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Beutler - Bug Juice 101 usafp 2009 (handout)

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					        Bug Juice 101

Choosing the Right Antibiotic

        Anthony Beutler, MD
         Major, USAF, MC
   Uniformed Services University
         Welcome to MIB
      Mission Objectives:
• Look at antibiotics by classes (not
  diagnoses)
• Treatment guideline updates for
  common diseases
• Be smarter about abx prescription
“The Ring”
The Rings




 Penicillin Ring




Cephalosporin Ring
Which is NOT effectively killed
  by alcohol hand rubs (ie
        Purell® etc)?
25%   1.Clostridium difficile
25%
      2.MRSA
25%
      3.H1N1
25%
      4.VRE
 Which is Treatment of Choice
for Otitiis Externa with possible
ruptured tympanic membrane?
25%   1.Cipro HC
25%
      2.Ciprodex or Floxin otic
25%
      3.gentamycin otic
25%
      4.Cortisportin otic
      Which is recommended for
         complicated UTIs?

25%    1.gemifloxicin (Factive)
25%
       2.levofloxicin (Levaquin)
25%
       3.moxifloxicin (Avalox)
25%
       4.ciprofloxicin (Cipro)
      First line treatment for
    localized CA-MRSA skin
infection in a healthy patient is:
25%   1.TMP-SMX (Bacrtim,Septra)
25%
      2.minocycline
25%
      3.I & D (irrigation and drainage)
25%
      4.mupirocin (Bactroban)
Which drug is NOT associated
     with any risk of fetal
 malformation in pregnancy?
25%   1.ciprofloxicin (Cipro)
25%
      2.TMP-SMX (Bactrim, Septra)
25%
      3.nitrofurantion (Macrobid)
25%
      4.cefpodoxime (Vantin)
          Topics
• UTI

• Skin

• HEENT

• Cases
            Antibiotics for UTI’s
Guidelines Uncomplicated UTIs
• 1st Line:
   – Septra BID X 7 days
• If resistance > 20%:
   – Macrobid (nitrofurantoin) 5 days
• Last Resort:
   – Cipro 250mg BID or 500mg QD
• Don’t use Respiratory Quinolones!
      • Levaquin (too broad)
      • Avalox & Factive (insufficient
        urinary concentration)
 Antibiotic Sensitivity
 at NNMC Bethesda (inpt)

            E. Coli
UTI Drug
            (% Susceptible)
         Quinolone Overuser?
            Guilty as Charged!
Do NOT Use:             Think Hard:
• 1st line              • Cellulitis?
  uncomplicated UTI        – Not Cipro
• High doses/long       • Sinusitis?
  courses for UTI          – Please no
• Levaquin for UTI      • Pneumonia?
• Resp. quinolones         – Not first line
  below the diaphragm
          Suboptimal (aka Bad)
       Treatment Strategies for UTI

• Amoxicillin
  – Only in pregnancy
  – Why not Augment?
  – Even Augmentin 50%
• Keflex
• Zithromax
               UTI in Pregnancy
• Macrobid
  – Still 1st line for outpt
  – Association NOT causation
• TMP-SMX
  – Still a bad idea most of the time
• Cipro
  – Bad karma, no clear evidence
• Amox & Keflex
  – Weak… except GBS
• Ceftriaxone, Cefpodoxime, Amp & Gent
  – Still work!!!
          MRSA & CA-MRSA
• 85% MRSA
  acquired in health
  care setting
• Community
  Acquired (CA) on
  the rise
  – Most common cause
    of skin infection in
    ER
  – Very common in
    military settings
         Treatment of MRSA
CA-MRSA                MRSA (inpt)
First-Line:            1. Vancomycin
Second Line:           2. Clindamycin
  1. Bactrim DS        3. Linezolid
  2. Doxy/Mino
  3. Clinda            Decontamination
                         (fingernails & nares)
Recurrent infection:   Bactroban      Prescriber's Letter
 add rifampin                              2007;23 (11):231102
              Strep Throat
PCN is your Friend!     Other Thoughts
• Easy dosing           • Amox will work
  – VK: 250 or 500mg      – BID if used
     BID x 10d            – Broad spectrum
  – PCN G: 0.9 or 1.2   • Macrolides for
     IM x 1
                          PCN allergic
• No discernable          – Avoid otherwise:
  resistance                20% resistance
• Narrow spectrum       • Cephs to treat
• Proven!                 carriers
               Otitis Externa
• LOTS of options
• No evidence that
  quinolones faster/better
• Cortisporin 1st line
  – Don’t use if perf
• Severe itch/pain?
  – Add steroid
• ORAL analgesia
  – Topicals really sting…
                        Detail-Document; Prescriber's Letter 2009; 16(8):250821

				
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