Clindamycin (Cleocin)
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Class(es)
Lincosamide
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Clinical use(s)
FDA approved: Bacterial disease (severe) Including susceptible infections due to anaerobic and aerobic gram positive organisms.
Off-label/clinical use: Acne vulgaris (topical). -
Mechanism(s) of action
Inhibits protein synthesis at the level of the 50S ribosomal subunit.
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Key adverse effects
The most common reported AE is mild to moderate morbilliform-like skin rashes. High risk antibiotic for C. difficile associated diarrhea.
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Key drug/food interactions
Concurrent use of clindamycin and erythromycin may result in antagonistic antimicrobial effects.
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Special considerations
Patient should take capsules with a full glass of water to avoid esophageal irritation.
Metronidazole (Flagyl)
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Class(es)
Antiprotozoal, antibacterial and antihelminthic nitroimidazole agent
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Clinical use(s)
FDA approved: Infection due to anaerobic bacteria, trichomoniasis, bacterial vaginosis.
Off-label/clinical use: Crohn's disease. -
Mechanism(s) of action
Bacteriocidal against anaerobes by hindering the DNA processes.
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Key adverse effects
Headache (5–18%), vaginitis (10–15%).
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Key drug/food interactions
Contraindications: Alcohol use during and for at least 3 days after metronidazole use. Disulfiram use within 2 weeks of therapy. Significantly increased risk of bleed with warfarin therapy.
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Special considerations
U.S. boxed warning: Metronidazole has been shown to be carcinogenic in mice and rats. Its use, therefore, should be reserved only for conditions for which it is approved.Â
Doxycycline (Oracea)
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Class(es)
Tetracycline
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Clinical use(s)
FDA approved: Gram-negative infections (E. coli, Enterobacter aerogenes, Shigella spp., Acinetobacter spp., Klebsiella spp., bacteroides spp., Neisseria menginitidis); gram-positive infections (Streptococcus spp.).
Off-label/clinical use: Cellulitis, bite-wound infection. -
Mechanism(s) of action
Inhibits protein synthesis by binding with the 30S and possibly 50S ribosomal subunit(s) of susceptible bacteria.
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Key adverse effects
Photosensitivity, diarrhea, nasopharyngitis.
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Key drug/food interactions
Penicillin, acitretin, methotrexate; food may decrease absorption.
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Special considerations
Take on empty stomach unless GI irritation occurs.
Vancomycin (Vancocin)
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Class(es)
Glycopeptide
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Clinical use(s)
FDA approved: C. difficile diarrhea, skin and soft tissue infection, infective endocarditis.
Off-label/clinical use: Bacteremia. -
Mechanism(s) of action
Inhibits bacterial cell wall synthesis by blocking glycopeptide polymerization of the cell wall.
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Key adverse effects
Red man syndrome, nephrotoxicity, hyperkalemia, hypotension (accompanied by flushing).
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Key drug/food interactions
Aminoglycosides may enhance the nephrotoxic effect of vancomycin.
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Special considerations
Available in IV form for systemic infections. Systemic dosing is based on patient weight and renal function. Available in oral form for use in C. difficile diarrhea treatment.
Linezolid (Zyvox)
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Class(es)
Oxazolidinone
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Clinical use(s)
FDA approved: CAP, HAP, SSTI, VRE infection.
Off-label/clinical use: Bacteremia associated with IV line, febrile neutropenia, infection of bone, infections disorder of joint, endocarditis. -
Mechanism(s) of action
Inhibits bacterial reproduction of aerobic gram-positive bacteria and certain gram-negative and anaerobic bacteria, by selectively binding to a site on the 23S ribosomal RNA of the 50S subunit, thereby preventing initiation complex formation with the 70S ribosomal subunit.
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Key adverse effects
Diarrhea, N/V.
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Key drug/food interactions
MAOIs, SSRIs, mirtazapine, carbidopa/levodopa.
Avocado, bitter orange, tyramine containing foods. -
Special considerations
Injection only.
Bacteriostatic against enterococci and staphylococci, and bactericidal for a majority of streptococci isolates.
Daptomycin (Cubicin)
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Class(es)
Cyclic lipopeptide
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Clinical use(s)
FDA approved: Bacteremia due to S. aureus, SSTI.
Off-label/clinical use: Bacteremia associated with IV line, disease due to Gram positive bacteria, osteomyelitis, septic arthritis. -
Mechanism(s) of action
Binds to bacterial cell membranes and causes cell death by inducing rapid depolarization of the membrane potential, leading to disruption of DNA, RNA, and protein synthesis.
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Key adverse effects
Pruritis, rash, diarrhea, vomiting, insomnia.
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Key drug/food interactions
HMG CoA reductase inhibitors.
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Special considerations
Injection only.
Renal impairment: CrCl <30 ml/min.—dose adjust.
Sulfamethoxazole-Trimethoprim (Bactrim)
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Class(es)
Sulfonamide antibiotic
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Clinical use(s)
FDA approved: Urinary tract infection, acute exacerbation of COPD.
Off-label/clinical use: UTI prophylaxis. -
Mechanism(s) of action
Interferes with the production of folic acid.
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Key adverse effects
Urticaria, anorexia, N/V, hepatotoxcity (rare).
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Key drug/food interactions
Concurrent use with potassium-sparing drugs may result in increased risk of hyperkalemia. Concurrent use with warfarin significantly increases risk of bleed.
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Special considerations
For IV formulation, do not administer by IM injection, bolus, or rapid infusion.
Nitrofurantoin (Macrodantin, Macrobid)
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Class(es)
Nitrofurans
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Clinical use(s)
FDA approved: UTI treatment and prophylaxis.
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Mechanism(s) of action
Nitrofurantoin is reduced by bacterial flavoproteins to reactive intermediates, which inactivate or alter bacterial ribosomal proteins and other macromolecules.
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Key adverse effects
Common: Skin eruptions, consisting of macular lesions, maculopapular lesions, or urticarial lesions. The most common reaction in pediatric patients was peripheral polyneuropathy.
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Key drug/food interactions
Concurrent use of NITROFURANTOIN and FLUCONAZOLE may result in increased risk of hepatic and pulmonary toxicity.
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Special considerations
Contraindicated for CrCl < 60 ml/min. Limited data suggests it’s safe and effective down to CrCl = 30 ml/min.
Fosfomycin (Monurol)
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Class(es)
Phosphonic acid derivative
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Clinical use(s)
FDA approved: Uncomplicated UTI.
Off-label/clinical use: Complicated UTI. -
Mechanism(s) of action
As a phosphonic acid derivative, fosfomycin inhibits bacterial wall synthesis (bactericidal) by inactivating the enzyme, pyruvyl transferase, which is critical in the synthesis of cell walls by bacteria.
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Key adverse effects
Diarrhea, nausea, headache.
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Key drug/food interactions
Cholera vaccine, lixisenatide.
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Special considerations
Supplied as powder for oral solution.
Gentamicin
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Class(es)
Aminoglycoside
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Clinical use(s)
FDA approved: Ophthalmic infections (eye drops), dermatologic infections (topical), infective endocarditis (systemic), synergy for gram-positive infections (systemic).
Off-label/clinical use: Adjunctive therapy for febrile neutropenia, pelvic inflammatory disease. -
Mechanism(s) of action
Inhibits protein synthesis in bacteria at the level of the 30S ribosome.
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Key adverse effects
CNS: Ataxia, vertigo.
EENT: Ototoxicity.
GU: Nephrotoxicity. -
Key drug/food interactions
Loop diuretics increase incidence of ototoxicity.
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Special considerations
US Boxed Warning: May cause nephrotoxicity.
US Boxed Warning: May cause neurotoxicity.
Monitor patient’s renal function throughout therapy.
Ciprofloxacin (Cipro)
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Class(es)
Fluoroquinolone
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Clinical use(s)
FDA approved: Treatment of cystitis and pyelonephritis.
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Mechanism(s) of action
Inhibits nucleic acid synthesis via inhibition of DNA gyrase.
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Key adverse effects
Tendon rupture, C Difficile colitis.
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Key drug/food interactions
Contraindicated with strong CYP3A4 inhibitors and QT prolonging agents. Significantly increased risk of bleed with warfarin therapy.
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Special considerations
Available in systemic, ophthalmic, and otic forms. The FDA advises that the serious side effects associated with fluoroquinolones generally outweigh the benefits for patients with acute sinusitis, acute bronchitis, and uncomplicated urinary tract infections who have other treatment options.
Levofloxacin (Levaquin)
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Class(es)
Fluoroquinolone
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Clinical use(s)
FDA approved: CAP/HAP, complicated UTI, pyelonephritis, SSTI.
Off-label/clinical use: Acute otitis media (recurrent), chlamydial infection, traveler’s diarrhea, tuberculosis. -
Mechanism(s) of action
Inhibits DNA-gyrase in susceptible organisms thereby inhibits relaxation of supercoiled DNA and promotes breakage of DNA strands.
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Key adverse effects
Diarrhea, headache, nausea, tendon rupture (rare).
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Key drug/food interactions
Avoid concurrent use QT prolonging medications, Warfarin (may ↑ risk bleeding).
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Special considerations
Risk of QT prolongation.
Renally adjusted: CrCl < 49 ml/min.
BBW: tendonitis/tendon rupture/peripheral neuropathy/CNS effects.
Clarithromycin (Biaxin)
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Class(es)
Macrolide
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Clinical use(s)
FDA approved: Bronchitis, AOM, CAP, Mycobacterium avium, SSTI, sinusitis, streptococcal pharyngitis.
Off-label/clinical use: Anthrax, endocarditis prophylaxis, LRTI, legionnaires, Lyme disease, pertussis, spotted fevers. -
Mechanism(s) of action
Clarithromycin binds to the 50S ribosomal subunit of the 70S ribosome of susceptible organisms, thereby inhibiting bacterial RNA-dependent protein synthesis.
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Key adverse effects
Taste disturbance, N/V, diarrhea.
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Key drug/food interactions
Significant bleed risk with concurrent warfarin therapy. Concomitant use with HMG-CoA reductase inhibitors extensively metabolized by CYP3A4 (eg, lovastatin or simvastatin) contraindicated.
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Special considerations
Renal impairment: CrCl <30 ml/min.—dose adjust.
Azithromycin (Zithromax)
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Class(es)
Macrolide antibiotic
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Clinical use(s)
FDA approved: Acute otitis media (ophthalmic), community acquired pneumonia (oral or IV for inpatient).
Off-label/clinical use: Bacterial endocarditis prophylaxis. -
Mechanism(s) of action
Inhibits protein synthesis at the level of the 50S ribosomal subunit.
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Key adverse effects
Injection site reaction (~6%), increased liver enzymes (~6%), QT interval prolongation.
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Key drug/food interactions
Avoid concomitant use with other QT prolonging agents. Increased risk of bleed with warfarin.
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Special considerations
Use contraindicated in patients with hepatic dysfunction. Separate oral administration from aluminum- or magnesium-containing antacids or decrease absorption may occur.