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Updated: Feb 28 2019


  • Snapshot
    • A 55-year-old man is in the medical step-down unit for management of his osteomyelitis. The patient has a past medical history of diabetes that is complicated by peripheral neuropathy and gastroparesis. After obtaining a bone culture he is started on empiric antibiotic treatment with vancomycin and ceftriaxone; however, the patient still has a fever. A bone culture grew Pseudomonas aeruginosa that is sensitive to cefepime; his antibiotics were narrowed.
  • Introduction
    • General principle
      • rule of thumb
        • lower generations favor gram-positive coverage
        • higher generations favor gram-negative coverage
          • except for 4th and 5th generation, which has extended gram-positive coverage
    • Drugs
      • 1st generation
        • cefazolin
        • cephalexin
      • 2nd generation
        • cefoxitin
        • cefaclor
        • cefuroxime
      • 3rd generation
        • ceftriaxone
        • cefotaxime
        • ceftazidime
        • cefixime
      • 4th generation
        • cefepime
      • 5th generation
        • ceftaroline
    • Mechanism of action
      • binds to penicillin-binding proteins, inhibiting bacterial cell wall synthesis
    • Mechanism of resistance
      • altered penicillin-binding proteins
      • production of cephalosporinases
    • Clinical use
      • 1st generation
        • P. mirabilis
        • E. coli
        • K. pneumoniae
        • preventative measure against S. aureus wound infection prior to surgery (cefazolin)
      • 2nd generation
        • H. influenzae
        • Enterobacter aerogenes
        • Neisseria spp.
        • S. marcescens
        • P. mirabilis
        • E. coli
        • K. pneumoniae
      • 3rd generation
        • gram-negative infections
        • meningitis, gonorrhea, and disseminated Lyme disease (ceftriaxone)
        • Pseudomonas (ceftazidime)
      • 4th generation
        • Pseudomonas
      • 5th generation
        • gram-negative and gram-positive organisms
          • does not cover Pseudomonas
    • Adverse events
      • hypersensitivity reaction
      • autoimmune hemolytic anemia
      • disulfiram-like reaction
      • vitamin K deficiency
      • note that there is low cross-reactivity with penicillin (even in penicillin-allergic patients)
      • increased nephrotoxicity with aminoglycosides
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