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Antibiotics
Antibiotics
James Clayton
Consultant Microbiologist
Coventry and Warwickshire Pathology
Antibiotic groups
• β-Lactams
– Penicillins
• Penicillin, Amoxicillin, Flucloxacillin PO/IV
– Penicillins + β-lactamase inhibitor
• Co-amoxiclav (Amoxicillin + clavulanate) PO/IV
• Tazocin (Piperacillin + tazobactam) IV
– Cephalosporins PO/IV
– Carbapenems
• Meropenem, Ertapenem IV
Coventry and Warwickshire Pathology
• Other antibiotics:
– Aminoglycosides
• Gentamicin, (Amikacin) IV
– Macrolides
• Erythromycin, Clarithromycin PO/IV
– Glycopeptides
• Vancomycin, (Teicoplanin) IV
– Tetracyclines
• Doxycycline PO
– Others
• Trimethoprim, Nitrofurantoin PO
• Rifampicin, Clindamycin PO/IV
• Ciprofloxacin PO
Coventry and Warwickshire Pathology
Coventry and Warwickshire Pathology
Common bacteria of medical importance
Clostridium
Streptococcus
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
E.coli
Neisseria
Other coliforms
Coventry and Warwickshire Pathology
Aerobes vs Anaerobes
ANAEROBES
Clostridium
Streptococcus
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
E.coli
Neisseria
Other coliforms
Coventry and Warwickshire Pathology
Gram Positives vs Gram Negatives
Clostridium
Streptococcus
Bacteroides
GRAM POSITIVES
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
GRAM NEGATIVES
E.coli
Neisseria
Other coliforms
Coventry and Warwickshire Pathology
Doxycycline (tetracycline)
Clostridium
Streptococcus
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
E.coli
Neisseria
Other coliforms
Coventry and Warwickshire Pathology
Streptococci
• Group A streptococci
–
–
–
–
Skin & soft tissue infection
Necrotising fasciitis
Tonsillitis
Toxic shock, sepsis
• Group B streptococci
– Neonatal infection, UTI
• Other streptococci
– Endocarditis, abscess
Coventry and Warwickshire Pathology
Streptococci & Enterococci
• Strep. pneumoniae
– URTI, pneumonia
• Enterococcus faecalis / E.faecium
– UTI, endocarditis
Coventry and Warwickshire Pathology
Staphylococcus
• Staph. aureus
–
–
–
–
–
Skin & soft tissue infection
Abscess
Bone & joint infection
Line infections
Severe pneumonia
– Remember MRSA
• (Meticillin resistant S.aureus)
Coventry and Warwickshire Pathology
E.coli & coliforms
• E.coli, Klebsiella, Proteus
– UTIs
– Intra-abdominal infection
• E.g. cholangitis, sepsis
– Hospital-acquired infection
– Remember ESBLs
Coventry and Warwickshire Pathology
Neisseria & Haemophilus
• N. meningitidis
– Meningitis
• N. gonorrhoeae
– Gonorrhoea
• H. influenzae
– Respiratory tract infection
– Meningitis (rare)
Coventry and Warwickshire Pathology
Pseudomonas
• P. aeruginosa
– UTIs (usually complicated / catheter)
– Hospital acquired infections
Anaerobes
– Intra-abdominal infections
– Skin & soft tissue infections
– Abscess
Coventry and Warwickshire Pathology
7 cases
Coventry and Warwickshire Pathology
Case 1
•
•
•
•
John, 18 yrs old
Sore throat for 2 days, feverish
Exudate on tonsils when examined by GP
Tonsillitis diagnosed.
• What organisms cause tonsillitis?
• What antibiotics are appropriate?
Coventry and Warwickshire Pathology
Upper Respiratory Tract Infection
ANAEROBES
Clostridium
Streptococcus
Bacteroides
GRAM POSITIVES
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
GRAM NEGATIVES
E.coli
Neisseria
Other coliforms
Coventry and Warwickshire Pathology
Penicillin
ANAEROBES
Clostridium
Streptococcus
Bacteroides
GRAM POSITIVES
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
GRAM NEGATIVES
E.coli
Neisseria
Other coliforms
Coventry and Warwickshire Pathology
Upper Respiratory Tract Infection
ANAEROBES Clostridium
Streptococcus
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
GRAM
NEGATIVES
E.coli
Neisseria
Penicillin
GRAM
POSITIVES
Clostridium
Bacteroides
Staphylococcus
E.coli
Neisseria
Other coliforms
Amoxicillin
Clostridium
Enterococcus
Haemophilus
E.coli
Neisseria
Streptococcus
Pseudomonas
Staphylococcus
Haemophilus
Other coliforms
Bacteroides
Enterococcus
Pseudomonas
Erythromycin / Clarithromycin
Clostridium
Streptococcus
Streptococcus
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
Other coliforms
Coventry and Warwickshire Pathology
E.coli
Neisseria
Other coliforms
CONDITION
NO ALLERGY TO PENICILLINS
ALLERGY TO PENICILLINS
ENT infections
Acute otitis media
Antibiotics not usually indicated - viral infections are common. Symptoms resolve
spontaneously in most cases. Consider symptomatic treatment first
Amoxicillin 500 mg tds for 5 days
Erythromycin 500 mg qds for 5 days
Avoid antibiotics if possible. Keep the ear clean and dry. Topical acetic acid 2% - 1
spray tds is sufficient in many cases. Antibiotics needed if acutely inflamed or extensive.
Otitis externa
Flucloxacillin 500 mg qds for 5 days
Erythromycin 500 mg qds for 5 days
Resolves spontaneously within 14 days in most cases. Antibiotics offer marginal benefit.
Antibiotics may be of benefit if purulent pharyngeal discharge.
Sinusitis
Amoxicillin 500 mg tds for 7 days
Pharyngitis / Tonsillitis
Doxycycline 200 mg on first day
then 100 mg od for 6 further days
This is often a viral infection. Consider antibiotics if 3 of the following – fever, exudate,
palpable anterior cervical lymph nodes, absence of cough
Phenoxymethyl penicillin 500 mg qds
for 10 days
Erythromycin 500 mg qds for 10
days
Coventry and Warwickshire Community Antibiotic Guidelines
Coventry and Warwickshire Pathology
Tonsillitis
• Majority caused by Group A streptococci
• Group A streptococci
– Penicillin susceptibility
– Erythromycin susceptibility
~ 100%
~ 80%
• Penicillin preferred to Amoxicillin as:
– Narrower spectrum
– EBV / glandular fever reaction
• Oral antibiotics in a community setting
Coventry and Warwickshire Pathology
Case 2
• Bob, 70 years old
– COPD. 60 pack year smoking history.
– Retired engineer.
– 3 day history of cough, green sputum, malaise,
raised temperature
– o/e crepitations, reduced air entry
• CXR – extensive consolidation
• CURB-65 = 2
• No allergies
Coventry and Warwickshire Pathology
Community Acquired Pneumonia
ANAEROBES
Clostridium
Streptococcus
Bacteroides
GRAM POSITIVES
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
GRAM NEGATIVES
E.coli
Neisseria
Other coliforms
Coventry and Warwickshire Pathology
And
Atypicals!
Community Acquired Pneumonia
ANAEROBES
Clostridium
Streptococcus
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
GRAM
NEGATIVES
E.coli
Neisseria
Antibiotic A
GRAM
POSITIVES
Clostridium
Bacteroides
Clostridium
Staphylococcus
E.coli
Neisseria
Other coliforms
Antibiotic C
Enterococcus
Haemophilus
E.coli
Neisseria
Streptococcus
Pseudomonas
Staphylococcus
Haemophilus
Other coliforms
Bacteroides
Enterococcus
Pseudomonas
Antibiotic B
Clostridium
Streptococcus
Streptococcus
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
Other coliforms
Coventry and Warwickshire Pathology
E.coli
Neisseria
Other coliforms
Community Acquired Pneumonia
ANAEROBES
Clostridium
Streptococcus
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
GRAM
NEGATIVES
E.coli
Neisseria
Staphylococcus
Pseudomonas
Haemophilus
E.coli
Other coliforms
Amoxicillin-clavulanate (Co-amoxiclav)
Clostridium
Staphylococcus
Haemophilus
Enterococcus
Neisseria
Enterococcus
Pseudomonas
Streptococcus
Bacteroides
Streptococcus
Bacteroides
E.coli
Neisseria
Clostridium
Other coliforms
Amoxicillin
Clostridium
Penicillin
GRAM
POSITIVES
Streptococcus
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
Other coliforms
Coventry and Warwickshire Pathology
E.coli
Neisseria
Other coliforms
Coventry and Warwickshire Treatment Guidelines (Hospital)
Coventry and Warwickshire Pathology
Community acquired pneumonia
– Strep. pneumoniae
– Haemophilus influenzae
– Staph. aureus
~ 30 - 40%
~ 5 - 10%
~ 0.5 - 5%
• Severity of infection (CURB-65 score)
– Determines need for IV or oral treatment
– Determines need for broad vs narrow cover
Coventry and Warwickshire Pathology
Don’t forget atypicals in CAP!
–
–
–
–
–
Legionella pneumophila
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Chlamydia psittaci, Coxiella
Viruses including Influenza
~ 1 - 5%
~ 1 - 10%
< 10% ?
< 2%
< 15%
• Addition of
– Macrolide e.g. erythromycin or clarithromycin
– Tetracycline e.g. doxycycline
– (Ciprofloxacin)
Coventry and Warwickshire Pathology
Case 3
• Katie, 25 years old
• Presents to A&E with history of dysuria,
frequency
• Previously well
Coventry and Warwickshire Pathology
Urinary Tract Infections
ANAEROBES
Clostridium
Streptococcus
Bacteroides
GRAM POSITIVES
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
GRAM NEGATIVES
E.coli
Neisseria
Other coliforms
Coventry and Warwickshire Pathology
Do all antibiotics get into urine?
These do:
• Penicillins (most)
– Amoxicillin, co-amoxiclav
– Cephalosporins
– Carbapenems
•
•
•
•
•
Gentamicin
Trimethoprim
Nitrofurantoin
Ciprofloxacin
Vancomycin
These don’t:
• Penicillins (few)
– Flucloxacillin (poorly only)
• Macrolides
– Erythro & Clarithromycin
• Tetracyclines
– Doxycycline
• Clindamycin
Coventry and Warwickshire Pathology
Urinary Tract Infections
ANAEROBES Clostridium
Streptococcus
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
GRAM
NEGATIVES
A
GRAM
POSITIVES
E.coli
Neisseria
Clostridium
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
Other coliforms
E.coli
Neisseria
B
Clostridium
Clostridium
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
E.coli
Neisseria
Other coliforms
C
Streptococcus
Bacteroides
Streptococcus
Streptococcus
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
Other coliforms
Coventry and Warwickshire Pathology
E.coli
Neisseria
Other coliforms
Urinary Tract Infections
ANAEROBES Clostridium
Streptococcus
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
GRAM
NEGATIVES
Trimethoprim
GRAM
POSITIVES
E.coli
Neisseria
Clostridium
Bacteroides
Clostridium
Staphylococcus
E.coli
Neisseria
Other coliforms
Amoxicillin
Enterococcus
Haemophilus
E.coli
Neisseria
Streptococcus
Pseudomonas
Staphylococcus
Haemophilus
Other coliforms
Bacteroides
Enterococcus
Pseudomonas
Nitrofurantoin
Clostridium
Streptococcus
Streptococcus
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
Other coliforms
Coventry and Warwickshire Pathology
E.coli
Neisseria
Other coliforms
Coventry and Warwickshire Treatment Guidelines (Hospital)
Coventry and Warwickshire Pathology
UTI
• Usually Gram-negatives as a cause
– E.coli
– Other coliforms (proteus, klebsiella)
– Less commonly enterococci, staphylococci
• Pseudomonas
– Mainly in catheterised patients or those with
underlying urinary tract disorders
Coventry and Warwickshire Pathology
Case 4
• Stephen, 17 years old
• Admitted through A&E
– Lethargic, drowsy, unwell
– High fever
– Photophobia & stiff neck
• No allergies
Coventry and Warwickshire Pathology
Meningitis
ANAEROBES
Clostridium
Streptococcus
Bacteroides
GRAM POSITIVES
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
GRAM NEGATIVES
E.coli
Neisseria
Other coliforms
Coventry and Warwickshire Pathology
Meningitis
ANAEROBES Clostridium
Streptococcus
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
GRAM
NEGATIVES
A
GRAM
POSITIVES
E.coli
Neisseria
Clostridium
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
Other coliforms
E.coli
Neisseria
B
Clostridium
Clostridium
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
E.coli
Neisseria
Other coliforms
C
Streptococcus
Bacteroides
Streptococcus
Streptococcus
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
Other coliforms
Coventry and Warwickshire Pathology
E.coli
Neisseria
Other coliforms
Meningitis
ANAEROBES Clostridium
Streptococcus
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
GRAM
NEGATIVES
Penicillin
GRAM
POSITIVES
E.coli
Neisseria
Clostridium
Bacteroides
Clostridium
Staphylococcus
E.coli
Neisseria
Other coliforms
Meropenem
Enterococcus
Haemophilus
E.coli
Neisseria
Streptococcus
Pseudomonas
Staphylococcus
Haemophilus
Other coliforms
Bacteroides
Enterococcus
Pseudomonas
Ceftriaxone
Clostridium
Streptococcus
Streptococcus
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
Other coliforms
Coventry and Warwickshire Pathology
E.coli
Neisseria
Other coliforms
Coventry and Warwickshire Treatment Guidelines (Hospital)
Coventry and Warwickshire Pathology
Meningitis
–
–
–
–
Neisseria menigitidis
(meningococcus)
Strep. pneumoniae
(pneumococcus)
Haemophilus influenzae (HiB)
Listeria (extremes of age, immunocompromise)
• Need IV therapy
• Need antibiotics with good meningeal
penetration
Coventry and Warwickshire Pathology
Case 5
• Albert, 82 years old
–
–
–
–
–
Had total hip replacement 5 days ago
On review today, unwell, coughing mucky sputum
Poor Oxygen sats, febrile
WCC 18, CRP 280
CXR – widespread opacity
• No allergies, no previous microbiology
samples
Coventry and Warwickshire Pathology
Hospital acquired pneumonia
ANAEROBES
Clostridium
Streptococcus
Bacteroides
GRAM POSITIVES
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
GRAM NEGATIVES
E.coli
Neisseria
Other coliforms
Coventry and Warwickshire Pathology
Hospital acquired pneumonia
ANAEROBES Clostridium
Streptococcus
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
GRAM
NEGATIVES
Amoxicillin-clavulanate (Co-amoxiclav)
GRAM
POSITIVES
E.coli
Neisseria
ANAEROBES Clostridium
Bacteroides
ANAEROBES Clostridium
Streptococcus
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
GRAM
NEGATIVES
GRAM
POSITIVES
E.coli
Neisseria
Other coliforms
Staphylococcus
Haemophilus
Piperacillin-tazobactam (Tazocin™)
GRAM
POSITIVES
Enterococcus
Pseudomonas
GRAM
NEGATIVES
Other coliforms
Streptococcus
E.coli
Neisseria
Other coliforms
Gentamicin
ANAEROBES Clostridium
Streptococcus
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
GRAM
NEGATIVES
Coventry and Warwickshire Pathology
GRAM
POSITIVES
E.coli
Neisseria
Other coliforms
Amoxicillin-clavulanate (Co-amoxiclav)
ANAEROBES Clostridium
Streptococcus
Bacteroides
GRAM
POSITIVES
Enterococcus
Staphylococcus
Pseudomonas
Co-amoxiclav + Gentamicin
ANAEROBES Clostridium
Haemophilus
GRAM
NEGATIVES
E.coli
Neisseria
Bacteroides
Staphylococcus
Pseudomonas
Enterococcus
Haemophilus
GRAM
NEGATIVES
Staphylococcus
Pseudomonas
Haemophilus
E.coli
Neisseria
Enterococcus
Streptococcus
Bacteroides
GRAM
NEGATIVES
GRAM
POSITIVES
Other coliforms
Gentamicin
ANAEROBES Clostridium
Streptococcus
Other coliforms
Coventry and Warwickshire Pathology
E.coli
Neisseria
Other coliforms
Coventry and Warwickshire Treatment Guidelines (Hospital)
Coventry and Warwickshire Pathology
Case 6
• Ivy, 82 year old
• #neck of femur
– Had a DHS 3 days ago.
• Now has some erythema around the wound
– Tender and wound feels hot. Well otherwise
• Determined to be non-severe wound infection
– Recent MRSA screen negative
– Penicillin allergic (previous rash)
Coventry and Warwickshire Pathology
Skin, soft tissue, bone and joint
ANAEROBES
Clostridium
Streptococcus
Bacteroides
GRAM POSITIVES
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
GRAM NEGATIVES
E.coli
Neisseria
Other coliforms
Coventry and Warwickshire Pathology
Skin, soft tissue, bone and joint
ANAEROBES Clostridium
Streptococcus
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
GRAM
NEGATIVES
E.coli
Neisseria
Flucloxacillin
GRAM
POSITIVES
Clostridium
Bacteroides
Staphylococcus
Haemophilus
Other coliforms
Staphylococcus
Haemophilus
E.coli
Other coliforms
Doxycycline (tetracycline)
Clostridium
Enterococcus
Pseudomonas
E.coli
Neisseria
Streptococcus
Bacteroides
Neisseria
Enterococcus
Pseudomonas
Erythromycin / Clarithromycin
Clostridium
Streptococcus
Streptococcus
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
Other coliforms
Coventry and Warwickshire Pathology
E.coli
Neisseria
Other coliforms
Coventry and Warwickshire Treatment Guidelines (Hospital)
Coventry and Warwickshire Pathology
Case 7
•
•
•
•
•
Rose, 75 year old
Has been on medical ward for 2 weeks
Diabetic, hypertensive
Catheterised to measure urine output
Today, unwell, high temperature,
hypotensive, MEWS score = 7.
• No obvious cause – chest OK, abdo normal.
• No known allergies
Coventry and Warwickshire Pathology
"Sepsis"
ANAEROBES
Clostridium
Streptococcus
Bacteroides
GRAM POSITIVES
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
GRAM NEGATIVES
E.coli
Neisseria
Other coliforms
Coventry and Warwickshire Pathology
"Sepsis"
ANAEROBES Clostridium
Streptococcus
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
GRAM
NEGATIVES
Penicillin + Gentamicin + Metronidazole
GRAM
POSITIVES
E.coli
Neisseria
Clostridium
Bacteroides
Clostridium
Staphylococcus
E.coli
Neisseria
Other coliforms
Piperacillin-tazobactam (Tazocin™)
Enterococcus
Haemophilus
E.coli
Neisseria
Streptococcus
Pseudomonas
Staphylococcus
Haemophilus
Other coliforms
Bacteroides
Enterococcus
Pseudomonas
Meropenem
Clostridium
Streptococcus
Streptococcus
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
Other coliforms
Coventry and Warwickshire Pathology
E.coli
Neisseria
Other coliforms
Coventry and Warwickshire Treatment Guidelines (Hospital)
Coventry and Warwickshire Pathology
• Blood cultures are returned positive:
MRSA grown after 24 hours
Flucloxacillin
Erythromycin
Gentamicin
Vancomycin
Rifampicin
Resistant
Resistant
Sensitive
Sensitive
Sensitive
– On careful examination, a cannula site is
found to be very inflamed and other sources
are excluded clinically.
• Should the antibiotics be changed?
Coventry and Warwickshire Pathology
Penicillin + Gentamicin + Metronidazole
Clostridium
Streptococcus
Bacteroides
Clostridium
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
E.coli
Neisseria
Vancomycin + Gentamicin + Metronidazole
Bacteroides
Clostridium
Staphylococcus
E.coli
Neisseria
Other coliforms
Rifampicin
Enterococcus
Haemophilus
E.coli
Neisseria
Streptococcus
Pseudomonas
Staphylococcus
Haemophilus
Other coliforms
Bacteroides
Enterococcus
Pseudomonas
Vancomycin
Clostridium
Streptococcus
Streptococcus
Bacteroides
Enterococcus
Staphylococcus
Pseudomonas
Haemophilus
Other coliforms
Coventry and Warwickshire Pathology
E.coli
Neisseria
Other coliforms
Sepsis
• Wide variety of causes
– May be clear cause e.g. urosepsis or unclear
– Needs to be treated promptly
• broad spectrum antibiotics
• IV route
• ‘empirical’
– ‘Targeted’ therapy if a cause is found
subsequently
Coventry and Warwickshire Pathology
Summary
•
•
•
•
•
Overview / revision of microbiology
Route:
Oral vs IV
Spectrum:
Narrow vs broad
Therapy
Empirical vs targeted
Antibiotics
Single vs multiple
– Which antibiotics and when
– Allergies
• Resistant organisms e.g. MRSA, ESBL
• Guidelines will help in most cases!
Coventry and Warwickshire Pathology
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