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Glossary of Antibiotic Pharmacology

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Which ABX inhibit or disrupt cell wall production?
Beta-lactams
monobactams
Glycopeptides
Which drugs are considered beta-lactams?
Penicillins, cephalosporins, and carbapenems
What drug is a glycopeptide?
Vancomycin
Which drugs inhibit protein synthesis by interfering with bacterial ribosomes?
Macrolides
Ketolides
Clindamycin
Aminogylycosides
Tetracycline
Which drugs inhibit DNA synthesis?
Fluoroquinolones
Metronidazole
Which drug inhibits folic acid synthesis?
TMP-SMX
When are bacteriocidal agents prefered over static?
1) host is compromised (e.g. neutropenic)
2) host defenses do not operate well in that area (e.g. endocarditis, meningitis)
3) critical condition
Which ABX are generally considered bacteriocidal?
Beta lactams
glycopeptides (vanco)
Aminoglycosides
Fluoroquinolones
Metronidazole
Cyclic lipopeptides
Which ABX are generally considered bacteriostatic?
Sulfonamides (TMP-SMX?)
Tetracyclines
Macrolides
Ketolides
Lincosamides
3 examples of concentration-dependent ABX.
Aminoglycosides
Fluoroquinolones
Cyclic lipopeptides
3 examples of Time-Dependent ABX.
Beta lactams
Monobactams
Vancomycin
Which drugs will inc -cidal effects when you increase the dosage? C-D or T-D?
Concentration Dependent
Which drugs have post ABX effect?
Aminoglycosides
Fluoroquinolones
Cyclic lipopeptides (daptomycin)
Which ABX are active against Intracellular Organisms?
Tetracyclines
TMP-SMX
Fluoroquinolones
Macrolides/Ketolides
Clindamycin
Rifampin
Which organisms are intracellular?
Chlamydia pneumoniae
Legionella pneumophila
Mycobacteria (TB and others)
Rickettsia
Erlichiae
Which ABX achieve equivalent levels PO and IV?
Fluoroquinolones
Rifampin
TMP-SMX
Tetracyclines
Metronidazole
Linezolid
Which ABX undergo renal excretion?
Beta lactams (except two)
Fluoroquinolones (split)
Tetracyclines (split)
Vanco
Aminoglycosides
Which Beta lactams are not excreted by the kidney? (2)
Ceftriaxone
Nafcillin
Which ABX are excreted hepatically?
Ceftriaxone
Nafcillin
Mainly:
Clindamycin
Metronidazole
Others:
Sulfamethoxazole
Macrolides/Ketolides
Rifampin
ABX associated with ototoxicity (3)
Aminoglycosides
Vancomycin
Azithromycin
Minocycline
Which ABX are associated with nephrotoxicity?
Amphotericin B
Aminoglycosides
Nafcillin
Tetracycline
Vancomycin (historically)
Which ABX is associated with ATN (acute proximal tubular necrosis)?
Aminoglycosides
Which ABX causes AIN (acute interstitial nephritis)?
Nafcillin
Which drug is associated w/Fanconi syndrome?
Tetracycline
What are the main ABX associated with psychiatric symptoms?
*Fluoroquinolones*(esp levo)
Clarithromycin
Isoniazid
Metronidazole
TMP-SMX
Which ABX are associated with chemical phlebitis?
Nafcillin
Cefepime
Vancomycin
Clindamycin
Which ABX is associated w/a disulfiram like rxn?
Metronidazole
What should you educate a patient about if you prescribe Metronidazole?
No ETOH for 3 days after they complete therapy
Associated with yellow babies
Sulfonamides
Which drugs are sulfonamides?
Trimethoprim
Sulfamethoxazole
(e.g. TMP-SMX)
What are sulfonamides often used to treat?
Urinary tract infections
What ABX are associated with gray babies?
Chloramphenicol
What is red man syndrome associated with?
Vancomycin
How can you decrease the chance of a person developing "red neck syndrome" from vancomycin?
Slow infusion
give diphenhydramine to tx
What drug is associated with Red Lobster syndrome? And what IS red lobster syndrome?
Rifampin --> red-orange discoloration or urine, tears, and sweat
What drug causes discolored teeth?
tetracyclines
What drugs may cause pt to lose red/green color perception?
Ethambutol
Amiodarone
What ABX may cause Hyperkalemia?
Trimethoprim (usually TMP-SMX)
What ABX may cause hypokalemia?
especially:
Nafcillin
Piperacillin
Associated with causing C. dif?
Aminopenicillins (amox, augmentin, ampicillin, amp/sulfabactam)
Cephalosporins
Clindamycin (classic)
Main drugs associated with rash when used in Infectious Mono?
Ampicillin
When else might a rash occur when taking ampicillin?
CLL
coadministration of allopurinol
What drugs does a true penicllin allergy apply to?
penicillins
cephalosporins
carbapenems
Can you use aztreonam (a monobactam) if pt had anaphylactic rxn to penicillin?
Yes - but no carbapenems
If pt had rash from penicillin what could you use?
possibly cephalosporins, carbapenems, if necessary
definitely aztreonam
What Oral ABX are effective against pseudomonas?
Ciprofloxacin
Levofloxacin
What oral ABX is gold standard to treat Methicillin susceptible Staph aureus?
Dicloxacillin
What IV ABX should be used for MSSA?
Nafcillin
What other IV drug can be used for MSSA if gold standard (naf) isn't used?
Cephazolin (2nd choice)
Vanco (3rd choice)
What oral drug should be used for MRSA?
**Linezolid
Minocycline/doxycycline
maybe TMP-SMX (not good choice)
What oral ABX work for MSSA but are not gold standard? (dicloxacillin)
cephalexin (2nd choice)
Minocycline/doxycycline >TMP/SMX
What oral ABX can be used if enterococcus is resistant to vanco?
linezolid
What are the 2 best anti-anaerobic oral ABX?
Metronidazole
Augmentin (amox/clav)
What is the silver standard to tx of anaerobic infxn w/oral ABX?
Clindamycin
If cephalexin is less active against MSSA than dicloxacillin then shy is it used often?
better absorbed, don't need emty stomach
What is the problem with using minocycline and TMP-SMX for MSSA?
They are static drugs while the first and second choice (dicloxacillin and cephalexin) are cidal
IV drugs for pseudomonas
piperacillin/tazobactam
aztreonam
ceftazidime
cefepime
cipro
levo
tobra
carbapenems (mero moreso than imipenem)
Top choices (in order) for IV drug against MSSA
#1) nafcillin
#2) cefazolin
#3) vancomycin
What is the gold standard parenteral ABX for anaerobes? (there are three)
beta-lactam/beta-lactamase inhibitor

Carbapenems

Metronidazole
What are the silver and bronze standard anti-anaerobes (IV form)
2nd choice - clindamycin
3rd choice - cefotetan, or cefoxitin
Are penicillins excreted by kidney or liver?
kidney
What is the difference between penicillin G and VK? what MO(s) do they cover?
VK is PO
G is IV
What is the difference between penicillin G and penicillin G benzathine?
benzathine is IM and long acting. . . also it covers treponema pallidum
When might penicillin V be used?
strep pharyngitis
Which penicillin is associated with Hoignes syndrome?
penicillin C procaine (IM)
What drugs are considered anti-staph penicillins?
Nafcillin
Dicloxacillin
Which anti-staph penicillin is PO?
dicloxacillin
What MOs do aminopenicillins cover?
s. pyogenes
s. aureus
Enterococci
B. burgorferi
P. multocida
Proteus
Listeria
SOME h.flu and e.coli
In what situations might you use an anti-staph penicillin?
cellulitis
staph aureus meningitis
endocarditis
What MOs are added by "augmenting" aminopenicillins?
h.flu and m.cat (even amox resistant strains)

most anaerobes

some e.coli and klebsiella

group B strep (agalactiae)
Name two augmented aminoPCNs
amoxicillin/clavulanate
ampicillin/sulfabactam
What drug is a Ureidopenicillin?
piperacillin = ureido
what organisms do augmented extended-spectrum penicillins cover that other penicillins do not?
Pseudomonas
Klebsiella
Enterobacter
Serratia
is piperacillin-tazobactam (extended-spectrum penicillin) IV or PO?
IV - only used in hospitals
Are cephalosporins excreted by the liver or kidney?
kidney
Name two 1st generation cephalosporins and whether they are IV or PO
Cefazolin (IV)

Cephalexin (PO)
What MOs do the 1st generation cephalosporins (like cefazolin and cefalexin) cover?
s. pyogenes
s. aureus
e. coli
klebsiella
proteus
what might a 1st generation cephalosporin be used for?
strep pharyngitis

bone infection

UTI?
Name a 2nd generation cephalosporin
Cefuroxime
What formulations is cefuroxime available in?
IV
PO
suspension
What are possible indications for the use of a second generation cephalosporin?
otitis, sinus infections, pneumonia
What is the big difference between first and second generation cephalosporins?
2nd generation get pneumococcus

- but also m. cat, h.flu, and pasteurella
Name 4 3rd generation cephalosporins
Ceftriaxone (IV) - rocephen
Ceftazidime (IV)
Cefpodoxime (PO)
Cefotaxime (IM/IV)
What would make you use Ceftazidime instead of Ceftriaxone (IV Rocephen)?
Ceftazidime covers resistant gram negatives like pseudomonas, enterobacter, and serratia but Ceftriaxone does not.
Name the only 4th generation cephalosporin we discussed
Cefepime (IV)
What is the difference between cefepime (4th gen) and 3rd generation cephalosporin?
Cefepime, like 3rd generation cephalosporins cover gram negatives, like ceftazidime it covers the "nasty" gram negatives (pseudomonas, enterobacter, serratia)

but. . . it ALSO has better staph aureus and s. pneumo coverage than 3rd generation cephalosporins
What drug class is aztreonam?
Monobactam
What should monobactams be used for?
Pseudomonas
other resistant gram neg. (enterobacter, serratia)
What are 3 Carbapenems?
Imipenem
Meropenem
Ertapenem
What MOs do carbapenems cover?
MDR Gram negatives

Extended spectrum beta lactase gram negatives
How are monobactams excreted?
renal excretion
How are carbapenems excreted?
renal excretion
Which carbapenem is available only IV, not IM?
Meropenem
What is the difference between ertapenem and the other two carbapemens (Imi and Mero)?
Ertapenem does not cover pseudomonas, Enterococci, or Acinetobacter
What ABX is a glycopeptide?

What formulations are avail?
Vancomycin

PO, IV, suspension
What should oral or suspension vanco be used for?
refractory c. dif
MOs covered by vancomycin
MSSA
MRSA
MRCNS
strep
enterococci (in PCN allergic pts)
clostridial species (perfringens and dif)
coagulase negative staph
What gram neg organisms does vanco cover?
none!

only G+ aerobes and anaerobes
Is vancomycin time-dependent or concentration-dependent?
time-dependent (measure troughs)
do tetracyclines have a long or short half life?
long
What decreases the absorption of tetracyclines?
Ca, Fe, Mg, Zn (di and trivalent cations)
What side effects of tetracycline is seen with minocycline in particular?
1) vestibular
2) purple/blue hyperpigmentation of skin
3) drug-induced lupus
What are the three tetracyclines?
doxycycline
tetracycline
minocycline (only PO)
What organisms are covered by tetracyclines?
strep pneumo
m cat
h flu
chlamydia
legionella
mycoplasma
rickettsia
erlichia
borrelia burdorferi
pasteurella
most staph aureus (+MRSA)
What might you prescribe a tetracycline for?
works just as well as azithromycin for otitis, sinusitis

can use for walking pneumonia, dog/cat bite, tick bite
Where are the macrolides metabolized?
liver
Which macrolide does not have P450 interactions?
azithromycin
Are macrolides static or cidal?
static
(interferes w/ribosome)
Why wouldn't a macrolide work well for a bacteremia from pneumonia?
high tissue levels but low serum levels
What unpleasant characteristic is associated with clarithromycin?
metallic taste
Rank the 3 macrolides in order of potency
clarithro > azithro > erythro
Which macrolide is only available PO?
clarithromycin (Biaxin)
What MOs are covered by macrolides
s. pneumo
h. flu
m. cat
chlamydia
legionella
mycoplasma
strep pyogenes
What drug is like a "supercharged biaxin"?

biaxin = clarithromycin
Ketolides
An example of a ketolide.
telithromycin
What is covered by ketolides but not by macrolides?
s. pneumo (even macrolide resistant)

h flu (drug unaffected by beta lactamase)

m cat (" ")

s. pyogenes (macrolide resistant)

**all the same MOs as macrolides
Which patients should not recieve a ketolide?
1. Class Ia or III antiarrhythmics

2. pts w/prolonged QT
How are aminoglycosides excreted?
kidney
Are aminoglycosides concentration or time dependent?
concentration
Adverse effects of aminoglycosides?
ototoxicity or vestibular damage

nephrotoxicity (ATN)

Neuromuscular blockade in myasthenia gravis pts
What are the two main examples of aminoglycosides and their formulations?
gentamycin (IV)

tobramycin (inhaled, IV)
What organisms are covered by Aminoglycosides?
aerobic gram negatives (proteus, e. coli, klebsiella, enterobacter, pseudomonas, serratia)
what anaerobic organisms are covered by aminoglycosides?
none!
Can aminoglycosides be used for gram positives?
Not most - except enterococcus

but. . . . must give in combination with PCN or ampicillin or vanco
Which aminoglycoside is most effective against pseudomonas? (gram neg aerobe)
tobramycin
Are fluoroquinolones cidal or static?
cidal
What is the similarity between fluoroquinolones and tetracyclines in terms of absorption?
multivalent cations decrease absorption
Adverse effects of fluoroquinolones
1. arthropathy
- CI if <18. . . except maybe cipro for complicated UTI or anthrax

2. CNS toxocity - watch kidney fcn

3. photosensitivity

4. QT prolongation

5. hypoglycemia
Hypoglycemia is most common with which fluoroquinolone?
gatifloxacin
What are the clinical uses of 1st generation quinolones?
none really
Name a 2nd generation fluoroquinolone
Ciprofloxacin (Cipro) - PO/IV
What organisms are covered by 2nd generation fluroquinolones?
gram negatives (e. coli, klebsiella, enterobacter, pseudomonas, proteus, serratia, gonorrhea, pasteurella, m. cat, h. flu)

B. anthracis
Name 3 3rd generation fluoroquinolones
levofloxacin (PO/susp/IV)

gatifloxacin (PO/IV)

moxifloxacin (PO/IV)
What is the difference between 2nd and 3rd generation fluoroquinolones in terms of coverage?
3rd offer great coverage of respiratory pathogens including atypicals (s. pneumo, s. pyogenes, legionella, mycoplasma, chlamydia)

Also - 3rd generation have significant anaerobic activity
Which fluoroquinolone would you choose to treat CAP?
levaquin, not cipro
What might you use ciprofloxacin to treat?
UTI, aspiration, perforation (diverticulosis, PUD), anthrax
Is TMP-SMX static or cidal?
static
How is TMP-SMX excreted?
kidney
What organisms does Bactrim cover?

Bactrim = TMP-SMX
s. pneumo
h. flu
m. cat
p. jiroveci
pasteurella
stenotrophomonas maltophila
e. coli
klebsiella
proteus
MRSA
Which patients cannot take TMP-SMX
sulfa allergy (have to use just trimethoprim)

G6PD deficiency (will cause hemolytic anemia)
What might you treat with TMP-SMX?
NOT outpatient CAP (despite pathogens covered) b/c resistance is too high

ok for ears and sinuses

PCP

UTIs (covers gram negs)
Which drug is a Lincosamide?
clindamycin
What organisms are covered by clinda?
anaerobes (best for above the diaphragm)

s. aureus and strep pyogenes in those with PCN allergies
Are lincosamides (clindamycin) cidal or static?
static
What is a major adverse effect of lincosamides?
diarrhea ( + C. dif colitis)
What categories of pathogens does clindamycin cover?
G + cocci
anaerobes

NOT gram negatives!
What is the difference between linezolid against staph, enterococci, and streptococci?
static against staph/entero

but cidal against strep
What category of drug is linezolid?
Oxazolidinone
2 side effects of linezolid?
reversible thrombocytopenia

reversible inhibition of MAO (watch dietary tyramine)
What is linezolid used for ?
MRSA

VancoResistant Enterococcus
What drug is a cyclic lipopeptide?
daptomycin
What is the main indication for daptomycin? (cyclic lipopeptide)
MRSA

vanco is still standard of care in this situation - but this is another IV option
Why must you be careful with daptomycin if pt is on a statin?
--> myalgias

monitor the CPK more closely
Where is metronidazole excreted?
liver
Is metronidazole cidal or static?
cidal
What MOs are covered by metronidazole?
anaerobes (esp below diaphragm)

some protozoa (trichomonas, giardia, entamoeba)
2 main side effects of metronidazole?
disulfiram-like rxn

metallic taste if you give too much
Possible long term side effect of Nitrofurantoin?
pulmonary fibrosis
What does nitrofurantoin cover?
gram negatives
enterococcus

for UTIs!
What organisms are covered by chloramphenicol?
h. flu
s. pneumo
n. meningitidis

some anaerobes
Why isn't chloramphenicol used much?
toxicities - but used as last resort in CNS infxn because it reaches therapeutic levels in CNS
What is Fosfomycin used for?
uncomplicated UTIs due to enterococci or e. coli
What is Polymyxin B used for?
only against gram negatives
(often topical)
What is Methanamine used for?
uncomplicated/chronic UTIs
(no systemic effects)
What is Rifaximin used for?
Traveler's diarrhea from noninvasive strains of e. coli
Which diarrheal infections can Rifaximin not be used for?
those associated w/fever or bloody stools
What are 2 ABX associated with hemolytic anemia in pts with G6PD deficiency?
Sulfa (Bactrim)
Nitrofurantoin

(anti-malarials also)
What ABX are most commonly associated with immune-mediated urticaria?
Beta lactams and sulfonamides
What ABX is associated with nonimmune-mediated urticaria?
Vanco (red neck syndrome)
With what ABX do you worry most about anaphylaxis?
Beta lactams
What drugs are associated with Drug-induced exanthems? (a drug eruption)
beta lactams and sulfonamides
What ABX are associated with hypersensitivity vasculitis?
Beta lactams and sulfonamides
What drugs are associated with exfoliative dermatitis/erythroderma?
Penicillins mostly

but also sulfa
What ABX is associated with SJS (Stevens Johnson Syndrome) and TEN (toxic epidermal necrolysis)?
Sulfonamides
How is SJS from a sulfonamide managed?
stop drug
tx like burn
high dose steroids
What two ABX are associated witha fixed drug eruption? (plaques with grayish center or frank bullae)
tetracyclines
sulfonamides
What abx is classically associated with serum sickness
cefaclor (2nd gen cephalosporin)

also. . .sulfonamides of course
Which ABX have photosensitivity as a side effect?
fluoroquinolones
tetracyclines
sulfonamides
What ABX might be associaled with drug-induced lupus?
minocycline
sulfonamides
rifampin
nitrofurantoin
What ABX are associate with drug fever?
beta lactams
sulfonamides

nitrofurantoin
minocycline

phenytoin
carbamazepine
allopurinol
H2blockers (cimetidine)
What ABX cause yellow-brown urine?
Nitrofurantoin
Sulfamethoxazole
What abx causes orange/pink urine?
rifampin
What 2 abx cause brown-black urine?
Metronidazole
Nitrofurantoin
What is the P450 action of rifampin?
inducer of 3A4 and 2C9
What is the P450 action of macrolides?
Both substrates and inhibitors of 3A4
(except azithromycin)
The elimination of which ABX is affected by glomerular filtration?

(will build up if filtration is affected)
Aminoglycosides
What ABX (IV and oral) work against pseudomonas?
Piperacillin/tazobactam
aztreonam
ceftazidime (3rd)
cefipime
ciprofloxacin (IV/oral)
levofloxacin (IV/oral)
tobramycin (not gent)
meropenem
imipenem
What ABX cover strep pneumo?
Cefuroxime (2nd gen)
Ceftriaxone (3rd gen)
Cefepime(4th)*better than 3rd
Doxycycline
Macrolides/Ketolides
Fluoroquinolones (3rd gen - not cipro)
TMP-SMX (but not CAP)
Aminopenicillins & augmented
Betalactam/Betalactamase
What ABX cover staph? (MSSA)
Nafcillin*
Dicloxacillin (PO)*
Cefazolin (1st gen)
Cephalexin (PO 1st gen)*
Cefuroxime (2nd gen)
Cefepime (IV only)
Minocycline*
Doxycycline* (may get MRSA)
TMP-SMX*
Clindamycin
What ABX is the #1 cause of chemical phlebitis?
Nafcillin
How are aminopenicillins excreted?
renal
What might you treat with amoxicillin or ampicillin?
Would cover strep throat, pneumo (if strep pneumo), lyme disease, animal bite
What is the gold standard for treating anaerobic infxns?
ampicillin/sulfabactam
or
amoxicillin/clavulanate

**these also cover everything that nL AminoPCNs do plus m. cat and h.flu
Which augmented aminopenicillin is IV and which is oral?
Amp/sulf is IV
Amox/Clav is PO
Piperacillin/tazobactam is the gold standard treatment for which (2) infections?
Pseudomonas and anaerobes

*the augmented aminoPCNs are also considered gold standard for anaerobes
Anaerobic organisms include. . . .
b. fragilis
bacteroides
prevotella
fusobacterium
(above are all gram neg)
peptostreptococci
actinomyces
clostridium
Which cephalosporins are anti-pseudomonal?
ceftazidime (3rd)
cefepime (4th)
Examples of infections when anaerobes are suspected
Diverticulitis (b frag)
GI infections (b frag)

lung or dental infxn (prevotella)
C. dif colitis

brain, liver, lung abscesses?
gangrene?

*anaerobes are nL flora in the oral cavity, GI tract, and vagina
What is zosyn?
piperacillin/tazobactam
Piperacillin/tazobactam is ideal for pseudomonas and anaerobic infxns. . . what other organisms does it cover?
s. pyogenes
s. pneumo
enterococci
m. cat/h. flu
GN-enterics
What are the "gram negative enterics"?
proteus
e.coli
klebsiella
enterobacter
serratia
pseudomonas
How are the cephalosporins excreted?
kidney

EXCEPT CEFTRIAXONE
What is a major SE of cephalosporins?
Associated with C. dif diarrhea
which macrolide covers MAC (mycobacterium avium complex)?
Azithromycin
Name two drugs that cover a chlamydia GU infection.
Azithromycin and Doxycycline
Doxycycline and Azithromycin can both be used to treat CAP, which one can also be used for animal and tick bites?
Doxycycline
In which patients is doxycycline contraindicated?
<8
or pg
WHich cephalosporins can be used to treat community-acquired pneumonia? and what must they be given with?
Cefuroxime or Cefpodixime

(give w/macrolide or doxycycline to cover atypicals)
What infections can be treated with a first or second generation cephalosporin?
Cystitis or skin/soft tissue infection
What cephalosporin can be used to treat amoxicillin resistant forms of m. cat and h.flu?
Cefuroxime
what organisms do second generation cephalosporins cover that first do not?
pasturella
m cat
h flu
what kind of URI would you use an augmented aminopenicillin for?
amox. failure URI

(AOM, sinusitis, ABECB)
What three beta lactams can be used for CAP if you add something to cover atypicals?
Amox/Clav
Cefuroxime
or cefpodoxime
what are clinical indications for use of amoxicillin?
Tick/dog/cat bites
pharyngitis
AOM
sinusitis
endocarditis prophylaxis
strep skin infxn
ABECB
cystitis
What does clarithromycin cover that azithromycin does not?
H. pylori
Which beta lactam does not cover enterococci or listeria?
Cephalosporins

(and obviously the nonaminopenicillins)
Rank the respiratory fluoroquinolones in their efficacy against strep pneumo (greatest to least)
Moxi > gati > levo
Which respiratory fluoroquinolone is least effective against resistant gram negatives?
moxifloxacin
Which abx covers stenotrophomonas maltophila?
TMP-SMX
Which oral abx can be used for traveler's diarrhea?
quinolones (all)
TMP-SMX
What is Pediazole?
erythromycin-sulfasoxazole
(alternative for AOM)
What two GU infections might you use metronidazole for?
bacterial vaginosis
trichomonas
If you use metronidazole for an anaerobic infxn (abscess), what must be added to it?
beta lactam or fluoroquinolone
What oral drugs can be used to treat strep pharyngitis in patient w/beta lactam allergy?
Clindamycin
or macrolide
What oral drugs can be used to treat cystitis?
nitrofurantoin
TMP-SMX
Amoxicillin or Ampicillin
Cephalexin or Cefuroxime
which abx is used for endocarditis prophylaxis?
amoxicillin
what is the big difference between amox and amox/clav or amp and amp/sul?
the augmented aminopenicillins also cover m.cat h.flu and anaerobes
what can you treat with an augmented aminopenicillin that you can't with an aminopenicillin?
CAP (but must add macrolide or doxy)

(and of course amox failure URIs)

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