaiba Al Khames Aga

Ms. Noor Batarseh

Outline of the lecture

•  Conferming The Presence of Infection •  Selection of Antibiotic •  Combinations of AB •  Antibiotics choices for common infections

Antibiotic/Antimicrobial •  Antibiotic: Chemical produced by a microorganism

that kills or inhibits the growth of another microorganism

•  Inhibit pathogens by interfering with intracellular processes

•  Antibiotics do not kill viruses -not effective in treating viral infections.

Questions before giving AB

•  Is it infection? •  Is it bacterial infection? •  If yes, take appropriate samples

first •  What is likely etiologic agent? •  What antibiotic?

1) CONFIRMING THE PRESENCE OF INFECTION

Doctors suspect an infection based on the person's symptoms, physical examination results, and risk factors. •  FEVER •  SIGNS AND SYMPTOMS 1.White Blood Cell Count Most infections result in elevated white blood cell (WBC) counts (leukocytosis) because of the mobilization of granulocytes and/or lymphocytes to destroy invading microbes. Bactrial infections are associated with elevated granulocyte counts (neutrophils, basophils), often with increased numbers of immature forms (band neutrophils) seen in peripheral blood smears

2.Pain and Inflammation Pain and inflammation may accompany infection and are sometimes manifested by swelling, erythema, tenderness, and purulent drainage. Unfortunately, these signs may be apparent only if the infection is superficial or in a bone or joint. The manifestations of inflammation with deep-seated infections such as meningitis, pneumonia, endocarditis, and urinary tract infection must be ascertained by examining tissues or fluids. For example, the presence of polymorphonuclear leukocytes (neutrophils) in spinal fluid, lung secretions (sputum), and urine is highly suggestive of bacterial infection. 3. IDENTIFICATION OF THE PATHOGEN Infected body materials must be sampled, if at all possible or practical, before the institution of antimicrobial therapy eg. Sputum, Blood cultures, spinal fluid in meningitis, joint fluid in arthritis, Abscesses and cellulitic areas should also be aspirated

2. Selection of Antibiotic

A) Indications for antibacterial therapy – definitive, empiric & prophylaxis B) Factors should be considered before prescribing antibacterial agents

A) Indications for antibacterial therapy – definitive, empiric & prophylaxis

•  An “empiric” antimicrobial regimen is begun before the offending organism is identified and sometimes prior to the documentation of the presence of infection, while a “definitive” regimen is instituted when the causative organism is known.

1. Definitive therapy •  This is for proven bacterial infections •  Attempts should be made to confirm the bacterial infection by

means of staining of secretions/fluids/exudates, culture & sensitivity, serological tests & other tests

•  Based on the reports, a narrow spectrum, least toxic, easy to administer & cheap drug should be prescribed.

2. Empirical therapy •  Empirical antibacterial therapy should be restricted to

critical cases, when time is inadequate for identification & isolation of the bacteria & reasonably strong doubt of bacterial infection exists:

ü  septicemic shock/sepsis syndrome ü  immunocompromised patients with severe systemic

infection ü  hectic temperature ü  neutropenic patient (reduction in neutrophils) •  In such situations, drugs that cover the most probable

infective agent/s should be used.

3. Prophylactic therapy •  Certain clinical situations require the use of antibiotics for

the prevention rather than the treatment of infections. •  In all these situations, only narrow spectrum & specific

drugs are used •  The duration of prophylaxis is dictated by the duration of

the risk of infection. eg. 1. Prevention for persons from non-malarious areas who visit areas endemic for malaria. 2. Treatment prior to certain surgical procedures to prevent infections

B) Factors should be considered before prescribing antibacterial agent

1.Site of infection 2.Type of infection 3.Severity of infection 4.Isolate & its sensitivity 5.Source of infection 6.Patient factors 7.Drug-related factors

1. Site of infection

Infection above the diaphragm: ² URTI eg pharyngitis, tonsilitis, sinusitis, otitis,

epiglottitis etc. §  Commonly caused by organism like Strep.

Pyogenes, S. pneumoniae, Fusobacteria, Peptostreptococci (rarely Mycoplasma, H. influenzae)

§  Can be treated with drugs like penicillins, macrolides, cephalosporins

1. Site of infection…con’t ² Lower respiratory tract infections: Eg. Bronchitis,

pneumonitis, pneumonia, lung abscess etc §  Generally caused by the organisms Strep. Pyogenes,

S. pneumoniae, Fusobacteria, Peptostreptococci, Staph aureus (rarely Mycoplasma, H. influenzae, Moraxella, Klebsiella) etc.

§  Can be treated penicillins, cephalosporins, macrolides & tetracylines

1. Site of infection…con’t ²  Infection below the diaphragm: •  Eg UTI, intra-abdominal sepsis, pelvic infections etc

--- these are caused by the organisms like E. coli, Klebsiella, Proteus, Pseudomonas, Bacteroides etc.

•  Quinolones, aminoglycosides, 3rd generation cephalosporins & metronidazole alone or in combination are useful in these infections.

Rule of the thumb Infections above the diaphragm Cocci & Gram +ve organisms Infections below the diaphragm Bacilli & Gram -ve organisms

1. Site of infection…con’t ²  There are certain sites where the infection tends to be difficult

for treatment : Ø  Meningitis (impenetrable BBB), Ø  Chronic prostatitis (non-fenestrated capillaris), Ø  Intra-ocular infections (non-fenestrated capillaries), Ø  Abscesses (thick wall, acidic pH, hydrolizing enzymes etc.), Ø  Cardiac & intravascular vegetations (poor reach & penetration), Ø  Osteomyelitis (avascular sequestrum) etc

²  In such cases:- ü  Higher & more frequent dose ü  Longer duration of therapy ü  Combinations ü  Lipophilic drugs may have to be used

2. Type of infection

² Infections can be localized/extensive; mild/severe; superficial/deep-seated; acute/sub acute/chronic & extracellular/intracellular.

v  For extensive, severe, deep-seated, chronic & intracellular infections –

ü  Higher & more frequent dose ü  Longer duration of therapy ü  Combinations ü  Lipophilic drugs may have to be used

3. Severity of infections •  Bacteremia / sepsis syndrome / septic shock; •  Abscess in lung / brain/ liver/ pelvis/ intra-abdominal; •  Meningitis/ endocarditis/ pneumonias / pyelonephritis / puerperal

sepsis; •  Severe soft tissue infections / gangrene & hospital acquired infections v  For severe infections •  only IV route - to ensure adequate blood levels. •  only bactericidal drugs - to ensure faster clearance of the infection. •  dose should be higher & more frequent. Ø  If the site is unknown, attempt should be made to cover all possible

organisms, including drug resistant Staphylococcus, Pseudomonas, & anaerobes.

•  - A combinations of Penicillins / 3rd generation cephalosporins, aminoglycosides & metronidazole may be used.

4. Isolate & sensitivity ²  Ideal management of any significant bacterial

infection requires culture & sensitivity (C&S) study of the specimen.

•  If the situation permits, antibacterials can be started only after the sensitivity report is available.

•  Narrow spectrum, least toxic, easy to administer & cheapest of the effective drugs should be chosen.

If the patient is responding to the drug that has already been started, it should not be changed even if the in vitro report says otherwise

5. Source of infection

u Community-acquired infections are •  less likely to be resistant •  whereas u Hospital-acquired infections are •  likely to be resistant & more difficult •  to treat (eg. Pseudomonas, MRSA etc)

6. Patient factors ²  Factors should be considered in choosing the antibacterial

agent: v  Age of the patient v  Immune status v  Pregnancy & lactation v  Associated conditions like renal failure, hepatic failure, epilepsy

etc. o  In infants, chloramphenicol (can cause grey baby) & sulpha

drugs (can cause kernicterus) are contraindicated

Patient factors…….con’t

Children q  Tetracycline are contraindicated < 8 years because

they discolors the teeth q  < 18 years ALL fluoroquinolones are contraindicated because

they cause arthropathy by damaging the growing cartilage.

Elderly q  In the elderly, achlorhydria may affect absorption of

anticbacterial agents; drug elimination is slower, requiring dose adjustments & ototoxicity of aminoglycosides may be increased.

Patient factors…….con’t

u Patients with compromised immune status

In patients with likelihood of compromised immune status, like extremes of age, HIV infection, diabetes mellitus, neutropenia, splenectomy, us ing co r t i cos te ro ids o r immunosuppresants, patients with cancers/blood dyscrasias, ONLY bactericidal drugs should be used.

Patient factors…….in pregnancy Contraindicated in all trimesters •  Tetracylines •  Quinolones •  Streptomycin •  Clarithromycin

Contraindicated in the last trimesters • Sulpha drug • Nitrofurantoin • Chloramphenicol

Safe in pregnancy * Penicillins * Isoniazid * Cephalosporins * Erythromycin * Ethambutol

Contraindicated in lactating mothers * Sulpha drug * Tetracylines * Nitrofurantoin * Quinolones * Metronidazole

Drugs with limited data on safety like aminoglycoside, azithromycin, clindamycin, vancomycin, metronidazole, trimethoprim, rifampicin & pyrazinamide should be used with caution when benefits overweigh the risks

Patient factors…….in patients with renal failure

Absolutely contraindicated •  tetracycline

Relatively contraindicated •Aminoglycoside •Cephalosporins •Fluoroquinolones •Sulpha drug

Relatively safe •Penicillins •Macrolides •Vancomycin •Metronidazole •Isoniazid •Ethambutol •Rifampicin

It is better to avoid

combinations of cephalosporins &

aminoglycosides in these patients because both classes

can cause nephrotoxicity

Patient factors…….in patients with hepatic failure

No drugs are absolutely contraindicated.

Safe •Penicillins •Cephalosporins •Ethambutol •Aminoglycosides

Relatively contraindicated •Chloramphenicol •Erythromycin estolate •Fluoroquinolones •Pyrazinamide •Rifampicin •Isoniazid •Metronidazole

7. Drug factors 1.  Hypersensitivity: 2.  Adverse reactions: 3.  Cost: 4.  Interactions: •  Interactions include enhanced nephrotoxicity or ototoxicity when

aminoglycosides are given with loop diuretics, vancomycin or cisplatin. •  Rifampicin, a strong inducer of hepatic drug-metabolizing enzymes,

decreases the effects of digoxin, ketoconazole, oral contraceptives, propranolol, quinidine & warfarin.

•  Erythromycin inhibits the hepatic metabolism of a number of drugs, including phenytoin, terfenadine, theophylline & warfarin.

5. Route of administration 6. Dosage

7. Drug factors…….con’t 7. Duration of therapy depends on the site A.  Tonsilitis – 10 days B. Bronchitis – 5-7 days C. UTI – single shot to 21 days D. Lung abscess- 2-4 weeks E. Tuberculosis – 6-24 months

• Longer courses of therapy are usually required for infections due to fungi or mycobacteria • Endocarditis & osteomyelitis require longer duration of treatment

Combinations of AB •  1) For synergistic effect: eg: combination of 2

bacteriostatic drugs such as trimethoprim + sulfamethoxazole = Co-Trimoxazole (bacterim®)

Therapeutic advantage of sulphonamide + trimethoprim I.  Synergistic effects II. Bactericidal activity III. Decrease resistance IV. Bigger spectrum of activity V. Reduced toxicity

Combinations…….con’t 2) Treatment of infections with multiple organisms: Mixed infections in lung abcess, peritonitis, soiled wounds etc naturally require multiple antibiotics for complete clearance of the infection – Ø  penicillins (for Gram +ve & certain anaerobes) &

aminoglycosides (for Gram –ve); metronidazole for bacteroides.

Ø  penicillins + aminoglycosides + metronidazole

Combinations…….con’t 3) To prevent resistance: •  Use of combination is a well known method of

preventing drug resistance. The classic example is the antiTB therapy,

•  Eg isoniazid + ethambutol + rifampicin 4) To overcome resistance: •  Combination of specific drugs can be useful in

overcoming that resistant infections, eg •  Penicillins + b-lactamase inhibitors (Co-amoxiclav/

augmentin)

Antibiotics choices for common infections

Infection

Common pathogens

Antibiotic treatment

First choice

Alternatives

COPD– acute

exacerbations

Respiratory viruses, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis

Amoxicillin Adult: 500 mg, three times daily, for five days

Doxycycline Adult: 200 mg, on day one (loading dose), followed by 100 mg, once daily, on days two to five

Pertussis (Whooping cough)

Bordetella pertussis

Azithromycin (first-line for children, alternative for adults) Child < 45 kg: 10 mg/kg/dose, once daily. Five days

Adult and Child > 45 kg: 500 mg , once daily.

Erythromycin (first-line for adults, alternative for children aged over one year) Child: 10 mg/kg/dose, four times daily, for 14 days

Adult: 400 mg, four times daily, for 14 days

non

Pneumonia adult

Respiratory viruses, Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, Chlamydophili

Amoxicillin Adult: 500 mg – 1 g, three times daily, for five to seven days

Monotherapy with roxithromycin or doxycycline is acceptable for people with a history of penicillin allergy.

Pneumonia child

Respiratory viruses, Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, Staphylococcus aureus

Amoxicillin Child: 25 – 30 mg/kg/dose, three times daily, for five to seven days (maximum 500 mg/dose age three months to five years, 1000 mg/ dose age > five years)

Erythromycin Child: 10 – 12.5 mg/kg/dose, four times daily, for seven days

Roxithromycin

Child: 4 mg/kg/dose, twice daily, for seven to ten days

Infection

Common pathogens


First choice Alternatives

Otitis externa acute

Staphylococcus aureus, Streptococcus pyogenes, Pseudomonas aeruginosa, polymicrobial infections

Clioquinol + flumethasone Adult and child > 2 years: 2 to 3 drops, twice daily, for 7 days OR Dexamethasone + framycetin + gramicidin (Sofradex)* Adult and child: 2 to 3 drops, three to four times daily, for 7 days

Acetic acid 2% (Vosol)* may be sufficient in mild cases. Ciprofloxacin + hydrocortisone (Ciproxin HC)* if Pseudomonas suspected. Flucloxacillin if there is spreading cellulitis or the patient is systemically unwell.

Otitis media

Respiratory viruses, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis

Amoxicillin Child: 15 mg/kg/dose, three times daily, for five days (seven to ten days.

Co-trimoxazole Child > 6 weeks: 0.5 mL/kg/dose oral liquid (40+200 mg/5 mL), twice daily, for five to seven days

Pharyngitis

Respiratory viruses, Streptococcus pyogenes

Phenoxymethylpenicillin (Penicillin V) Child: 250 mg, two or three times daily, for ten days Amoxicillin Child: 25 mg/kg, twice daily for ten days OR IM benzathine penicillin (stat) Child < 30 kg: 450 mg (600 000 U) Child ≥ 30 kg and Adults: 900 mg (1 200 000 U)

Erythromycin Child: 20 mg/kg/dose, twice daily or 10 mg/kg/dose, four times daily, for ten days (maximum 1 g/day) Adult: 400 mg, twice daily, for ten days

Sinusitis acute

Respiratory viruses, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, anaerobic bacteria

Amoxicillin Child: 15 mg/kg/dose, three times daily, for seven days

Doxycycline Adult and child: 200 mg on day one, followed by 100 mg, once daily, on days two to seven Amoxicillin clavulanate (if symptoms persist despite a treatment course of amoxicillin)

Infection

Common pathogens



Conjunctivitis

Viruses, Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus Less commonly: Chlamydia trachomatis or Neisseria gonorrhoeae

Chloramphenicol 0.5% eye drops Adult and child > 2 years: 1 – 2 drops, every two hours for the first 24 hours, then every four hours +/– chloramphenicol eye ointment at night until 48 hours after symptoms have cleared

Fusidic acid eye gel Adult and child: 1 drop, twice daily until 48 hours after symptoms have cleared

Bacterial meningitis

Neisseria meningitidis, Streptococcus pneumoniae Less common: Listeria monocytogenes, Haemophilus influenzae

Benzylpenicillin (penicillin G) Child < one year: 300 mg IV or IM Child one to nine years: 600 mg IV or IM Adult and child > ten years: 1.2 g IV or IM

Ceftriaxone Adult and child: 50_100 mg/kg up to 2 g IV or IM

Infection

Common pathogens



Bites human and animal (Includes injury to fist from contact with teeth)

Polymicrobial infection, Pasteurella multocida, Capnocytophaga canimorsus (cat and dog bites), Eikenella corrodens (fist injury), Staphylococcus aureus, streptococci and anaerobes

Amoxicillin clavulanate Child: 10 mg/kg/dose (amoxicillin component), three times daily, for seven days (maximum 500 mg/dose, amoxicillin component) Adult: 500+125 mg, three times daily, for seven days

Adult and child > 12 years: Metronidazole 400 mg, three times daily, + doxycycline 200 mg on day one, followed by 100 mg, once daily, on days two to seven Metronidazole + co-trimoxazole is an alternative for children aged under 12 years (doxycycline contraindicated)

Boils

Staphylococcus aureus Consider MRSA if there is a lack of response to flucloxacillin.

Most lesions may be treated with incision and drainage alone. Antibiotics may be considered if there is fever, surrounding cellulitis or co-morbidity, e.g. diabetes, or if the lesion is in a site associated with complications, e.g. face. Flucloxacillin Child: 12.5 mg/kg/dose, three to four times daily, for seven days Adult: 500 mg, four times daily, for five to seven days OR (if flucloxacillin not tolerated in children) Cephalexin Child: 12.5-25 mg/kg/dose, twice daily, for five to seven days

Cephalexin Adult: 500 mg, four times daily, for five to seven days Erythromycin Child aged < 12 years: 20 mg/kg/dose, twice daily, or 10 mg/kg/ dose, four times daily, for five to seven days (maximum 1 g/day) Adult: 800 mg, twice daily, or 400 mg, four times daily, for five to seven days Co-trimoxazole (if MRSA present): Child > 6 weeks: 0.5 mL/kg oral liquid (40+200 mg/ 5

Infection

Common pathogens



Cellulitis

Streptococcus pyogenes, Staphylococcus aureus, Group C or Group G streptococci

Flucloxacillin Child: 12.5 mg/kg/dose, four times daily, for seven days Adult: 500 mg, four times daily, for five to seven days OR (if flucloxacillin not tolerated) Cephalexin Child: 12.5 mg/kg/dose, four times daily, for seven to ten days (maximum 500 mg/dose) Adult: 500 mg, four times daily, for seven days

Cephalexin Adult: 500 mg, four times daily, for seven days Erythromycin Child < 12 years: 10 mg/kg/dose, four times daily, for seven to ten days Adult: 400 mg, four times daily, for seven days Co-trimoxazole (if MRSA present): Child > 6 weeks: (40+200 mg/5 mL), twice daily, for five to seven days

Diabetic foot infections

Early infection is usually due to Staphylococcus aureus and/or streptococci. Later infection may be polymicrobial with a mixture of Gram-positive cocci, Gram-negative bacilli and anaerobes.

Amoxicillin clavulanate Adult: 500+125 mg, three times daily, for five to seven days

Cephalexin 500 mg, four times daily, + metronidazole 400 mg, twice to three times daily, for five to seven days OR (for patients with penicillin hypersensitivity) Co-trimoxazole 160+800 mg (two tablets), twice daily, + clindamycin* 300 mg, three times daily, for five to seven days

Mastitis

Staphylococcus aureus in lactating women, S. aureus and anaerobes in non-lactating females, or in males

Flucloxacillin Adult: 500 mg, four times daily, for seven days

Cephalexin Adult: 500 mg, four times daily, for seven days Erythromycin Adult: 400 mg, four times daily, for seven days Treat mastitis in males or non-lactating females with amoxicillin clavulanate 500+125 mg, three times daily, for seven days

Infection

Common pathogens



Campylobacter enterocolitis

Campylobacter jejuni

Erythromycin Child: 10 mg/kg/dose, four times daily, for five days Adult: 400 mg, four times daily, for five days

Ciprofloxacin Adult: 500 mg, twice daily, for five days (not recommended for children)

Clostridium difficile colitis

Clostridium difficile

Metronidazole Adult: 400 mg, three times daily, for 10 days

Vancomycin If patient has not responded to two courses of metronidazole; discuss with an infectious diseases physician or clinical microbiologist. Oral vancomycin (using the injection product) may be required.

Giardiasis

Giardia lamblia

Ornidazole Child : 125 mg/3 kg/dose,* once daily, for one to two days Adult : 1.5 g, once daily, for one to two days OR Metronidazole Child: 30 mg/kg/dose, once daily, for three days (maximum 2 g/dose) Adult: 2 g, once daily, for three days

Metronidazole Child: 10 mg/kg/dose, three times daily, for seven days, (maximum 400 mg/dose) Adult: 400 mg, three times daily, for seven days

Salmonella enterocolitis

Salmonella enteritidis, Salmonella typhimurium

Ciprofloxacin Adult: 500 mg, twice daily, for three days

Co-trimoxazole Adult: 160+800 mg (two tablets), twice daily, for three days

Infection

Common pathogens



Bacterial vaginosis

Gardnerella vaginalis, Bacteroides, Peptostreptococci, Mobilunculus and others

Metronidazole Adult: 400 mg, twice daily, for seven days, or 2 g, stat, if adherence to treatment is a concern, however, this is associated with a higher relapse rate

Ornidazole 500 mg, twice daily, for five days or 1.5 g, stat may be used instead of metronidazole, but is not recommended in women who are pregnant as no study data is available

Chlamydia

Chlamydia trachomatis

Azithromycin Adult: 1 g, stat OR Doxycycline Adult: 100 mg, twice daily, for seven days. Do not use in pregnancy or breast feeding.

Amoxicillin 500 mg, three times daily, for seven days (only in women who are pregnant who are unable to take azithromycin)

Gonorrhoea

Neisseria gonorrhoeae

Ceftriaxone Adult: 500 mg IM, stat (make up with 2 mL of 1% lignocaine or according to data sheet) AND Azithromycin Adult: 1 g, stat (including in pregnancy and breastfeeding)

Ciprofloxacin 500 mg, stat + azithromycin 1 g, stat, only if the isolate is known to be ciprofloxacin sensitive. Resistance rates vary by location.

Pelvic inflammatory

disease

Chlamydia trachomatis, Neisseria gonorrhoeae

Ceftriaxone Adult: 500 mg IM, stat (make up with 2 mL of 1% lignocaine or according to data sheet) AND Doxycycline Adult: 100 mg, twice daily, for 14 days AND Metronidazole Adult: 400 mg, twice daily, for 14 days (metronidazole may be discontinued if not tolerated)

Ceftriaxone 500 mg IM, stat + azithromycin 1 g on day one and day eight is an alternative if compliance is likely to be poor. Ornidazole may be considered as an alternative, if metronidazole is not tolerated.

Infection

Common pathogens



Pyelo-nephritis acute

Escherichia coli, Proteus spp., Klebsiella spp., Enterococcus spp.

Co-trimoxazole Adult: 160+800 mg (two tablets), twice daily, for 10 days

Amoxicillin clavulanate Adult: 500+125 mg, three times daily, for 10 days Ciprofloxacin 500 mg, twice daily, for seven days – but should be reserved for isolates resistant to initial empiric choices and avoided during pregnancy

Trichomoniasis

Trichomonas vaginalis

Metronidazole Adult: 2 g, stat

For those intolerant of the stat dose, use metronidazole 400 mg, twice daily, for seven days Ornidazole 1.5 g, stat or 500 mg, twice daily, for five days may be used instead of metronidazole

Urethritis acute non specific

Urethritis not attributable to Neisseria gonorrhoeae or Chlamydia trachomatis is termed non-specific urethritis

Azithromycin Adult: 1 g, stat OR Doxycycline Adult: 100 mg, twice daily, for seven days If purulent discharge, treat as for gonorrhoea, i.e. ceftriaxone 500 mg IM, stat + azithromycin 1g, stat

Nil

Urinary tract infection (UTI) child

Escherichia coli, Proteus spp., Klebsiella spp., Enterococcus spp.

Co-trimoxazole Child: 0.5 mL/kg/dose oral liquid (40+200 mg/ 5 mL), twice daily, for three days (maximum 20 mL/dose)

Cefaclor Child: 8 – 10 mg/kg/dose, three times daily, for three days (maximum 500 mg/dose) Amoxicillin clavulanate Child: 10 mg/kg/dose (amoxicillin component), three times daily, for three days (maximum 500 mg/dose,amoxicillin component)

Urinary tract infection (UTI) adult

Escherichia coli, Staphylococcus saprophyticus, Proteus spp., Klebsiella spp., Enterococcus spp.

Trimethoprim Adult: 300 mg, once daily, for three days (avoid during the first trimester of pregnancy) OR Nitrofurantoin Adult: 50 mg, four times daily, for five days (avoid at 36+ weeks in pregnancy, and in patients with creatinine clearance < 60 mL/min)

Norfloxacin Adult: 400 mg, twice daily for three days – but should be reserved for isolates resistant to initial empiric choices and avoided during pregnancy

Case 1 •  P.L., a 16-year-old boy diagnosed with acute lymphocytic

leukemia 8 months ago, is now admitted for a bone marrow transplant. Admission clinical presentation reveal that he has, during a course of chemotherapy, he developed Cellulitis .

•  What are the Common pathogens? •  What are the First choice of antibiotics?

Case 2 •  K.K. has a Dog bite and has a puncture wound, have

not sought medical attention within 12 hours of injury, and are older than 50 years of age. Now presented with a localized cellulitis and pain at the site of injury. The cellulitis usually spreads proximally from the initial site of injury.

•  What are the Common pathogens? •  What are the First choice and alternative of antibiotics?

THANK YOU

clinical pharmacy and therapeutics 2 · • 1. pharmacotherapy (principles & practice), 3th ed,...

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