Infectious Disease

 -ve: thin cell wall, take up safranin => pink, reddish color
 +ve: thick cell wall, crystal violet statin => purple or bluish color
 Atypical organism do not have cell wall and do not statin well:
Chlamydia, Legionella, Mycoplasma pneumoniae, Myobacterium
tuberculosis

Types Features Notes

Strep pneumoniae CNS/Meningitis +ve
Respiratory
Strep pyogenes Upper respiratory +ve
Skin/Soft tissue
Staph aureus Heart/Endocarditis +ve
Lower respiratory (MRSA)
Skin/Soft tissue
Bone/Joint
Staph epidermidis Heart/Endocarditis +ve
Skin/Soft tissue
Bone/Joint
Neisseria meningitidis CNS/Meningitis -ve
Neisseria gonorrhoeae Bone/Joint -ve
Enterococci Heart/Endocarditis +ve
Urinary Tract
Streptococci Heart/Endocarditis +ve
 Bone/Joint
Urinary Tract
H. influenzae CNS/Meningitis -ve
Respiratory

 Antibiotic resistance: Kill – Each – And – Every – Strong – Pathogen

Klebsiella pneumoniae (ESBL, CRE)
E.Coli (ESBLE, CRE) ESBL = extended-spectrum beta-lactamse
Acinetobacter baumannii CRE = carbapenem-resistant Enterobacterales
Enterococcus faecalis/faecium (VRE) VRE = vancomycin-resistant Enterococcus
Staphylococcus aureus (MRSA)
Pseudomonas aeruginosa

- Intrinsic resistance: natural to organism. EX: E.coli is resistant to vancomycin because this abx too large to penetrate the bacterial
cell wall
- Selection pressure: resistance occurs when abx kill off susceptible bacteria, leaving behind more resistant strains to multiply.
- Acquired resistance: bacterial DNA containing resistant genes can be transferred between different species and/or picked up from
dead bacterial fragments in environment
- Enzyme inactivation: enzymes produced by bacteria break down the abx
 ESBL: beta-lactamases can break down all penicillin and most cephalosoporins => treated with carbapenem or
cephalosporin/beta-lactamase inhibitor
 CRE: Multi-drug resistant -ve organism that produce enzyme capable of breaking down penicillin, most cephalosporins,
carbapenem => treated with combination of abx
Hydrophilic: beta-lactams, aminoglycosides,
vancomycin, daptomycin, polymyxins
=> small volume of distribution => less tissue
penetration
=> renally eliminated => dose accumulation and
ADRs
=> low intracellular concentrations => not active
against atypical pathogens

Lipophilic: quinolones, macrolides, rifampin,

linezolid, tetracyclines
=> large volume of distribution => better tissue
penetration
=> hepatically metabolized => hepatotoxicity and
DDI
=> achieve intracellular concentrations => active
against atypical pathogens
 Beta-lactam abx
- Inhibit bacterial cell wall synthesis by binding to penicillin-binding proteins => prevent the final step of peptidoglycan synthesis in
bacterial cell walls
Penicillins - Not active against MRSA/atypical  Antistaphylococcal penicillins: cover streptococci, against
pathogens MSSA
- Active against  Aminopenicillins: cover streptococci, enterococci, +ve
 +ve cocci: streptococci, enterococci anaerobes, -ve Haermophilus, Neisseria, Proteus, E.coli
 +ve anaerobes: mouth flora Combined with Beta-lactamase inhibitor => against MSSA, -ve
HNPEK (-Klebsiella), -ve anaerobes (B.fragilis)
 Extended-spectrum penicillins, combined with beta-
lactamase inhibitor => cover same aminopenicillin/beta-
lactamase inhibitor combination PLUS expanded coverage
of -ve including Citrobacter, Acinetobacter, Providencia,
Enterobacter, Serratia CAPES and Pseudomonas

DRUG DOSING NOTES

Natural Penicillins CI:
Penicillin V Potassium PO: 125-500 mg Q6-12H on - hypersensitivity rx, beta-lactam
=> 1st line: pharyngitis (strep empty stomach allergy
throat), mild nonpurulent skin - Augmentin/Unasyn: hx of
infections (no abscess) jaundice, hepatic dysfunction
associated with previous use
Penicillin G Benzathine (Bicillin IM: 1.2-2.4 million units x 1 - CrCl < 30: not use Augmentin
L-A) XR, 875 mg Augmentin
=> DOC syphilis
ADRs:
- Seizure
- GI upset, diarrhea, rash
(SJS/TEN), anaphylaxis,
hemolytic anemia

Monitoring: renal function

Antistaphylococcal Penicillins - Preferred for MSSA soft tissue,
Dicloxacillin PO: 125-500 mg Q6H bone/joint, endocarditis,
Nafcillin IV/IM: 1-2 g Q4-6H bloodstream infection
Oxacillin IV: 250-2000 mg Q4-6H - No renal dose adjustment
- Nafcillin: vesicant ->
administrate through central line
is preferred. If extravasation
occurs, use cold packs and
hyaluronidase injections.

Aminopenicillins - Ampicillin PO -> poor

Amoxicillin PO (chewable): 24-hr ER taken bioavailability
=> 1st line: acute otitis media QD - Amoxicillin is preferred if
(pediatric: 80-90 mg/kg/d) switching from IV ampicillin
=> DOC infective endocarditis - Augmentin: use 14:1 ratio to
prophylaxis before dental decrease diarrhea
procedure - IV diluted in NS only
(2 g PO x 1, 30-60 min before
procedure)

Amoxicillin/Clavulanate PO (chewable): XR taken Q12H

(Augmentin) with food
=> 1st line: acute otitis media
(pediatric: 90 mg/kg/d) and
bacterial sinusitis
=> lower dose of clavulanate to
decrease risk of diarrhea

Ampicillin PO: 250-500 mg Q6H on empty

stomach 1hr before / 2hr after
meals

IV/IM: 1-2 g Q4-6H

 Ampicillin/Sulbactam (Unasyn) IV: 1.5 – 3 g Q6H
Extended-spectrum Penicillins - Zosyn contains 65 mg Na per 1
Piperacillin/Tazobactam (Zosyn) IV: 3.375 g Q6H or 4.5 g Q6-8H g of piperacillin
- Only penicillin active against
Prolonged or extended infusions: Pseudomonas
3.375-4.5 g IV Q8H (over 4h)

Cephalosporins - Not active against Enterococcus spp. or atypical organism

DRUG DOSING NOTES

1st gen - Against +ve cocci (strep and
Cefazolin IV/IM: 1-2 g Q8H staph), -ve rods (Proteus, E.coli,
=> Common use: surgical Klebsiella PEK)
prophylaxis - MSSA

Cephalexin (Keflex) PO: 250-500 mg Q6-12H

=> common use: skin infection
MSSA, strep throat

Cefadroxil
2nd gen - Cefotetan and Cefoxitin
Cefuroxime PO/IV/IM: 250-1500 mg Q8-12H => anaerobic coverage
=> PO common use: acute otitis (B.fragilis)
media, CAP => Common use: surgical
Cefotetan (Cefotan) IV/IM: 1-2 g Q12H prophylaxis (GI)
=> cause disulfiram-like rx with
EtOH ingestion
Cefoxitin IV/IM: 1-2 g Q6-8H
Cefaclor, Cefproxil
3rd gen (Group 1) - Ceftriaxone and Cefotaxime
Cefdinir PO: 300 mg Q12H or 600mg QD => Common use: CAP,
=> Common use: acute otitis meningitis, spontaneous bacterial
 media
Ceftriaxone IV/IM: 1-2 g Q12-24H
=> no renal dose adjustment
=> not use in neonates (age 0-
28d)
Cefotaxime IV/IM: 1-2 g Q4-12H
Cefixime, Cefpodoxime
3rd gen (Group 2)
Ceftazidime (Fortaz, Tazicef) IV/IM: 1-2 g Q8-12H
4th gen
Cefepime IV/IM: 1-2 g Q8-12H
5th gen
Ceftaroline fosamil (Teflaro) IV: 600 mg Q12H
Cephalosporin Combiantion
Ceftazidime/Avibactam (Avycaz) IV: 2.5 g Q8H
Ceftolozane/Tazobactam IV: 1.5-3 g Q8H
(Zerbaxa)
Siderophore Cephalosporin
Cefiderocol (Fetroja) IV: 2g Q8H (over 3h)

CI (ceftriaxone)
- Hyperbilirubinemic neonates => cause biliary sludging kernicterus
- Concurrent use with calcium-containing IV products in neonates  28d

Warning:
- PCN allergy

ADRs:
- Seizures, GI upset, diarrhea, rash/allergic rx/anaphylaxis

Monitoring: renal function, CBC, LFT

Carbapenems - Reserved for MDR -ve infection
- Active against +ve, -ve (including ESBL-producing bacteria), anaerobic pathogens
- No coverage of atypical pathogens, MRSA, VRE
- Ertapenem: no activity against Pseudomonas, Aconetobacter, Enterococcus

DRUG DOSING NOTES

Meropenem IV: 500-1000 mg Q8H CI:
- Anaphylactic rx to beta-lactam
abx

Warning:
- Not use in pts with PCN allergy
- CNS ADRs, seizure

ADRs:
- Diarrhea
- Rash/severe skin rx
- Bone marrow suppression w
prolonged use

Monitoring: renal function

Common use:
- Polymicrobial infections
- Empiric therapy when resistant
organism is suspected
- ESBL-positive infection
- Resistant Pseudomonas or
Acinetobacter infections (except
ertapenem)

Ertapenem IV/IM: 1 g QD As above PLUS

=> stable in NS only - Commonly used for diabetic
 foot infection
Imipenem/Cilastatin Doripenem IV
Imipenem/Cilastatin/Relebactam => not used for pneumonia

Monobactam - MOA similar beta-lactam => inhibit bacterial cell wall synthesis by binding to PBPs, which prevent final
step of peptidoglycan synthesis in bacterial cell walls
- Cover -ve, including Pseudomonas and CAPES
- NO +ve or anaerobic activity

DRUG DOSING NOTES

Aztreonam (Azactam) IV: 500-2000 mg Q6-12H ADRs:
=> can be used with penicillin - Similar to penicillins, including
allergy rash, N/V/D, increase LFT

CrCl < 30 => dose adjustment

Aminoglycosides - Bind to ribosome, which interferes with bacterial protein synthesis => defective bacterial cell membrane
- Active against -ve, including Pseudomonas
- Combined with beta-lactam/vancomycin for +ve => gentamicin, streptomycin
- Two dosing:
 Traditional dosing: lower doses more frequently
 Extended interval dosing: higher doses less frequently => less accumulation, lower risk of nephrotoxicity,
decreased cost
- Risk: nephrotoxicity, irreversible ototoxicity

DRUG DOSING NOTES

Gentamicin - Most TBW Boxed Warning:
Tobramycin - Obese => AdjBW - Nephrotoxicity, ototoxicity,
Amikacin Traditional dosing neuromuscular blockade
 Gentamicin/Tobramycin
1 - 2.5 mg/kg/dose Warning:
Lower dose => +ve - Caution in impaired renal
Higher dose => -ve function, elderly
 Amikacin - Amphotericin B, cisplatin,
5 – 7.5 mg/kg/dose Q8H polymyxins, cyclosporine, loop
Renal dosing adjustment diuretics, NSAIDs, radiocontrast
(traditional dosing) eye, tacrolimus, vancomycin
CrCl  60: Q8H
CrCl 40-60: Q12H ADRs:
CrCl 20-40: Q24H - Nephrotoxicity (ATN)
CrCl < 20: 1x dose - Hearing loss
Extended interval IV dosing - Vestibular toxicity
(Gentamicin/Tobramycin)
4 – 7 mg/kg/dose Monitoring: drug level, renal
Frequency function
Avoid when clearance and/or Vd
altered (pregnancy, ascites, burns, Traditional dosing: draw trough
cystic fibrosis, CrCl < 30 before the 4th dose, draw peak
including end-stage renal disease 30min after the end of 30-min
 on dialysis) infusion for 4th dose
Streptomycin => IM
Plazomicin (Zemdri) IV for complicated UTI only Extended interval dosing: draw
15 mg/kg Q24H random level per timing on
=> dosing adjustments required if nomogram
CrCl < 60

Quinolones - Inhibit bacterial DNA topoisomerase IV and DNA gyrase (topoisomerase II)
- Concentration-dependent
- Against -ve, +ve, atypical pathogens
- Common use: pneumonia, UTI, intra-abdominal infection, traveler’s diarrhea
- Levo and Moxi => IV:PO = 1:1

DRUG DOSING NOTES

Ciprofloxacin (Cipro) PO: 250-750 mg Q12H Boxed Warnings:
=> enhanced -ve, including IV: 200-400 mg Q8-12H - Tendon inflammation and/or
against Pseudomonas rupture
CrCl 30-50: Q12H - Peripheral neuropathy
=> combination ear drops CrCl < 30: Q18-24H - Seizure
+ dexamethasone (Ciprodex)
+ fluocinolone (Otovel) Cipro oral suspension: shake 15s CI:
+ hydrocortisone (Cipro HCl) before each dose, NOT put - Ciprofloxacin: concurrent
through NG or other feeding tube administration of tizanidine

Cipro: can crush IR tablet, mix Warning:

with water and give it via a - QT prolongation (highest risk
feeding tube. Hold tube feedings with moxifloxacin)
at least 1 hour before and 2 hours -> moxi > levo > cipro
after the dose - Hypo/Hyperglycemia
- Psychiatric disturbances
Levofloxacin (Levaquin) PO/IV: 250-750 mg daily - Avoid systemic quinolones in
=> “respiratory quinolone” due to children, pregnancy/breastfeeding
enhanced coverage of CrCl < 50: Q48H and/or decrease - Photosensitivity
S.pneumonia and atypical dose
pathogens ADRs:
=> enhanced -ve, including - N/D, HA, SJS/TEN
against Pseudomonas
DDI:
Moxifloxacin (Avelox) PO/IV: 400 mg Q24H - Antacids
=> NOT USED for UTI - Polyvalent cations (Ma, Al,
=> enhanced +ve, anaerobic and No renal dose adjustment PO4, Ca, Fe, Zn)
can be used alone for - Multivitamins, sucralfate, bile
polymicrobial infection acid resins
 => “respiratory quinolone” due to - Lanthanum carbonate
enhanced coverage of (Fosrenol), sevelamer (Renvela,
S.pneumonia and atypical Renaqel) => decrease PO
pathogens quinolone concentration
-> separate administration 2hr
Delafloxacin - Active against MRSA before/2hr after (lanthanum)/6hr
- Preferred for skin infection after (sevelamer)
suspected to be caused by MRSA - Warfarin
- Sulfonylureas, insulin,
Gatifloxacin hypoglycemia drugs
Ofloxacin (Ocuflox eye drop) PO: 200-400 mg Q12H - Theophylline

CrCl < 30: dose adjustment

required

Macrolides - Bind to 50S ribosomal subunit => inhibit RNA-dependent protein synthesis
- Coverage of atypical (Legionella, Chlamydia, Mycoplasma, Myobacterium avium complex) and
Hawmophilus
- Treatment options for community-acquired respiratory tract infections, sexually transmitted infection
- Common use:
 All: CAP, alternative to beta-lactam for pharyngitis (strep throat)
 Azithromycin: COPD exacerbation, pertussis, chlamydia (pregnancy), MAC prophylaxis, traveler’s
diarrhea
 Clarithromycin: H.pylori treatment regimen
 Erythromycin: gastroparesis (increase gastric motility)

DRUG DOSING NOTES

Azithromycin (Zithromax, Z- Z-pack: 500 mg on day 1, then CI:
pack) 250 mg on day 2-5 - Hx of jaundice/hepatic
=> better -ve dysfunction with prior use
Tri-pack: 500 mg QD for 3d - Clari/Eryth => NOT USE with
lovastatin/simvastatin
 IV: 250-500 mg QD
Warning:
No renal dose adjustment required - QT prolongation
Clarithromycin PO: 250-500 mg Q12H - Hepatotoxicity
=> better +ve or 1 g ER QD - CAD

CrCl < 30 => dose adjustment ADRs:

required - GI upset, ototoxicity, taste
perversion, SJS/TEN/DRESS
Erythromycin (E.E.S, Ery-Tab,
Erythrocin)

Tetracyclines - Bind to 30S ribosomal subunit => inhibit bacterial protein synthesis
- Cover +ve, -ve, including respiratory flora (Haemophilus, Moraxella, atypical)
- Common use:
 Doxycycline and minocycline: CA-MRSA skin infection, acne
 Doxycycline: 1st line for tickborne illnesses (Lyme disease, Rocky Mountain Spotted Fever), chlamydia.
Treatment option for CAP, COPD exacerbation, bacterial sinusitis, VRE UTI
 Tetracycline: used in H.pylori treatment regimens

DRUG DOSING NOTES

Doxycycline (Vibramycin) PO/IV: 100-200 mg QD 1-2 Warnings:
divided dose - Children < 8, pregnancy,
breastfeeding
Take with food to decrease GI - Photosensitivity
irritation - GI inflammation/ulceration
- Minocycline: drug-induced
No renal dose adjustments lupus erythematosus
required
ADRs: N/V/D, rash
Doxycycline: sit upright for at
 least 30min after dose to avoid Monitoring: LFT, renal
esophageal irritation function ,CBC
Minocycline (Minocin, Solodyn) PO/IV: 200 mg x 1, then 50-100
=> preferred for acne mg Q12H IV:PO ratio 1:1 (doxycycline,
minocycline)
Eravacyclin
Omadacycline Tablet and capsule should be
Sarecycline taken with 8 oz of water
Tetracycline

Sulfonamides - SMX inhibit dihydrofolic acid formation from para-aminobenzoic acid, which interfere with bacterial folic
acid synthesis
- TMP inhibit dihydrofolic acid reduction to tetrahydrofolate, resulting in inhibition of the folic acid pathway
- Against staphylococci (including MRSA, CA-MRSA), -ve, Haemophilus, Proteus, E.coli, Klebsiella,
Enterobacter, Shiqella, Salmonella, Stenotrophomonas
- Active against some opportunistic pathogen (Pneumocytis, Toxoplasmosis)
- NOT against Pseudomonas, enterococci, atypical, anaerobes

DRUG DOSING NOTES

Sulfamethoxazole/Trimethoprim Single strength - SMX:TMP = 5:1
(Bactrim, Bactrim DS) 400 mg SMX / 80 mg TMP - Dosing based on TMP
Double strength
800 mg SMX / 160 mg TMP CI:
Severe infection - Sulfa allergy
PO/IV: 10-20 mg TMP/kg/d - Anemia due to folate deficiency
divided Q6-8H - Renal or hepatic disease
- Infants < 2 month
Uncomplicated UTI
1 DS tablet PO BID X 3d Warning:
- Skin reactions: SJS/TEN, TTP
Pneumocystis pneumonia (PCP) - Hemolytic anemia: can be
prophylaxis immune-mediated, caused by
 1 DS or SS tablet daily G6PD deficiency

PCP treatment ADRs:

PO/IV: 15-20 mg TMP/kg/d - Photosensitivity
divided Q6H - Increase K, crystalluria

CrCl 15-30 => dose adjustment DDI:

CrCl < 15 => not recommend - Increase INR => caution with
warfarin
- Hyperkalemia => ACEi/ARB,
aliskiren, ARA, K-sparing
diuretics, cyclosporine,
tacrolimus, NSAIDs

Abx for +ve infections

Vancomycin (Vancocin) - Inhibit bacterial cell wall synthesis by binding to D-alanyl-D-alanine cell wall precursor and blocking
peptidoglycan polymerization.
- Only cover +ve, including MRSA, streptococci, enterococci (not VRE), C.diff (using PO pnly)
- 1st line: MRSA
- Alternative when MRSA MIC  2 mcg/mL
Systemic infection (IV only) C.diff (PO only) Warning:
IV: 15-20 mg/kg Q8-12H PO: 125 QID x 10d - Ototoxicity, nephrotoxicity
(TBW) - Infusion rx
CrCl 20-49 => Q24H 500 mg QID used for severe,
complicated disease (in ADRs:
combination with IV - Abdominal pain, nausea
metronidazole) - Phlebitis
- Myelosuppression
 Monitoring:
- Renal function, drug level
- AUC/MIC ratio, trough (draw
30min before 4th or 5th dose)
- MRSA infection
- AUC/MIC 400-600
- Trough 15-20

Lipoglycopeptides - “-vancin”
- Inhibit bacterial cell wall synthesis by
1/ Binding to D-alanyl-D-alanine portion of the cell wall, blocking polymerization, and cross-linking of
peptidoglycan
2/ Disrupting bacterial membrane potential and changing cell permeability (lipophilic side chain)
- Concentration – dependent activity against similar pathogens as vancomycin =>EXCEPTION: only IV
and not used to treat C.diff

DRUG DOSING NOTES

Telavancin (Vibativ)
=> Approved for complicated
skin and soft-tissue infection
SSTI, and hospital-acquired and
ventilator-associated pneumonia

Oritavancin (Orbactiv, Single-dose

Kymyrsa)
=> Approved for SSTI

Dalbavancin (Dalvance) Single-dose

=> Approved for SSTI
Daptomycin (Cubicin) - Cyclic lipopeptide
- Bind to cell membrane components, causing rapid depolarization
=> inhibit all intracellular replication processes, including protein synthesis => cell death
- Concentration – dependent activity against +ve, including staphylococci (MRSA), enterococci (VRE)
- No activity against -ve
*NOT use to treat pneumonia

INDICATION DOSING NOTES

SSTIs and S.aureus (including 4 mg/kg IV QD *CrCl < 30 => dose adjustment
MRSA) bloodstream infection
Right-sided endocarditis 6 mg/kg IV QD Warning:
- Myopathy and rhabdomyolysis
- Falsely increase PT/INR

ADRs:
- Increase CPK (creatine
phosphokinase)
- Muscle toxicity with statins

Monitoring:
- CPK weekly

Oxazolidinones - Bind to 50S subunit of bacterial ribosome, inhibiting translation and protein synthesis
- Against similar pathogens as vancomycin, also cover VRE

DRUG DOSING NOTES

Linezolid (Zyvox) PO/IV: 600 mg Q12H CI:
- Not use with or within 2 weeks
No renal dose of MAOi, tyramine-containing
foods, serotonergic drugs
IV:PO ratio 1:1
Warning:
 - Duration-related
myelosuppression
(thrombocytopenia) when used >
14d
- Optic neuropathy when used >
28d
- Serotonin syndrome
- Hypoglycemia

ADRs:
- Decrease platelets

Monitoring: weekly CBC

*DO NOT shake suspension

Tedizolid (Sivextro) Warning:
=> Approved SSTI - Alternative treatment in pt with
neutropenia

ADRs:
- N/D, paresthesia, HTN, visual
impairment, blurred vision

Quinupristin/Dalfopristin - Bind to 50S ribosomal subunit => inhibit protein synthesis

- Active against +ve, including staphylococci (MRSA), enterococcus (VRE caused by E.faecium but not
E.faecalis)
- Approved for SSTI but not well tolerated

DRUG DOSING NOTES

Synercid IV: 7.5 mg/kg Q8-12H ADRs:
- Arthralgias/myalgias
Infuse over 60min - Infusion reactions
 - Hyperbilirubinemia
No renal dosing
*Dilute in D5W only
*Administer via central line

Additional Broad-Spectrum Drugs

Tigecycline (Tygacil) - Derivative of minocycline –> related to tetracycline
- Glycylcycline
- Bind to 30S ribosomal subunit and inhibit protein synthesis
- Against +ve, including staphylococci (MRSA), enterococci (VRE), -ve, anaerobes, atypical organism
*Among -ve, NO activity against “3P”: Pseudomonas, Proteus, Providencia
- Approved for SSTIs, Intra-abdominal infections, CAP
Dosing: Boxed warning:
IV: 100 mg x 1 dose, then 50 mg Q12H - Increase risk of death

Severe hepatic impairment: dose adjustment Warning:

- Hepatotoxicity
No renal dosing - Pancreatitis
- Photosensitivity

ADRs:
- N/V/D, HA, dizziness, SJS

*NOT use for bloodstream infection

*Reconstituted solution should be yellow-orangem
discard if not this color
Polymyxins
DRUG DOSING NOTES
Colistimethate (Coly-Mycinn IV/IM: 2.5 -5 mg/kg/d in 2-4 Warnings:
M) divided dose - Dose-dependent
-> referred as colistin nephrotoxicity
 -> inactive prodrug that is - Neurotoxicity
hydrolyzed to colistin
-> colistin acts as cationic
detergent and damage bacterial
cytoplasmic membrane =>
leakage of intracellular
substance and cell death
Polymyxin B IV: 15,000 – 25,000 units/kg/c Boxed warning:
-> Against -ve (Enterobacter, divided Q12H - Nephrotoxicity
E.coli, Klebsiella pneumoniae, - Neurotoxicity => resulted in
Pseudomonas aeruginosa) respiratory paralysis from
=> primarily used for MDR -ve neuromuscular blockade
pathogen in combination with
other abx Monitoring: renal function

* 1mg = 10,000 units

DDI: aminoglycosides, amphotericin B, cisplatin, cyclosporine, loop diuretics, NSAIDs, radiocontrast

dye, tacrolimus, vancopmycin

Chloramphenicol - Reversibly bind to 50S Dosing: Boxed warning:

ribosomal subunit => inhibit IV: 50-100 mg/kg/d in divided - Blood dyscrasias (aplastic
protein synthesis dose Q6H (max 4g/d) anemia, pancytopenia)
- Against +ve, -ve, anaerobic,
atypical No renal dose Warning:
- Rarely used due to ADRs - Gray syndrome

Miscellaneous abx
Clindamycin (Cleocin) - Lincosamide that reversibly Dosing: Boxed warning: C.diff
bind to 50S ribosomal subunit PO: 150-450 mg Q6H
=> inhibit protein synthesis IV: 600-900 mg Q8H Warning: SJS/TEN/DRESS
- Against +ve, including CA-
MRSA, anaerobes No renal dose ADRs: N/V/D
 - NOT cover enterococcus, -ve
- Induction test (D-test) should Common uses: purulent and
be performed on S.aureus that is non-purulent skin infection, beta-
susceptible for clindamycin BUT lactam alternative to dental
resistan tot erythromycin abscesses and surgery
=> flattened zone (+ D-test) => prophylasix
clindamycin resistance => NOT
USED

Metronidazole (Flagyl) - Loss of helical DNA structure Dosing: CI:

and strand breakage => inhibit PO/IV: 500-750 mg Q8-12H or - 1st trimester pregnancy
protein synthesis 250-500 mg Q6-8H - Use of alcohol or propylene
- Against anaerobes, protozoal glycol-containing products
organism No renal dose during tx or within 3d of tx DC
- Effective for bacterial (disulfiram rx)
vaginosis, trichomoniasis, Take IR tab with food to
giardiasis, amebiasis, C.diff (not decrease GI upset Warning:
preferred), in combination for - CNS effect
intra-abdominal infections IV:PO ratio = 1:1 - Aseptic meningitis,
encephalopathy, optic
Topical and vaginal form neuropathy

ADRs:
- Metallic taste
- HA, nausea, furry tongue,
darkened urine

Lefamulin (Xenleta) - Pleuromutilin Dosing: CI: use with CYP3A4 substrates

- Inhibit bacterial protein PO: 600 mg Q12H => prolong QTc
synthesis by binding to peptidyl IV: 150 mg Q12H
transferase center of 50S Warning:
ribosomal subunit - Pregnancy (teratogenic)
- Approved for CAP tx - QTc prolongation
 - C.diff associated diarrhea

ADRs:
- Diarrhea, nausea
- Injection site rx

Fidaxomicin (Dificid) - Inhibit RNA polymerase => Dosing: Warning:

inhibit protein synthesis and cell PO: 200 mg BID x 10d - Not effective for systemic
death infections – absorption is
- Used for C.diff No renal dose minimal

ADRs:
- M/V, abdominal pain
- GI bleeding
- Anemia
Rifaximin (Xifaxan) - Inhibit bacterial RNA synthesis Dosing: ADRs:
by binding to bacterial DNA-  Travelers’ diarrhea - Peripheral edema
dependent RNA polymerase PO: 200 mg TID x 3d - Dizziness, HA
- Structurally related to rifampin - Flatulence
- Not effective for systemic  Decrease recurrence of - Nausea, abdominal pain
infections hepatic encephalopathy
- USED off-label for C.diff PO: 550 mg BID

 IBD w diarrhea
PO: 550 mg TID x 14d

No renal dose

Urinary Agents
Fosfomycin (Monurol) - Inhibit bacterial cell wall Dosing: ADRs: HA, diarrhea, nausea
synthesis by inactivating the  Female, uncomplicated UTI
enzyme pyruval transferase 3 g PO x 1, mixed in 3-4 oz of *Concentrate in urine
- Against E.coli (including cold water
 ESBL-producing strains),
E.faecalis (including VRE)
- Sing-dose regimen for
uncomplicated UTI (cystitis
only)
- Packet granules = 3g per packet

Nitrofurantoin - Bacterial cell wall inhibitor Dosing: CI: CrCl < 60

(Macrobid, Macrodantin) - Used for uncomplicated UTI  Macrodantin
(cystitis only) PO: 50-100 mg QID x 3-7d Warning:
- Covers E.coli, Klebsiella, 50-100 mg QHS for phx - G6PD deficiency (cause
Enterobacter, S.aureus, hemolytic anemia)
Enterococcus (including VRE)  Macrobid - Optic neuritis
PO: 100 mg BID x 5d - Hepatotoxicity
- Peripheral neuropathy

ADRs:
- GI upset (take with food)
- HA, rash
- Brown urine discoloration

Topical decolonization
Mupirocin (Bactroban) - Nasal antimicrobial ointment Dosing: ADRs:
- Used to eliminate staphylococci 1 g tubes - HA
(MRSA) colonization of nares  Decolonization - Burning
- Infected kin lesions ½ tube in each nostril BID x 5d - Localized irritation
- Rhinitis
- Pharyngitis
Perioperative abx selection
- cefazolin => 1st gen => preferred for most surgeries to prevent MSSA and streptococcal infections
- clindamycin => alternative if beta-lactam allergy
- GI surgery => prophylactic abx regimen need to cover skin flora plus broad -ve and anaerobic
- vancomycin => MRSA, alternative if beta-lactam allergy
Surgical procedure Recommended abx Beta-lactam Allergy
Cardiac or vascular Cefazolin or cefuroxime Clindamycin or Vancomycin
Orthopedic (e.g, joint replacement, hip Cefazolin
fracture repair)
Gastrointestinal Cefazolin + metronidazole, cefotetan, Clindamycin or metronidazole +
cefoxitin aminoglycoside or quinolone
OR ampicillin/sulbactam

Meningitis
- Inflammation of meninges (membranes) - Sx: fever, HA, stiff neck, altered mental - Add coverage for Listeria
that cover brain and spinal cord status, chills, vomiting, seizures, rash, monocytogenes
- Caused by viral infection BUT can be photophobia - Add vancomycin in pts  1-month old
due to bacteria or fungi - Diagnosis: lumbar puncture, CSF for double coverage of Streptococcus
+ Neisseria meningitidis -> High CSF => infection pneumoniae
+ Streptococcus pneumonia
+ Haemophilus influenzae
- Listeria monocytogenes => higher in
neonates, age > 50, immunocompromised
Acute bacterial meningitis treatment - Abx duration:
(Community-acquired)  N.meningitidis and H.influenzae: 7d
 S.pneumoniae: 10-14d
 Listeria monocytogenes: at least 21d
- Dexamethasone: 15-20min prior to or with 1st abx dose, can prevent neurological
complications
- Adult dose: 0.15 mg/kg (~10 mg) IV Q6H
- Steroid treatment should be continue for 4d
- If S.pneumoniae is not identified as the cause of meningitis, dexamethasone can be
DC
Age < 1 month (neonates) Age 1 month to 50 yrs Age > 50 yrs or Immunocompromised
Ampicillin (for Listeria coverage) Ceftriaxone or cefotaxime Ampicillin
+ + +
Cefotaxime Vancomycin Ceftriaxone or cefotaxime
or +
Gentamicin Vancomycin
*AVOID ceftriaxone in neonates (<1 *If severe penicillin allergy
month) => biliary sludging and => treat with quinolone + vancomycin 
kernicterus (brain damage from high SMX/TMP (for Listeria coverage)
bilirubin)

Upper respiratory tract infections

Acute otitis media (AOM) - Common in kid Observation:
- Sx: bulging tympanic (eardrum), - 2-3d if sx non-severe (otalgia < 48 hrs,
otorrhea (middle ear effusion/fluid), no otorrhea, temp < 102.2F/39C)
otalgia (ear pain), tugging or rubbing ears  Age 6-23 months: sx in 1 ear only
- Most viral infection => abx ineffective  Age  2 yrs: sx in 1 or both eears
- Bacterial infection: S.pneumoniae, - If sx not improve/worsen => use abx
H.influenzae, Moraxella catarrhalis

1st line Alternative (mild penicillin allergy) Tx failure (Not improve after 2-3d)
Amoxicillin 90 mg/kg/d in 2 divided dose  Cefdinir 14 mg/kg/d in 1 or 2 doses Amoxicillin/clavulanate in 2 divided dose
OR  Cefuroxime 30 mg/kg/d in 2 divided  90 mg/kg/d of amoxicillin
Amoxicillin/clavulanate in 2 divided dose dose  6.4 mg/kg/d of clavulanate
 90 mg/kg/d of amoxicillin  Cefpodoxime 10 mg/kg/d in 2 divided OR
 6.4 mg/kg/d of clavulanate dose Ceftriaxone 50 mg/kg IM daily for 3d
 Ceftriaxone 50 mg/kg IM daily for 1
or 3d
- Received amoxicillin in the past 30d => preferred amoxicillin/clavulanate
- Clavulanate => decrease risk of diarrhea
- Target ratio => amoxicillin:clavulanate = 14:1 => Augmentin ES-600 (amoxicillin 600 mg and clavulanate 42.9 mg per 5 mL)
- Tx duration:
 Children < 2yrs => 10d
 Ages 2-5 yrs => 7d
 Ages  6 yrs => 5-7d

Non-AOM Upper Respiratory Tract Infections

 Common Cold Influenza Pharyngitis Acute Sinusitis
Typical Etiology Respiratory viruses Influenza virus Respiratory viruses, Respiratory viruses,
(rhinovirus, seasonal S.pyogenes => strep S.pneumoniae,
coronavirus) throat H.influenzae,
M.catarrhalis
Clinical Presentations Sneezing, runny nose, Sudden onset fever, Sore throat, fever, Nasal congestion,
mild sore throat, cough, chills, fatigue, myalgia, swollen lymph nodes, purulent nasal discharge,
congestion dry cough, sore throat, white patches facial/ear/dental pain,
headache (exudates) on the tonsils headache
Criteria for anti- NONE Sx < 48 hrs Rapid antigen test  10d of persistent sx
infective tx => resolve in few days Severe illness Throat culture  3d of severe sx (temp
Sx plus risk factors => positive for > 102F)
S.pyogenes Worsening sx after initial
improvement
Tx options Symptomatic: OTC Symptomatic care Penicillin or Amoxicillin/clavulanate
analgesics, with/without antiviral amoxicillin OR
decongestants, cough therapies Symptomatic care for
suppressants, Mild penicillin allergy up to 7d with OTC
expectorant, => 1st/2nd cephalosporin decongestants,
antihistamine antihistamine,
Severe rx to penicillin expectorants, analgesics
=> macrolide
(clarithromycin, *Abx can be used if sx
azithromycin) or worsen or not improve
clindamycin

Lower respiratory tract infection

Acute bronchitis - Inflammation of mucous membrane of bronchi Pertussis
 Non-productive or productive cough lasting - Caused by Bordetella pertussis (whooping
1-3 weeks, chest wall tenderness, wheezing, cough)
rhonchi - Highly contagious
 Virus - Tx: macrolide (azithromycin, clarithromycin)
  S.pneumoniae, H.influenza, atypical
pathogens
 Chest X-ray => normal
 Abx not recommended
 Supportive care

Acute COPD exacerbation - Sx: increase dyspnea, Supportive tx (e.g, oxygen, short-
acting inhaled bronchodilators,
increase sputum volume, IV/PO steroids)
increase sputum purulence
- Exacerbation can be triggered
by viral/bacterial infection Abx for 5-7d if meet one of following:
(H.influenzae, M.catarrhalis, + All 3 cardinal sx present: increase
dyspnea/sputum volume/sputum
S.pneumoniae) purulence
+ Increase sputum purulence + 1
additional sx
+ Mechanically ventilates

Preferred abx:
+ Amoxicillin/clavulanate
+ Azithromycin
+ Doxycycline
+ Respiratory quinolone

Community-acquired - Sx: SOB, fever, cough with purulent sputum, rales (crackling noises in lungs), tachypnea
pneumonia (increase RR)
- Chest X-ray: infiltrates, opacities, consolidations
- Sx mild => walking pneumonia
- Most bacterial cases caused by S.pneumoniae, H.influenzae, M.pneumoniae
- Ciprofloxacin NOT USED for CAP => not a respiratory quinolone because it does not cover
S.pneumoniae
- Duration tx: 5-7d
Outpatient CAP tx
Patient characteristics Recommended empiric regimen
Healthy  Amoxicillin high dose (1g
 No comorbidities TID), or
 Doxycycline, or
 Macrolide (azithromycin or
clarithromycin) if local
pneumococcal resistance is <
25%

High-risk  Beta-lactam + macrolide or

With comorbidities doxycycline
o Amoxicillin/clavulanate
or cephalosporin (e.g
cefpodoxime, cefuroxime)
PLUS
o Macrolide or doxycycline
 Respiratory quinolone
monotherapy
o Moxifloxacin or
levofloxacin

Inpatient CAP tx
Non-severe Beta-lactam +
macrolide/doxycycline
o Preferred beta-lactam:
ceftriaxone, cefotaxime,
ceftaroline,
ampicillin.sulbactam
Respiratory quinolone
monotherapy
Severe (ICU) Beta-lactam + macrolide
Beta-lactam + respiratory
quinolone (NOT USE quinolone
monotherapy)
 Risk factors for  MRSA: add coverage with
Pseudomonas and/or vancomycin or linezolid
MRSA  Pseudomonas: beta-lactam
abx with activity against
Pseudomonas =>
piperacillin/tazobactam,
cefepime, ceftazidime,
imipenem/cilastatin,
meropenem
 Hospitalization: parenteral
abx in past 90d => use
regimen with abx active
against both MRSA and
Pseudomonas

Hospital-acquired Pneumonia - Onset > 48hrs after hospital - Nosocomial pathogens Abx for Pseudomonas,
administration - MRSA MSSA
Ventilator-associated - Occurs > 48hrs after the start - MDR -ve rods, including - Cefepime
Pneumonia of medical ventilation P.aeruginosa, Acinetobacter, - Piperacillin/tazobactam
- Incidence can be reduced by Enterobacter, E.coli, Klebsiella - Levofloxacin
proper hand-washing,
elevating head of bed  30
degrees, weaning off ventilator
asap, remove NG Add vancomycin or linezolid
if MRSA
- Risk factor: IV abx use in
past 90d
- Cefepime + vancomycin
- Meropenem + linezolid
- Aztreonam + vancomycin

Use 2 abx for Pseudomonas if

 MDR -ve
- Risk factor: IV abx use in
past 90d
- Piperacillin/tazobactam +
ciprofloxacin + vancomycin
- Cefepime + gentamicin +
linezolid

Abx for Pseudomonas (NOT

USE 2 beta-lactam together)
- Beta-lactam:
piperacillin/tazobactam,
cefepime, ceftazidime,
imipenem/cilastatin,
meropenem
- Levofloxacin or ciprofloxacin
- Aztreonam
- Aminoglycosides
(tobramycin)
Tuberculosis - Caused by Mycobacterium Latent TB Active TB
TB - Immune system is able to - Transmitted by aerosolized
contain the infection and pt droplets (sneezing, coughing,
lacks sx talking) and highly contagious
- Diagnosed using TST/PPD - Present with
(skin), IGRA (blood) cough/hemoptysis, fever, night
sweat
- Diagnosis must be confirmed
MTB is acid-fast bacilli
Latent TB tx - INH and rifapentine once
weekly for 12 weeks via DOT.
*NOT use in pregnancy
- INH + rifampin QD for 3
months
 - Rifampin 600 mg QD for 4
months
- INH 300 mg QD for 6-9
month
*Preferred in HIV-positive, 9-
months tx
Active TB tx Intensive Phase Continuation Phase
- 4 drugs for 2 months (until - 2 drugs for 4 months (based
cultures and susceptibilities are on culture and susceptibility
available) results)
- RIPE: rifampin (RIF) + - INH and RIF
isoniazid (INH) + - Daily, 5x per week or 3x per
pyrazinamide (PZA) + week
ethambutol - Duration: 18 weeks
- Daily or 5x per week
- Duration: 8 weeks

DRUG DOSING NOTES

Rifampin (Rifadin) 10 mg/kg (max 600 mg) PO daily or 2- CI: not use with protease inhibitors
3x/week
ADRs:
Take on empty stomach - Increase LFT
- Hemolytic anemia (detect with + Coombs test)
- Flu-like syndrome
- Orange-red discoloration (saliva, urine, sweat, tears)
- Stain contact lenses, clothing

DDI:
- Protease inhibitor, warfarin, oral contraceptive =>
decrease serum concentration
- Not use with apixaban, rivaroxaban
*Rifabutin => can replace rifampin (HIV pt taking
protease inhibitor)
 Isoniazid 5 mg/kg (max 300 mg) PO daily OR Boxed warning: hepatitis
15 mg/kg (max 900 mg) 1-3x/week
CI: active liver disease
Take on empty stomach
Warning:
Use pyridoxine (vit B6) 25-50 mg PO - Peripheral neuropathy
daily to decrease risk of INH-associated
peripheral neuropathy ADRs:
- Increase LFTs
- Drug-induced lupus erythematosus (DILE)
- Hemolytic anemia

Pyrazinamide 20-25 mg/kg PO daily CI: acute gout

CrCl < 30 => extend interval ADRs:

- Increase LFT
- Hyperuricemia/gout

Ethambutol (Myambutol) 15-20 mg/kg (max 1.6 g) PO daily CI:

OR - Optic neuritis (risk vs benefit)
25-30 mg/kg (max 2.4 g) 3x/week - Not use in young children, unconscious pts, visual
OR changes
50 mg/kg (max 4 g) 2x/week ADRs:
- Increase LFTs
CrCl < 50 => extend interval - Optic neuritis (dose-related)
- Confusion, hallucinations

Infective Endocarditis
- Infection of inner tissue of heart => heart valves
- Staphylococci, Streptococci, Enterococci
- Gentamycin is added to antimicrobial regimen for synergy
*Target peak level of 3-4 mcg/mL, trough level < 1 mcg/mL
- 4-6 weeks of IV abx is required
IE treatment

Organism Preferred abx regimen

Viridans group streptococci Penicillin or Ceftriaxone ( gentamicin)
If beta-lactam allergy, use vancomycin monotherapy
Staphylococci (MSSA) Nafcillin or cefazolin (+ gentamicin and rifampin if prosthetic valve)
If beta-lactam allergy, use vancomycin (+ gentamicin and rifampin if prosthetic valve)
Staphylococci (MRSA) Vancomycin (+ gentamicin and rifampin if prosthetic valve)
Enterococci For both native and prosthetic valve IE: penicillin or ampicillin + gentamicin or ampicillin +
high-dose ceftriaxone
If beta-lactam allergy => use vancomycin + gentamicin
If VRE => use daptomycin or linezolid

*Daptomycin monotherapy => alternative for MSSA/MRSA IE when pt has beta-lactam allergy and no prosthetic valve

IE Dental Prophylaxis
- Mouth bacteria that can enter blood during dental procedure.
- Risk: cardiac conditions

Pt at high risk for IE Adult prophylaxis regimen

Dental work needed, such as root canal All given as single dose 30-60min before dental procedure
+ 1st line:
Select cardiac conditions, including: Amoxicillin 2 g PO
 Artificial (prosthetic) heart valve If unable to take PO med:
 Hx of endocarditis Ampicillin 2 g IM/IV
 Heart transplant with abnormal heart valve function OR
 Certain congenital heart defects including heart/heart Cefazolin or ceftriaxone 1 g IM/IV
valve disease If able to take PO med but allergic to penicillin:
Azithromycin or Clarithromycin 500 mg
 OR
Doxycycline 100 mg

Intra-Abdominal Infection
Spontaneous Bacterial - Infection of peritoneal space Empiric tx => cover Common intra-abdominal
Peritonitis that often occurs in pts with streptococci, Proteus, E.coli, infection:
cirrhosis and ascites Klebsiella  Appendicitis
- Ascitic fluid sample reveals  Ceftriaxone for 5-7d  Cholecystitis (acute
 250 cell/mm3 PMNs inflammation of
Alternative => critically ill or gallbladder)
MDR  Cholangitis (infection of
 Carbapenem common bile duct)
 Secondary peritonitis
Secondary prophylaxis (caused by ulceration,
 SMX/TMP, or ischemia, obstruction,
 Quinolone surgery)
 Diverticulitis

- Polymicrobial
- Empiric tx target multiple
pathogens: streptococci,
enteric -ve, anaerobes
(Bacteroides fraqilis)
- MDR => coverage
Pseudomonas and other
resistant organism
- If abx selected not have
anaerobic coverage => add
metronidazole
- Tx duration: 4-5d
 Community-acquired (low risk) Risk for resistant or Nosocomial pathogens
Cover PEK, anaerobes, streptococci Cover PEK, Pseudomonas, Enterobacter, anaerobes,
streptococci  enterococci
Ertapenem Carbapenem (except ertapenem)
Moxifloxacin Piperacillin/tazobactam
(Cefuroxime, cefotaxime or ceftriaxone) + metronidazole (Cefepime or ceftazidime) + metronidazole
(Ciprofloxacin or levofloxacin) + metronidazole

Ampicillin or vancomycin may be added to cephalosporin-based regimen if Enterococcus coverage is needed

Vancomycin is added if MRSA

Skin and soft-tissue infection (SSTI)

- Staphylococci, streptococci - Superficial: impetigo, - Systemic signs: - Mild infection: systemic
furuncle, carbuncle  Temp > 100.4F signs absent
- Subcutaneous tissues:  HR > 90 - Moderate infection: systemic
cellulitis  WBC > 12,000 or signs present
- Nonpurulent or purulent < 4000 cells/mm3 - Severe infection: systemic
(contain pus): abscess signs present, signs of deeper
infection (fluid-filled blisters,
skin sloughing, hypotension or
evidence of organ
dysfunction),
immunocompromised pt, failed
PO abx + incision and drainage
Outpatient tx of common SSTIs

INFECTION PRESENTATION TREATMENT

Superficial Infections
Impetigo - Common in children - Use warm, wet compresses to help
=> S.pyogenes, S.aureus (most often - Blister-like rash: mouth, nose, hands, remove dried crusts (NOT SHARE)
MSSA) arms - Limited, localized lesion:
- Honey-colored crusts  Apply topical abx: mupirocin
 Alternative: Retapamulin (Altabax),
 Ozenoxacin (Xepi)
- Numerous, extensive lesion:
 Cephalexin 250-500 mg PO QID
 Dicloxacillin 250-500 mg PO QID

Folliculitis/furuncle/carbuncle - Folliculitis: infection of hair follicles - Folliculitis and small furuncles

=> S.aureus (including CA-MRSA) (red pimples) => warm compresses to decrease
- Furuncle (boil): purulent infection of inflammation and help with drainage
hair follicle - Large furuncles and carbuncles
- Carbuncle: group of infected furuncles => incision and drainage (I&D)  abx
- Use abx to cover MSSA/MRSA
 SMX/TMP DS 1-2 tab PO BID
 Doxycycline 100 mg PO BID
- Folliculitis due to fungal infection
=> ketoconazole cream

Cellulitis (Non-purulent infections)

Mild infection - Mild sx: localized pain, swelling, - PO abx active against streptococci and
=> Streptococci, including S.pyogenes, redness, warmth. MSSA
S.aureus - Often occurs on legs, generally  Cephalexin 500 mg PO QID
unilateral, rapidly spread  Dicloxacillin 500 mg PO QID
 Beta-lactam allergy:
=> clindamycin 300 mg PO QID
- Duration: 5d (longer is no
improvement)

Abscess (Purulent Infections)

Mild-moderate infection - Localized fluid collection - I&D
=> S.aureus, including CA-MRSA - Recurrent MRSA infection: consider - PO abx to cover MSSA/MRSA
nasal decolonization with nasal  SMX/TMP DS 1-2 tab PO BID
mupirocin, and skin decolonization with  Doxycycline 100 mg PO BID
chlorhexidine or dilute bleach  Minocycline 200 mg PO x 1, then
100 mg PO BID
  Clindamycin 300 mg PO QID
- Alternative: linezolid
- MSSA: cephalexin

Severe SSTIs

INFECTION NOTE TREAMENT

Severe purulent SSTI - Duration of therapy: 7-14d - IV Abx with MRSA activity:
 Vancomycin (goal trough 10-15)
 Daptomycin
 Linezolid
 Others: ceftaroline, tedizolid,
telavancin
- Once clinically stable, transition to PO
abx

Necrotizing fasciitis - Rapidly destroy tissue and penetrate - Urgent surgical debridement
=> S.pyogenes, S.aureus (including down to muscle - Empiric therapy is broad: IV abx
MRSA), -ve, anaerobes - Presentation: intense pain/tenderness  Vancomycin or daptomycin + beta-
over affected skin and underlying muscle, lactam (piperacillin/tazobactam,
skin discoloration, edema, systemic signs meropenem) + clindamycin

Diabetic Foot Infection

- Polymicrobial
=> need broad-spectrum Etiology +ve -ve
empiric abx to target +ve, -ve, Aerobic S.aureus (including MRSA) E.coli
anaerobic pathogens Group A streptococcus Klebsiella pneumonia
- If deeper infection is present Viridans group streptococci Proteus mirabilis
(osteomyelitis) => longer S.epidemidis Enterobacter cloacae
course of IV abx required Pseudomonas aeruginosa

Anaerobic Peptostreptococcus Bacteroides fragilis and others

Clostridium perfringens

Treatment of moderate-
severe TYPES OF REGIMES TREATMENT DURATION
No MRSA coverage needed Ampicillin/sulbactam - 7-14d
(cover MSSA) Piperacillin/tazobactam - More severe, deep tissue
Carbapenem (meropenem, infection: 2-4 weeks
ertapenem) - Severe, limb-threatening or
Moxifloxacin bone/joint infection: 4-6
(Ceftriaxone, cefepime, weeks
levofloxacin, ciprofloxacin) + - Osteomyelitis: require
metronidazole longer course of therapy, and
may require chronic
MRSA coverage needed Add vancomycin, daptomycin suppressive therapy
or linezolid to 1 of regimens
above

UTIs
Acute cystitis: lower UTI - Bladder and urethra - Urgency and frequency, - Urinalysis: + pyuria (WBC >
- More common in females nocturia (overnight) 10 cells/mm3), bacteria, +
- Dysuria leukocyte esterase and/or
- Suprapubic tenderness nitrites
- Hematuria
Pyelonephritis: upper UTI - Kidney - Flank/pain
- Abdominal pain, N/V
- Fever, chills, malaise
 DIAGNOSIS DOC NOTES
Acute uncomplicated cystitis Nitrofurantoin (Macrobid) 100 mg PO - Empiric => outpt
=> Common pathogen: E.coli, Proteus, BID x 5 d (CI if CrCl < 60) - If no response with 1st line
Klebsiella, Staphylococcus, => check urine culture and treat
Saprophyticus, Enterococci OR accordingly
- NOT use moxifloxacin for UTIs
SMX/TMP DS 1 tab PO BID x 3d (NOT - Prophylaxis: if  3 episodes in 1
use if sulfa allergy)  SMX/TMP SS 1tab QD
 Nitrofurantoin 50 mg PO QD
OR  SMX/TP DS 1 tab after sexual
intercourse
Fosfomycin 3 g x 1 dose

Alternative options:

Beta-lactam (amoxicillin/clavulanate or Pregnancy:

cephalosporin) x 5-7d  Amoxicillin
 Cephalexin
OR  Fosfomycin (if beta-lactam allergy)

Ciprofloxacin 250 mg PO BID x 3d Pregnant women with acute cystitis

(symptomatic) => treated for 7d
OR

Levofloxacin 250 mg PO QD x 3d

Quinolones: NOT use in children, pregnancy, those with seizures, neuropathy or QT

prolongation
=> watch for tendinitis/rupture and BG changes

Acute pyelonephritis Moderately ill outpt (PO) - If risk for or documented Pseudomonas
=> Common pathogen: E.coli, Proteus, - If local quinolone resistance  10% infection
 Klebsiella  Ciprofloxacin 500 mg PO BID x 5-7d  piperacillin/tazobactam
 Levofloxacin 750 mg PO QD x 5-7d  Antipseudomonal carbapenem
(meropenem, doripenem,
- If local quinolone resistance > 10% imipenem/cilastatin)
 Ceftriaxone 1g IV/IM x 1
 Ertapenem 1 g IV/IM x 1 - Last-line option:
 Aminoglycoside extended-interval  Cefiderocol (Fetroja)
dose IV/IM x 1, then continue with a  Imipenem/cilastatin/relabactam
quinolone (above) x 5-7d (Recarbrio)
 Meropenem/vaborbactam (Vabomere)
- Concern for quinolone ADRs:  Plazomicin (Zemdri)
 SMX/TMP
 Beta-lactam (amoxicillin/clavulanate,
cefdinir, cefadroxil, cefpodoxime)
 7-10d
Severe ill hospitalized pt (IV)
- Initial: ceftriaxone or quinolone
(ciprofloxacin or levofloxacin)

- Concern for resistance:

piperacillin/tazobactam or carbapenem (if
ESBL-producing organism suspected)

- Step down to PO tx options based on

culture & susceptibility

- Duration: 5-10d

Urinary Analgesics - Phenazopyridine (Pyridium, CI: renal impairment, liver - Help with dysuria
Azo Urinary Pain Relief) disease (pain/burning with urination)
BUT not treat infection
200 mg PO TID x 2d (max) ADRs: - Cause red-orange urine and
 - HA, dizziness other body fluids, contact
Take with 8oz water, with food - Stomach cramps lenses/clothes can be stained
to minimize stomach upset - Body secretion discoloration
Bacteriuria ( 105 bacteria/mL - Treated even if asymptomatic  Beta-lactam - Alternative (beta-lactam
on urinalysis) and Pregnancy Amoxicillin  clavulanate allergy) => should be avoided
in 1st trimester
OR  Nitrofurantoin: avoid 3rd
trimester
Oral cephalosporin  SMX/TMP
 Fosfomycin
- Quinolones AVOIDED

C.diff Infection
- Sx: at least 3 watery stool per day, abdominal cramps, fever, elevated WBC
- Diagnosis: + C.diff stool toxin or PCR
- When infection is suspected, DC unnecessary abx and possible causative agents (PPIs), isolate patients
1st episode 2nd episode (1st recurrence) 3rd or subsequent episodes Fulminant/Complicated
Fidaxomicin (Dificid) 200mg FDX 200 mg PO BID x 10d FDX 200 mg PO BID x 10d disease
PO BID x 10d - Diagnosed when significant
OR OR systemic toxic effects are
OR present (hypotension, shock,
VAN followed by prolonged VAN followed by prolonged ileus, toxic megacolon)
Vancomycin 125 mg PO QID x pulse/tapered course pulse/tapered course
10d VAN 500 mg PO/NG/PR QID
*vancomycin 125 mg PO QID OR + metronidazole 500 mg IV
*If non-severe (WBC < 15,000 x 10d Q8H
and SCr < 1.5), tx above -> BID x 1 week VAN followed by rifaximin
unavailable -> daily x 1 week 400 mg TID x 20d
=> metronidazole 500 mg PO -> 125 mg Q2-3d for 2-8 week
TID x 10d OR

Fecal microbiota
transplantation
Adjunct bezlotoxumab (in addition to antibacterial tx)
- Age > 65 yrs
- Immunocompromised status
- Severe presentation and/or experiencing 2nd episode of CDI within past 6 month

Sexually transmitted infections

- Chlamydia: genital discharge or no sx
- Gonorrhea: genital discharge or no sx
- Genital warts: single or multiple pink/skin-toned lesions
- Latent syphilis: asymptomatic
- Primary syphilis: painless, smooth genital sores (chancre)
Female only
- Bacterial vaginosis: vaginal discharge (clear, white, gray), fishy odor, pH > 4.5, little or no pain
- Trichomoniasis: yellow/green, frothy vaginal discharge with pH > 4.5, soreness, pain with intercourse

INFECTION DOC DOSING/DURATION NOTES

Syphilis (primary, secondary, Penicillin G benzathine 2.4 million units IM x 1 Beta-lactam allergy
early latent) (Bicillin L-A)  Doxycycline 100 mg PO
=> Treponema pallidum, a BID x 14d
spirochete  If pregnancy, desensitize
and treat with Bicillin L-A
Early latent: acquired within
the past year, asymptomatic

Syphilis (late latent, tertiary) Bicillin L-A 2.4 million units IM weekly x Beta-lactam allergy
3 weeks  Doxycycline 100 mg PO
Late latent: acquired > 1 yr ago BID x 28d
or unknown duration,  If pregnancy, desensitize
asymptomatic and treat with Bicillin L-A

Neurosyphilis Penicillin G aqueous 3 - 4 million units IV Q4H x  Penicillin G procaine

10-14d
 Beta-lactam allergy:
 desensitization followed by
penicillin G aqueous IV

Gonorrhea Ceftriaxone < 150 kg: 500 mg IM x1  Pregnancy: same tx

=> Neisseria gonorrhoeae
If chlamydia not excluded  150 kg: 1 g IM x 1  If ceftriaxone unavailable
=> add doxycycline  cefixime 800 mg
PO x 1

 If cephalosporin allergy
 gentamicin 240 mg
IM x 1 +
azithromycin 2 g
PO x 1

 Ceftriaxone most effective

for pharyngeal infections

Chlamydia Non-pregnant: doxycycline 100 mg PO BID x 7d  Erythromycin base 500 mg

=> Chlamydia trachomatis PO QID x 7d
Pregnant: azithromycin 1 g PO x 1
 Levofloxacin 500 mg PO
daily x 7d

 Pregnancy: amoxicillin 500

mg PO TID x 7d

Bacterial vaginosis Metronidazole 500 mg PO BID x 7d Clindamycin 300 mg PO BID

x 7d (or clindamycin ovules
OR 100 mg intravaginally QHS x
3d)
Metronidazole 0.75% gel 1 applicator intravaginally QD
x 5d OR
 OR
Tinidazole 2 g PO QD x 2d (or
Clindamycin 2% cream 1 applicator intravaginally 1 g PO QD x 5d)
QHS x 7d
OR

Secnidazole 2 g PO x 1 dose

*Female should not douche

Trichomoniasis Metronidazole Females: Pregnancy: CI in 1st trimester

=> Trichomonas vaginalis 500 mg PO BID x 7d
CDC recommends
Males: metronidazole in all trmesters
2 g PO x 1
Genital warts Imiquimod cream (Aldara, Apply topically to clean, dry, - Tx not required if
=> HPV strain 6&11 Zyclara) warty tissue and wash off in 6- asymptomatic
*Gardasil vaccine reduce risk 10 hrs - Local ADRs: erythema,
burning, scaling, ulcers,
Apply 3x/week unitl cleared vesicles
(or 16 week)

Common Tickborne Disease

DISEASE ORGANISM TREATMENT

Rocky Mountain Spotted Fever Rickettsia rickettsii Doxycycline 100 mg PO/IV BID x 5-7d
Lyme Disease Borrelia Doxycycline 100 mg PO BID x 10d

OR

Amoxicillin 500 mg PO TID x 14d

OR
 Cefuroxime 500 mg PO BID x 14d

Ringworm Fungal infection -> tinea corporis Clotrimazole or topical antifungal

Ehrlichiosis Ehrlichia chaffeensis Doxycycline 100 mg PO/IV BID x 7-14d

Antifungals & Antivirals

AMPHOTERICIN B - Bind to ergosterol, altering cell membrane permeability => cell death
- Active against:
 Yeasts: Cryptococcus neoformans
 Molds: Asperqillus
 Dimorphic fungi: Histoplasma capsulatum, B;astomyces dermatitidis, Coccidiodes immitis

FORMULATION DOSING NOTES

Conventional Formulation
Amphotericin B Deoxycholate Injection: 0.1-1.5 mg/kg/d
=> many toxicities
Lipid Formulation
Amphotericin B Lipid Complex Injection: 5 mg/kg/d
(Abelcet)
Liposomal Amphotericin B (AmBisome) Injection: 3-6 mg/kg/d
=> fewer toxicities
*decreased infusion rx
*decreased nephrotoxicity
FLUCYTOSINE - Penetrates fungal cells and is 50 – 150 mg/kg/d PO divided Boxed warning:
5 F-C (Ancoban) converted to fluorouracil Q6G - Renal dysfunction
=> competes with uracil can - monitor hematologic, renal
interferes with fungal RNA CrCl  40 => dose adjustment and hepatic status
and protein synthesis
- SHOULD NOT be use alone ADRs:
=> combination with - Myelosuppression
amphotericin B for treatment - Increase SCr, BUN, bilirubin
of invasive cryptococcal - Liver injury
(meningitis)

AZOLE ANTIFUNGALS - Decrease ergosterol synthesis - Class effects: - Drug-specific concerns

- IV administration  Increase LFT  Fluconazole: only azole
 IV:PO = 1:1  QT prolongation requires renal dose
 Drugs with sulfobutyl ether  DDI adjustment
beta-cyclodextrin  Ketoconazole:
(SBECD) vehicle: hepatotoxicity
voriconazole, posaconazole  Itraconazole: HF
 Voriconazole: visual
changes, phototoxicity
 Posaconazole:
Tablet dose  suspension dose
Take with food

DRUG DOSING NOTES

Fluconazole (Diflucan) 50 – 800 mg PO/IV QD Boxed warning:
=> active against: C.albicans,  Itraconazole: HF, increase plasma
C.parapsilosis, C.tropicalis Vaginal candidiasis: 150 mg PO x 1 concentration, QT prolongation,
=> limit efficacy against: C.qlabrata ventricular tachyarrhythmias
=> fluconazole-resistant: C.krusei CrCl  50 => decrease dose by 50%  Ketoconazole: hepatotoxicity, QT
prolongation, use PO tab only other
*Indication: nail bed infection unavailable/not tolerated
(onychinycosis), thrush/candidiasis Warnings:
Itraconazole (Sporanox, Tolsura) 200 mg PO QD or BID - Hepatotoxicity
=> formulations have different - Fluconazole: not recommended in
bioavailability and NOT interchangeable Tolsura: 130 mg PO QD or BID pregnancy, exfoliative skin disorders
=> oral solution better absorption
*Solution is taken on empty stomach *Indication: dimorphic fungi ADRs: Increase LFT, QT prolongation
*Capsules are taken with food (Blastomycoses and Histoplasma), nail
bed infection *Fluconazole and voriconazole penetrate
CNS => treat fungal meningitis
Ketoconazole 200 – 400 mg PO QD
=> Topical form: Nizoral A-D DDI: antacids => separate 2 hr before
and after dose

Voriconazole (Vfend, Vfend IV) Loading dose: CI:

6 mg/kg IV Q12H x 2 doses - Coadministration with barbiturates
(long-acting), carbamazepine, efavirenz
Maintenance dose: ( 400 mg/d), ergot alkaloids, pimozide,
4 mg/kg IV Q12H or 200 mg PO Q12H quinidine, rifabutin, rifampin, ritonavir
( 800 mg/d), sirolimus, St.John’s wort
Mild-moderate hepatic impairment
=> reduce maintenance dose by 50% Warning: hepatotoxicity, visual
disturbances (optic neuritis),
CrCl < 50 => SBECD accumulate => PO phototoxicity, QT prolongation
preferred
ADRs: visual changes, increase
Monitor SCr if IV is used LFT/SCr, CNS toxicity

*Therapeutic range (trough): 1-5 *Vfend: taken on empty stomach

mcg/mL *Caution when driving at night
*Avoid direct sunlight

Posaconazole (Noxafil) Suspension: 200 mg TID or 400 mg BID CI:

*Give with full meal (during or within - Coadministration with sirolimus, ergot
20min) alkaloids, pimozide, quinidine,
 atorvastatin, lovastatin, simvastatin
Tablet: 300 mg PO BID on day 1, then
300 mg PO QD with food (range from Warning: QT prolongation
100-400 mg/d, divided in 1-3 doses)
ADRS: N/V/D, fever, rash, increase LFT,
IV: 300 mg BID on day 1, then 300 mg decrease K/Mg
QD
Monitoring: LFT, renal function,
eGFR < 50 => SBECD =>PO preferred electrolytes

DDI: PPIs, cimetidine decrease

absorption => stop

Isavuconazonium sulfate (Cresemba) IV/PO: 372 mg Q8H for 6 doses, then CI:
=> prodrug of isavuconazole 372 mg QD - Use with CYP 3A4 inhibitors/inducers
=> shorten QT
No renal dose adjustment, caution with
hepatic impairment Warning: hepatotoxicity, infusion-
related rx, hypersensitivity rx
Swallow capsule whole, not crush/open
ADRs: N/V/D, HA, injection site rx,
peripheral edema, decrease K, increase
LFT

Monitoring: electrolytes, LFT

*Requires filter

ECHINOCANDINS - Inhibit synthesis of beta (1,3)-D-glucan => inhibit synthesis of fungal cell wall
- Effective against most Candida species, including C.glabrata, C.krusei
- Only injection
 DRUG DOSING NOTES
Caspofungi (Cancidas) 70 mg IV on day 1, then 50 mg IV QD Warning: histamine-mediated symptoms

Moderate hepatic impairment: 70 mg ADRs: increase LFT, HA, hypotension,

IV on day 1, then 35 mg IV QD SJS/TEN, increase/decrease K, decrease
Mg, fever, N/V/D
Increase dose to 70 mg IV QD when used
in combination with rifampin or other Monitoring: LFTs
strong enzyme inducers
*All given once daily, not require renal
Micafungin (Mycamine) Candidemia: 100 mg IV QD dose adjustment
*Few DDI
Esophageal candidiasis: 150 mg IV QD *Micafungin: require light-protection
during administration
Anidulafungin (Eraxis) Candidemia: 200 mg IV on day 1, then
100 mg IV QD

Esophageal candidiasis: 100 mg IV on

day 1, then 50 mg D

OTHER ANTIFUNGAL AGENTS

DRUG DOSING NOTES

Nystatin Oral candida ADRs: N/V/D, stomach pain
=> suspension: mild, localized Candida Suspension: 400,000 – 600,000 units
infection (thrush) QID x 7-14d *Suspension: swish in mouth and retain
for as long as possible (several minutes)
Intestinal infection before swallowing
Oral tab: 500,000 – 1,000,000 units Q8H

Griseofulvin Microsize: 500 – 1000 mg/d in 1-2 CI: pregnancy

=> Indication: skin, hair, nails divided dose
=> less effective than systemic drugs and ADRs: photosensitivity, increase LFTs
require prolonged course Ultramicrosize: 375 – 650 mg/d in 1-2
divided dose *Take with fatty meal or with food/milk

Duration of therapy: DDI: hormonal contraceptives

+ Tinea corporis: 2-4 weeks
+ Tinea pedis: 4-8 weeks

Terbinafine 250 mg/d in 1-2 divided dose without CI: liver disease
=> topical: Lamisil AT regard to meals
Warning: hepatotoxicity

ADRs: HA, increase LFT

Clotrimazole Oropharyngeal candidiasis ADRs: increase LFT, nausea, dysgeusia

=> 10 mg troche/lozenge Prophylaxis: 10 mg TID
=> mild, localized Candida infection Treatment: 10 mg 5x/d x 7-14d *Allow troche to dissolve slowly over
(thrush) 15-30min

Miconazole Oropharyngeal candidiasis CI: hypersensitivity to milk protein

=> buccal (Oravig): mild, localized 50 mg (1 tab) applied to the upper gum concentrate
Candida infection (thrush) region daily for 7-14d
ADRs: local application site rx

Oteseconazole (Vivjoa) 600 mg x 1 on day 1, then 450 mg x 1 on CI: pregnancy, breastfeeding, eGFR < 30
=> Indication: recurrent vulvovaginal day 2
candidiasis ADRs: nausea, HA, menstrual bleeding,
Starting on day 14: 150 mg once weekly vulvovaginal irritation/pain
x 11 weeks

EMPIRIC TREATMENT FOR SELECT FUNGAL PATHOGENS/INFECTIONS

PATHOGENS PREFERRED REGIMEN ALTERNATIVE REGIMEN
Candida albicans Mild: topical antifungals (clotrimazole, Nystatin
=> Oropharyngeal infection (thrush) miconazole)

Moderate-severe or HIV+ : fluconazole

Candida albicans Fluconazole Echinocandin

=> Esophageal infection

Candida krusei and glabrata Echinocandin Amphotericin B, high-dose fluconazole

=> All Candida species bloodstream (susceptible isolates only)
infection

Aspergillus Voriconazole Amphotericin B, isavuconazonium

=> Invasive

Cryptococcus neoformans Amphotericin B + Flucytosine (5-FC) High-dose fluconazole + flucytosine (5-

=> Meningitis FC)

Dermatophytes Terbinafine or itraconazole (confirm Fluconazole

=> Nail bed infection fungal infection prior to treatment)

Viral Infections
Influenza - Influenza A and B
- Sx: fever, chills, fatigue, myalgia
- Vaccine: all pts age  6 months

DRUG DOSING NOTES

Neuraminidase Inhibitors => inhibit enzyme which enables release new viral particles from infected cells, decrease sx by 1 day
and reduce complications
*Start within 48 hours of illness
Oseltamivir (Tamiflu) Treatment, age > 12 yrs Warning: neuropsychiatric events
=> capsule, suspension 75 mg BID x 5d
ADRs: HA, N/V
 Prophylaxis, age > 12 yrs
75 mg QD x 10d *Preferred in pregnancy
*Suspension: room temp for 10d,
CrCl  60: dose adjustment refrigerator for 17d

Pediatric: dose based on BW

Zanamivir (Relenza Diskhaler) Treatment, age  7 yrs Warning: bronchospasm (NOT use in
10 mg (two 5 mg inhalation) BID x 5d asthma/COPD)

Prophylaxis, age  5 yrs ADRs: HA, throat pain, cough

10 mg (two 5 mg inhalation) QD x 10d
(household setting) or 28d (community
outbreak)

Peramivir (Rapivab) Treatment (adult) Warning: neuropsychiatric events,

=> injection 600 mg IV x 1 SJS/TEN, anaphylaxis

CrCl < 50: dose adjustment ADRs: HTN, insomnia, increase BG,
D/C
Endonuclease Inhibitors => post-exposure prevention of influenza
*Single-dose regimen
*Start within 48 hours of sx onset
Baloxavir marboxil (Xofluza) Treatment and prophylaxis, age  5 Warning: hypersensitivity
=> capsule, suspension yrs
 80 kg: 80 mg PO x 1 ADRs: diarrhea
20 to < 80 kg: 40 mg PO x 1
< 20 kg: 2 mg/kg PO x 1 *AVOID administration with dairy
products, antacids, supplements
containing polyvalent cations

COVID-19 - Remdesivir (Veklury), nirmatrelvir/ritonavir (Paxlovid), tocilizumab

 - Systemic steroids can be added to antiviral and/or immunomodulator treatment in hospitalized
pts who require supplemental oxygen

Herpes Viruses - VZV = varicella zoster virus

- HSV-1 commonly associated with oropharyngeal disease
- HSV-2 closely associated with genital disease
Antiviral for HSV and VZV

DRUG NOTES
Acyclovir (Zovirax) Warning: caution in renal impairment, elderly, nephrotoxic
Valacyclovir (Valtrex) drug
=> prodrug of acyclovir
Famciclovir ADRs: malaise, HA, N/V/D, increase SCr/BUN with crystal
=> prodrug of penciclovir nephropathy, anaphylaxis

*Acyclovir dose is based on IBW, including obese pts

* 5 mg/kg IV acyclovir = 1,000 mg PO valacyclovir

Herpes Simplex Labialis (Cold - Preceded by prodrome (sx occurs before lesions appear) of tingling, itching, soreness.
Sores) - OTC/Rx topicals => shorten duration by up to 1 d
- PO antivirals shorten duration up to 2 d

Topical treatment
DRUG DOSING NOTES
Docosamol (Abreva) => OTC Apply 5x/d at first sign of outbreak Systemic antivirals more effective
Acyclovir (Zovirax) => cream Apply 5x/d for 4d (can be used on genital
sores)
Acyclovir (Sitavig) => buccal tab Apply 50 mg tab x 1 to upper gum region
Penciclovir (Denavir) Apply Q2H during walking hours for 4d

Systemic (PO) treatment

EPISODE Acyclovir Valacyclovir Famiciclovir
 Initial (treat for 7-10d) 200 mg 5x/d or 400 mg TID 1 g BID 250 mg TID or 500 mg BID
Recurrence 400 mg TID x 5-10d 2 g BID x 1 day 1.5 g x 1
Chronic suppression 400 mg BID 500 mg or 1 g QD

Genital Herpes - Caused by HSV-2, lesions begin as papules/vesicles that rapidly spread
- Tx must be initiated within 1 day of lesion onset

EPISODE Acyclovir (Zovirax) Valacyclovir (Valtrex) Famciclovir

Initial (7-10d) 400 mg TID or 200 mg 5x/d 1 g BID 250 mg TID

Recurrence 400 mg TID x 5d or 500 mg BID x 3d or 125 mg BID x 5d or

800 mg BID x 5d or 1 g QD x 5d 500 mg x 1, then 250 mg BID
800 mg TID x 2d x 2d or
1 g BID x 1 day

Chronic suppression 400 mg BID 500 mg or 1 g QD 250 mg BID

VZZV (chickenpox) and - Chickenpox: childhood

Herpes Zoster - Herpes Zoster/Shingles: recurrence
- Antiviral therapy: within 72hrs of onset
- Pain: topical meds (Lidoderm patch, lidocaine gel), neuropathic pain med (pregabalin,
gabapentin, duloxetine, TCA), NSAIDs, opioids
- Shingrix vaccine:  50 yrs, 19yrs, immunosuppressed

DRUG DOSING NOTES

Acyclovir (Zovirax) 800 mg PO x5/d for 7d (or 10d) Cluster of fluid-filled blisters, often in
band
Valacyclovir (Valtrex) 1 g PO TID for 7d

Famciclovir 500 mg PO TID for 7d

Cytomegalovirus (CMV)

DRUG DOSING NOTES

Ganciclovir Tx: 5 mg/kg IV BID x 14-21d Boxed Warning: myelosuppression

Maintenance/Prophylaxis: ADRs:
5 mg/kg IV QD - Fever, N/V/D, anorexia, neutropenia,
leukopenia, anemia
CrCl < 70: Decrease dose and extend
interval *Female should use contraception during
tx and for 30d after
Valganciclovir (Valcyte) Tx: 900 mg PO BID x 21d *Male should use barrier contraception
for 90d after
Maintenance/Prophylaxis:
900 mg PO QD IV ganciclovir 5mg/kg = PO
valganciclovir 900mg
CrCl < 60: Decrease does and extend
interval

Cidofovir 5 mg/kg/week IV x 2w, then 5 mg/kg Boxed warning: nephrotoxicity,

=> CMV retinitis in HIV only once Q2w neutropenia, carcinogenic/teratogenic

CI: Scr > 1.5, CrCl  55, urine protein 

100, sulfa allergy

ADRs: nephrotoxicity, myelosuppression

*Hydration before each dose, probenecid

before and after each dose

Foscarnet Induction: Boxed warning: renal impairment

=> CMV retinitis, resistant HSV 90 mg/kg IV Q12H or
 60 mg/kg Q8H x 2-3 week ADRs: electrolytes abnormalities, QT
prolongation, increase SCr/BUN
Maintenance: 90-120 mg/kg IV QD
*NOT exceed max infusion rate

Opportunistic Infections
- Occurs when immune system - Immunocompromised states:
unable to respond normally to  HIV with CD4 < 200
bacteria, fungi, viruses,  Use of systemic steroids for 14d or longer at prednisone dose  20 mg/d or  2 mg/kg/d
protozoa  Asplenia
 Use of immunosuppressants
 Use of cancer chemotherapy with severe neutropenia (ANC < 500)
Primary phrophylaxis - Sulfa allergy: atovaquone, dapsone, pentamidine
- G6PD deficiency: atovaquone, pentamidine
- Rescue therapy: leucovorin is added to pyrimethamine containing regime
=> reduce risk of pyrimethamine-induced myelosuppression

OIs CRITERIA FOR STARTING REGIMEN CRITERIA FOR DC

Pneumocystis jirovecii CD4 < 200 Preferred CD4 > 200 for 3 mths on ART
pneumonia (PJP/PCP) AIDS SMX/TMP DS or SS daily

Alternatives
 SMX/TMP DS 3x/week
 Dapsone
 Dapsone + pyrimethamine +
leucovorin
 Atovaquone
 Atovaquone + pyrimethamine
+ leucovorin
 Inhaled pentamine
 Toxoplasma gondii Toxoplasma IgG + Preferred CD4 > 200 for 3 mths
encephalitis CD4 < 100 SMX/TMP DS QD

Alternatives
 SMX/TMP DS 3x/week or SS
daily
 Dapsone + pyrimethamine +
leucovorin
 Atovaquone
 Atovaquone + pyrimethamine
+ leucovorin

Mycobacterium avium Not taking ART Preferred Taking fully suppressive ART
complex (MAC) CD4 < 50 Azithromycin 1,200 mg weekly

Alternatives
 Azithromycin 600 mg twice
weekly
 Clarithromycin 500 mg BID

Tx of OIs - After completing initial tx, secondary prophylaxis is given to prevent recurrence of infection
- Thrush => systemic tx

OIs PREFERRED REGIMEN ALTERNATIVE REGIMEN SECONDARY

PROPHYLAXIS
Candidiasis (thrush) Fluconazole Oropharyngeal: itraconazole, NOT recommended
=> oropharyngeal/esophageal Posaconazole, topicals
*white film in mouth/throat (clotrimazole troche,nystatin)

Esophageal: voriconazole,
isavuconazonium,
 echinocandin (caspofungin)

Cryptococcal meningitis Amphotericin B (deoxycholate  Fluconazole + flucytosine Fluconazole (low dose)

or liposomal) + flucytosine  Amphotericin B +
fluconazole

CMV Valganciclovir or If toxicities to ganciclovir or Maintain CD4 > 100

Ganciclovir resistant strains
=> foscarnet or cidofovir

MAC (Clarithromycin or Add 3rd/4th agent using Same as tx

Azithromycin) + ethambutol rifabutin, amikacin,
streptomycin, moxifloxacin,
levofloxacin

PJP/PCP SMX/TMP   Atovaquone Same as primary prophylaxis

prednisone/methylprednisolone  Pentamidine IV
 Clindamycin +
Duration 21d primaquine
 Dapsone + trimethoprim

Toxoplasmosis gondii Pyrimethamine + leucovorin +  SMX/TMP Same as tx (reduced dose)

enxephalitis sulfadiazine  Clindamycin +
*risk: exposure to pyrimethamine +
undercook/raw meat, car leucovorin
feces/litter  Atovaquone
 Atovaquone +
sulfadiazine
 Atovaquone +
pyrimethamine +
leucovorin
HIV

Stage and description Drugs

Stage 1: Binding/Attachment  CCR5 antagonist: maraviroc
HIV attaches to CD4 receptor/CCR5/CXCR4 on surface of  Attachment inhibitor: fostemsavir
CD4 host cells  Post-attachment inhibitor: ibalizumab-uiyk

Stage 2: Fusion  Fusion inhibitors: enfuvirtide

HIV viral envelope fuses with CD4 cell membrane
-> HIV enter host cell and release HIV RNA, viral proteins,
enzymes

Stage 3: Reverse Transcription  Nucleoside reverse transcriptase inhibitor (NRTIs):

HIV RNA is converted to HIV DNA emtricitabine, tenofovir
-> enter CD4 nucleus  Non-nucleoside reverse transcriptase inhibitors
(NNRTIs): efavirenz, rilpivirine

Stage 4: Integration  Integrase strand transfer inhibitors (INSTIs): bictegravir,

Once inside CD4 cell nucleus, integrase is released and used to dolutegravir, raltegravir
insert HIV DNA into host cell DNA

Stage 5: Replication NONE

Host cell transcribe and translate HIV DNA into HIV RNA and
long-chain protein

Stage 6: Assembly NONE

New HIV RNA, proteins, enzymes move to cell surface and
assemble into immature HIV

Stage 7: Budding and Maturation  Protease inhibitor (PIs): atazanavir, darunavir

Immature HIV pushes out of CD4 cell and protease break up
 long viral protein chains
=> create mature virus that can infect other cell

AIDS is diagnosed when - CD4 indicator of immune - HBV/HCV - HLA-B*5701 allele

CD4 < 200 function => need for OIs - Pregnancy (abacavir)
prophylaxis - Tropism assay (maraviroc)
- HIV viral load indicator of
response to ART
ART Preferred regimen: Triumeq CrCl < 30 => NOT USE
2 NRTIs + 1 INSTIs  Dolutegravir/abacavir/lamivudine  Biktarvy
 NRTI back bone:  Test for HLA-B*5701 allele  Triumeq
 Emtricitabine/tenofovir before using  Dovato
disoproxil fumarate  Truvadda
(Truvada)  Descovy
 Emtricitabine/tenofovir
alafenamide (Descovy)

Dovato (1 NRTI + 1 INSTI)

 Dolutegravir/lamivudine
 NOT use in treatment-naïve
if HIV RNA > 500,000

One-pill, Once daily (Single tablet regimen)

Biktarvy Bictegravir/Emtricitabine/Tenofovir alafenamide
Triumeq Dolutegravir/Abacavir/Lamivudine
Dovato Dolutegravir/Lamivudine
Two-pills (Once daily for most)
Tivicay + Truvada Dolutegravir + Emtricitabine/Tenofovir disoproxil fumarate
Tivicay + Descovy Dolutegravir + Emtricitabine/Tenofovir alafenamide

Alternative ART regimens

 - A complete HIV ART regimen has 1 “base” + 2 NRTIs to serve as “backbone”
PI-based (boosted with cobicistat  Darunavir
or ritonavir)  Atazanavir
NNRTI-based  Efavirenz
 Rilpivirine
INSTI-based  Elvitegravir (only available in combination products)
 Raltegravir
NRTI backbone (2 drugs, 1 from  TDF or TAF or abacavir PLUS
each row)  Emtricitabine or lamivudine
Complete regimen example  Rilpivirine + TDF + emtricitabine
 Raltegravir + TAF + emtricitabine

NRTIs - All:
Warning => lactic acidosis, hepatomegaly with steatosis (fatty liver)
Boxed warning => didanosine, stavudine, zidovudine
ADRs: N/D, HA, increase LFTs
- HIV and HBV coinfection Boxed warnings
 Emtricitabine, lamivudine, tenofovir-containing product: Severe acute HBV exacerbation can
occur
 NOT use Epivir-HBV for tx of HIV

Abacavir (Ziagen) Once daily No dose adjustment if renal Boxed warning: risk for
Twice daily impairment hypersensitivity rx
 HLA-B*5701 positive
 Never re-challenge

Consider avoiding with

CVD due to potential
increase risk of MI

Emtricitabine (Emtriva) Decrease dose if renal impairment Hyperpigmentation of

palms of hands or soles of
 feet

Lamivudine (Epivir) Once daily

Twice daily

Tenofovir disoproxil Once daily  Renal impairment

fumarate, TDF (Viread)  Avoid nephrotoxic drugs
PO powder: mix with 2-4 oz of  Decrease bone mineral
solf food to avoid bitter taste, density: consider
contains lactose calcium/vit D
supplementation and
Tenofovir alafenamide, Once daily DEXA scan
TAF  Monitor lipids if
=> Only in combination switching from TDF to
for HIV TAF
*Vemlidy: single-entity  TAF higher risk
product for HBV of lipid
abnormalities

*TDF higher risk

Zidovudine (Retrovir) Twice daily  Hematologic toxicity:
neutropenia and anemia
Administrate IV during labor  Myopathy
and delivery (protect baby) in pt
with unknown HIV RNA level
or HIV RNA > 1,000

INSTIs - All: HA, insomnia, diarrhea, weight gain

- DDI: polyvalent cations
=> Take INSTI 2 hrs before or 6 hrs after: aluminum, calcium, magnesium and iron-containing
products

Bictegravir Once daily CrCl < 30  Increase SCr with no

=> only in combination: => NOT start effect on GFR
Biktarvy
Can take with oral calcium or iron if
also take with food

Dolutegravir (Tivixay) Once daily Preferred for tx of HIV during  Increase SCr with no
pregnancy effect on GFR
*those with INSTI resistance or  Increase CPK,
those taking UGT1A1/CYP3A4 Can take with oral calcium or iron if myopathy,
inhibitor also take with food rhabdomyolysis
=> twice daily  HSR: rash, fever,
allergic rx
 Hepatotoxicity (if
coninfection with
HBV/HCV)

Elvitegravir Once daily CrCl < 70

=> only in combination: => NOT start Stribild
Genvoya, Stribild
CrCl < 50
=> DC Stribild

CrCl < 30
=> NOT start Genvoya

Raltegravir (Isentress) Isentress HD: Once daily Dose separations may not be  Increase CPK,
effective myopathy,
*Isentress: those with INSTI => avoid cations if possible rhabdomyolysis
resistance or those taking  HSR: rash, fever,
UGT1A1/CYP3A4 inhibitor allergic rx
=> twice daily

Cabotegravir (Vocabria, PO: indicated only for lead-in  IM: Injection site
Apretude) treatment to assess tolerability reaction
prior to initiation of
cabotegravir/rilpivirine
(Cabenuva) injection

IM: Apretude indicated for pre-

exposure prophylaxis (PrEP)

NNRTIs - Used in alternative ART regimen (not 1st-line in most pts): 1 NNRTI + 2 NRTIs
- All: hepatotoxicity, rash/severe rash (SJS/TEN) => highest risk with nevirapine

Efavirenz (Sustiva) Take on empty stomach QHS CYP3A4 inducers => many DDI  Psychiatric sx
(depression, suicidal
thoughts)
 CNS effects, resolve in
2-4 weeks
 Increase total
cholesterol, TG

Rilpivirine (Edurant) Take with meal (not substitute CYP3A4 substrates  Depression
with protein drink) => NOT use with strong CYP3A4  Increase SCr with no
inducers (phenytoin, rifampin, effect GFR
rifapentine, carbamazepine,  Not use if viral load >
oxcarbazepine, phenobarbital, 100,000 and/or CD4 <
St.John’s wort) 200
Acid-suppressants
=> NOT use with PPIs
=> Separate H2RA: take H2RA at
least 12 hrs before or 4 hrs after
=> Separate antacids: take antacids
at least 2 hrs before or 4 hrs after

Doravirine (Pifeltro)
Etravirine (Intelence) CYP3A4 inducers => many DDI

Nevirapine
PIs - All:
 Take with a booster (ritonavir or cobicistat)
 No renal dose adjustment
 Take with food to decrease GI upset
(except: fosamprenavir oral solution, lopinavir/ritonavir tab)
- Metabolic abnormalities: hyperglycemia/insulin resistance, dyslipidemia, increase body fat and
lipodystrophy
- Increase CVD risk
- Hepatic dysfunction: increase LFTs, hepatitis
- Hypersensitivity rx: rash, angioedema, bronchospasm, anaphylaxis
- ADRs: N/D
- DDI:
 Alfuzosin
 Colchicine
 Dronedarone
 Lovastatin, simvastatin
 CYP3A4 inducers (phenytoin, rifampin, rifapentine, carbamazepine, oxcarbazepine,
phenobarbital, St.John’s wort)
 Anticoagulants/antiplatelets: apixaban, edoxaban, rivaroxaban, ticagrelor
 Direct-acting antivirals for HCV
 Hormonal contraceptives
 Steroids
Atazanvir (Reyataz) Need acidic gut for absorption Hyperbilirubinemia: reversible, not  Antacid: take atazanvir
require DC 2 hrs before or 1 hrs
after
 H2RA: avoid or take
atazanvir 2 hrs before or
10 hrs after
 PPIs: avoid with
unboosted atazanavir
 => take boosed atazanavir
at least 12 hrs after

Darunavir (Prezista) Caution with sulfa allergy

Fosamprenavir (Lexiva) Caution with sulfa allergy

Lopinavir/ritonavir Ritonavir: only used for Oral solution contains 42% alcohol:
(Kaletra) pharmacokinetic boosting cause a disulfiram reaction if take
with metronidazole

Tipranavir (Aptivus) Caution with sulfa allergy Intracranial hemorrhage

Pharmacokinetic boosters - CI with:

(Enhancers)  Alfuzosin, tamsulosin
 Colchicine
 Lovastatin, simvastatin
 Azole antifungals
 Cardiovascular drugs: amiodarone (ritonavir only), dronedarone, eplererone, ivabradine,
ranolazine
 PDE-5i used for pulmonary hypertension: tadalafil, sildenafil
 Tyrosine kinase inhibitor (nibs)
 CYP3A4 inducers: carbamazepine, phenytoin, phenobarbital, rifampin, St.John’s wort
Ritonavir (Norvir) Difficult to co-formulate 100 – 400 mg PO QD (in 1-2 divided Booster dosing is lower
=> used as single entity product dose) with food than tx dosing

Oral solution contains 43% alcohol: Not interchangeable

can cause disulfiram rx if taken with
metronidazole

Cobicistat (Tybost) Can be co-formulated 150 mg PO QD with boosted drug

=> combination and with food
 Increase SCr with no effect on GFR

Entry and Attachment inhibitors

CCR5 antagonist Maraviroc (Selzentry) Safety issue: Baseline test required:
Hepatotoxicity, hypersensitivity rx, Must have tropism result
Tablet, solution CV events, orthostatic hypotension before starting

CI with CrCl < 30 and potent If HIV stain bind to CXCR4

CYP3A4 inhibitors/inducers or mixed CXCR4/CCR5
coreceptor => not work

Attachment inhibitors Fostemsavir (Rukobia) Safety issue: Notes:

NOT use with CYP3A4 inducers Indicated in combination
Tablet with other ART in heavily
Must maintain effective HBV tx in treatment-experienced pt
coinfected pts with HBV who are failing current
therapy
Increase SCr

Post-Attachment inhibitors Ibalizumab-uiyk (Trogarzo) Safety issue: Notes:

Infusion-related reaction Refrigerate unused vials
Injection IV N/D
Dizziness, rash Administrate immediately
after dilution

Indicated in combination
with other ART in heavily
treatment-experienced pt
who are failing current
therapy

Fusion inhibitors Enfuvirtide (Fuzeon) Safety issue: Notes:

Risk of bacterial pneumonia, Stored unused at room temp
 Powder for injection SC hypersensitivity rx
Once reconstituted,
Injection site sx refrigerate and use within
24hrs

Combination ART products

Complete regimen
=> 1 tab once daily GENERIC BRAND NOTES
INSTI-based
Bictegravir/emtricitabine/TAF Biktarvy 1st-line

CrCl < 30: NOT start TAF-

containing product

Cabotegravir/rilpivirine Cabenuva IM once monthly

Replace current stable ART

regimen in pts with
virologic suppression

Dolutegravir/abacavir/lamivudine Triumeq 1st-line

Dolutegravir/lamivudine Dovato 1st-line

Replace current stable ART
regimen in pts with
virologic suppression

Dolutegravir/rilpivirine Juluca Replace current stable ART

regimen in pts with
virologic suppression

Elvitegravir/cobicistat/emtricitabine/TDF Stribild Take with food

 CrCl < 70: NOT start TDF-
containing product

Elvitegravir/cobicistat/emtricitabine/TAF Genvoya Take with food

CrCl < 30: NOT start TAF-

containing product

NNRTI-based
Doravirine/lamivudine/TDF Delstrigo CrCl < 50: NOT start TDF-
containing product

Efavirenz/emtricitabine/TDF Atripla Taken on empty stomach

CrCl < 50: NOT start TDF-

containing product

Efavirenz/lamivudine/TDF Symfi, Symfi Lo Taken on empty stomach

CrCl < 50: NOT start TDF-

containing product

Rilpivirine/emtricitabine/TDF Complera Take with food

CrCl < 50: NOT start TDF-

containing product

Rilpivirine/emtricitabine/TAF Odefsey Take with food

CrCl < 30: NOT start TAF-

containing product
 PI-based
Darunavir/cobicistat/emtricitabine/TAF Symtuza Take with food

CrCl < 30: NOT start

Must be used with

additional ART to make GENERIC BRAND NOTES
complete regime NRTI combination (1 tab daily)
Abacavir/lamivudine Epzicom Require baseline testing
for HLA-B*5701
Abacavir/lamivudine/zidovudine Trizivir Require baseline testing
for HLA-B*5701

Twice daily
Emtricitabine/TAF Descovy 1st-line

CrCl < 30: NOT use

Emtricitabine/TDF Truvada 1st-line

CrCl < 30: NOT use

CrCl < 60 and PrEP: NOT

use

Lamivudine/zidovudine Combivir Twice daily

Lamivudine/TDF Cimduo CrCl < 50: NOT use

PI combination (1 tab daily)

Atazanavir/cobicistat Evotaz Take cobicistat-containing
Darunavir/cobicistat Prezcobix product with food
Recommendation for treatment-naïve pregnant pts
- Already taking effective ART regimen => continue
- Not take => start asap
- 2 NRTIs + INSTI (dolutegravir preferred) / boosted PI (darunavir preferred)

HIV prevention strategies

Pre-exposure prophylaxis Tx options: Before starting PrEP PrEP follow-up visit
(PrEP) PO regimen, taken daily, no - Confirm HIV negative - Test for HIV negative
more than 90-d supply - Confirm CrCl  60 (if using  Truvada/Descovy:
 Truvada Truvada), CrCl  30 (if using Q3mths
 Descovy Descovy)  Cabotegravir: 1 month
- Screen for HBV and STIs after 1st injection, then
IM cabotegravir (Apretude) Q2mths
 Monthly for 2 doses, then
Q2mth

Post-exposure prophylaxis Nonoccupational (nPEP) Occupational (oPEP) Both

(PEP) - Can be used after sex without - Needlestick - Treatment: within 72hrs
condom of exposure and continue
- Injection drug use for 28d
 Truvada (if CrCl  60)
+
 Dolutegravir (Tivicay)
or Raltegravir
(Isenstress)

- Received baseline HIV Ab

test and follow-up test at 4-
6 weeks, 3 months, 6
months after exposure