WEBVTT 1 00:00:00.240 --> 00:00:03.120 All right, so antibiotic review. This is going to be a triple distilled 2 00:00:03.160 --> 00:00:06.960 antibiotic review. I'm going to go over every single antibiotic or every single detail, 3 00:00:07.120 --> 00:00:09.160 nor would you want me to. There's a ton to know, but 4 00:00:09.199 --> 00:00:11.640 I'm focusing on the high yield stuff, the stuff that always seem to come 5 00:00:11.720 --> 00:00:14.839 up on exams. Thank you so much, as always for your support, 6 00:00:14.839 --> 00:00:17.359 the really nice comments. I'm going to say it on every single podcast because 7 00:00:17.359 --> 00:00:20.879 I really do appreciate it. And if you haven't checked out the YouTube channel, 8 00:00:20.879 --> 00:00:23.760 please do is Cram the pants on YouTube has some good visuals to go 9 00:00:23.800 --> 00:00:26.440 along with the audio. All right, so let's get started with antibiotics. 10 00:00:26.480 --> 00:00:29.679 We'll start with the beta lactams, your penicillin, and sephalosporins, carbon penoms, 11 00:00:29.719 --> 00:00:32.399 amount of backdam, and then we'll start with penicillin, and that's our 12 00:00:32.439 --> 00:00:35.719 og antibiotic. That was our first So let's go ahead and get started with 13 00:00:35.759 --> 00:00:39.399 those, and we'll break down each individual penicillin to kind of talk about the 14 00:00:39.439 --> 00:00:43.240 evolution of penicillin and how we had to change with the evolving bacteria and the 15 00:00:43.280 --> 00:00:46.960 resistance. So let's start with penicillin, penicillin G, and penicillin v or 16 00:00:47.039 --> 00:00:51.479 VK. So penicillin G and penicillan VK what are they good for? They're 17 00:00:51.479 --> 00:00:55.079 good for grand positive organisms. They have really good grand positive coverage, but 18 00:00:55.200 --> 00:00:58.600 unfortunately they've been around so long there's a ton of resistance against them, and 19 00:00:58.640 --> 00:01:02.679 they're not good for a lot of things anymore unfortunately. So what are our 20 00:01:02.759 --> 00:01:06.599 high yield indications. It's gonna be syphilis, STRAP, dental infections, and 21 00:01:06.680 --> 00:01:08.680 rheumatic fever. Those are the ones that seem to come up often, particularly 22 00:01:08.959 --> 00:01:12.480 syphilis, so first line for STRAP. That's why we also see an indicator 23 00:01:12.560 --> 00:01:15.920 for a rheumatic fever which is caused by STRAP. Can be used for dental 24 00:01:15.959 --> 00:01:19.439 infections because it does cover most oral anaerobes. But the high yield one, 25 00:01:19.480 --> 00:01:22.799 like I said before, that's cyphilis. That's the one they'll always ask you 26 00:01:22.799 --> 00:01:26.640 about on exams, and that's when you use penicillin G that injectable form. 27 00:01:26.840 --> 00:01:30.840 Just an fy in regards to the strep eringitis coverage. So in real life, 28 00:01:30.280 --> 00:01:34.480 penicillin V has really good coverage for STRAP and it works well. But 29 00:01:34.519 --> 00:01:37.840 are you actually going to use it in clinical practice? Probably not often, 30 00:01:37.879 --> 00:01:41.159 and you'll see when you're out in clinicals, it's not used often. Moxiscillin 31 00:01:41.280 --> 00:01:44.480 is the one that we always really use for STRAP in real life because one, 32 00:01:44.680 --> 00:01:49.079 it's much more palatable, particularly in children. Penicillin V does not taste 33 00:01:49.079 --> 00:01:52.879 good. And then the second thing is a moxiscillin has twice daily dosing compared 34 00:01:52.879 --> 00:01:55.760 to penicillin V which can be up to four times a day. So all 35 00:01:55.799 --> 00:02:00.519 penicillan VK works really well to cover strap and might be your exam It might 36 00:02:00.560 --> 00:02:02.959 be your answered choice on the exam question. In real life, you're probably 37 00:02:04.079 --> 00:02:06.719 more often going to use am oxycillin, which covers it just as well. 38 00:02:07.000 --> 00:02:09.919 All right, So penicillin it was our first antibiotic, but eventually bacteria started 39 00:02:09.960 --> 00:02:15.400 to evolve and resist penicillin by producing something called penicillanase, So we had to 40 00:02:15.439 --> 00:02:17.919 go back to the drawing board. We had to come up with a semisynthetic 41 00:02:17.919 --> 00:02:27.120 penicillin called penicillinase resistant penicillin also known as anti staffhlococco penicillin. So penicillinase is 42 00:02:27.159 --> 00:02:30.800 an enzyme that's produced by bacteria that destroys the beta lactam ring of penicillin, 43 00:02:30.879 --> 00:02:35.560 making it ineffective. Well, now we had this antibiotic class that we created 44 00:02:35.599 --> 00:02:40.879 that was resistant to penicillanase, the medicines class or nafficillin oxycillin dicloxyscillin. Back 45 00:02:40.919 --> 00:02:44.719 in the day, this list used to include methycillin. That's how we came 46 00:02:44.759 --> 00:02:47.599 up with the name MIRZA, or methysillin Resistant staff oreus. We don't use 47 00:02:47.599 --> 00:02:52.599 methyscillin anymore due to its poor side effect profile, but just be aware that 48 00:02:52.680 --> 00:02:53.759 this used to be in that class, and that's how we came up with 49 00:02:53.800 --> 00:02:58.080 MIRSA. What do they cover? They cover gram positive again, just like 50 00:02:58.120 --> 00:03:01.879 the ones we previously went over, but particularly beta lactimates producing staff areas. 51 00:03:02.159 --> 00:03:09.000 High old indication. There's just one MSSA methyscillin susceptible staff areas. So whether 52 00:03:09.039 --> 00:03:15.280 it's bactoreemia, asteomyelitis, cellulitis, endocarditis, if it's from MSSA, they're 53 00:03:15.319 --> 00:03:20.319 generally going to be your drug of choice. These men basically exist to treat 54 00:03:20.400 --> 00:03:23.759 staff. That's the only indication I would know for them. That's really the 55 00:03:23.879 --> 00:03:30.879 main indication in real life. Nafcillin oxycillin dicloxycillin think about staff. MSSA not 56 00:03:30.960 --> 00:03:36.080 good for marca though, but methysillas sensitive or susceptible staff oreus. That is 57 00:03:36.120 --> 00:03:39.120 the indication for these medications. All right, So we created a penicillin which 58 00:03:39.120 --> 00:03:44.800 covered strap and staff so most of our gram positive organisms. But these last 59 00:03:44.840 --> 00:03:47.240 two generations I just spoke about didn't really cover gram negatives, or at least 60 00:03:47.280 --> 00:03:51.400 not very well. So we had to create a penicillin that did. So 61 00:03:51.479 --> 00:03:55.759 what we developed was amino penicillans for that specific reason to fight gram negative infection. 62 00:03:55.840 --> 00:04:00.520 So amino penicillans, you'll notice they have the AM prefix, so amoxycillin 63 00:04:00.599 --> 00:04:04.840 ampicillin. So if amino penicillans, we brought in our coverage with penicillin, 64 00:04:04.879 --> 00:04:09.879 and now we have the ability to fight gram negative organisms as well as gram 65 00:04:09.919 --> 00:04:15.759 positive. So amoxiscillin is your oral medication. Ampicillin is your parental iv im 66 00:04:16.160 --> 00:04:19.680 And if you wanted a way to remember those, it's probably pretty I probably 67 00:04:19.680 --> 00:04:24.439 already know because amoxycilla is so common. But moxyscillin the third letter has an 68 00:04:24.439 --> 00:04:27.879 OH, so that's oral. Ampicillin in the third third letter has a P, 69 00:04:28.120 --> 00:04:30.920 so that's parental. So that's just a way if you've forgotten an exam 70 00:04:31.000 --> 00:04:36.639 maybe high yield indications qutotitis, media, strep, pharyngitis, listeria. Those 71 00:04:36.680 --> 00:04:41.519 are the three big ones I would know for yourmino penicillans, titus, media, 72 00:04:41.639 --> 00:04:46.040 strep, lesteria. There's some other hot less, high yield indications. 73 00:04:46.040 --> 00:04:49.199 Remember maxycillina is one of the medications used to treat hpylori. Remember in your 74 00:04:49.199 --> 00:04:56.639 triple therapy CHLORITHRUMYC and amoxyscillin PPI. It's another option in treatment for lyme disease, 75 00:04:56.680 --> 00:05:00.160 although doxy is generally preferred unless the patients pregnant or young young child. 76 00:05:00.279 --> 00:05:03.800 With some caveats I'll discuss when we get to the tetracyclines, but generally remember 77 00:05:03.800 --> 00:05:08.240 otitis, media, strep, listeria. Know those all right. So this 78 00:05:08.319 --> 00:05:12.519 subclass of penicillin worked well. We picked up some gram negative coverage in addition 79 00:05:12.560 --> 00:05:15.839 to our gram positive. But the problem was this class was susceptible to beta 80 00:05:15.920 --> 00:05:23.040 lactamase. So beta lactamasis are beta lactamase our enzymes produced by bacteria that break 81 00:05:23.040 --> 00:05:27.120 open the beta lactame ring in activating the beta lactam antibiotic. So we had 82 00:05:27.120 --> 00:05:30.079 to find a way to help these antibiotics resist this. And what we did 83 00:05:30.279 --> 00:05:35.000 was we added a component onto the antibiotic called a beta lactamase inhibitor, and 84 00:05:35.079 --> 00:05:40.199 what we came up with was our beta lactamase inhibitor penicillins. So we take 85 00:05:40.240 --> 00:05:44.120 the same antibiotics. We just went over moxycilla and ampicillin, and we added 86 00:05:44.120 --> 00:05:48.720 a beta lactamase inhibitor which prevents the beta lactamase from eating the beta lactam ring 87 00:05:48.759 --> 00:05:51.879 and destroying the antibiotics. You can just think of it as a shield for 88 00:05:51.920 --> 00:05:56.800 the antibiotics. So we're just taking the two antibiotics, a moxycillin ampicillin, 89 00:05:57.000 --> 00:06:01.040 and we give them their shield against beta lactamase. The for amoxicillin is called 90 00:06:01.120 --> 00:06:05.399 clavilanate or claviulonic acid, and that combo, the brand name is known as 91 00:06:05.399 --> 00:06:10.120 Augmentin. And then with ampicillin, its shield is called soulbactim and we have 92 00:06:10.240 --> 00:06:12.920 unison that brand name for that combo. So that's all we did. We 93 00:06:12.920 --> 00:06:15.360 took am oxycillin, gave it clavilanate, We took amposilla, we gave it 94 00:06:15.399 --> 00:06:21.040 soul back to him, and then we covered we protected them against these betolactomas, 95 00:06:21.439 --> 00:06:25.480 and that brought in our coverage once again. So now we had coverage 96 00:06:25.480 --> 00:06:29.079 of gram positive, gram negative, and then we also added some really good 97 00:06:29.079 --> 00:06:31.439 coverage of anaerobes. And that's the key is picking up that good coverage of 98 00:06:31.480 --> 00:06:36.240 anerobe with these betolactamase inhibitors. So again, the meds in this class or 99 00:06:36.240 --> 00:06:42.160 a moxycillin clavulanate also known as augmentin, ampicillin soul backtim also known as unison. 100 00:06:42.279 --> 00:06:45.920 So what are the high yeldentications for these medications. Cute cine eucitis. 101 00:06:46.079 --> 00:06:50.079 Moxyclave is first line animal bites including human bites too, dog, cat, 102 00:06:50.199 --> 00:06:54.199 human, All of those animal bites are going to be covered really well with 103 00:06:54.240 --> 00:06:58.879 this class. And then aspiration ammonia because remember aspiration ammonia we know is commonly 104 00:06:58.920 --> 00:07:00.920 caused by anaerobes. We know we just talked about, this class is a 105 00:07:00.959 --> 00:07:05.920 good choice for coverage of anaeropes. Also be aware amoxyclav can be used this 106 00:07:06.000 --> 00:07:11.439 first line agent for cute otitis media as an alternative to amoxicilla in some specific 107 00:07:11.480 --> 00:07:14.639 cases. But those are your high yield ones, all right. So we 108 00:07:14.720 --> 00:07:17.519 have all of these different types of penicillans. We covered a wide variety of 109 00:07:17.639 --> 00:07:23.199 organisms. What about pseudomonus coverage, We haven't talked about that, and that's 110 00:07:23.240 --> 00:07:27.000 where our anti pseudomonal penicillans come in. So our anti pseudomonal penicillans, these 111 00:07:27.040 --> 00:07:30.639 are a broad spectrum antibiotics. You're not going to use these in your average 112 00:07:30.639 --> 00:07:33.399 patient. It's really just for your sick patients. The key here is their 113 00:07:33.439 --> 00:07:39.560 coverage of pseudomonas, so they cover most organisms gram positive, gram negative anaerobes 114 00:07:39.720 --> 00:07:43.319 pseudomonas, which is obviously the key and what they're most commonly used for. 115 00:07:44.000 --> 00:07:46.360 It's really easier to focus on what they don't cover because they cover so much. 116 00:07:46.399 --> 00:07:50.879 So they don't cover mersa and they won't cover your atypicals like microplasma legionella, 117 00:07:51.040 --> 00:07:55.839 but most other organisms they're going to have coverage for their really broad spectrum 118 00:07:55.839 --> 00:07:58.959 antibiotics. So the meds in this class are going to be piperus cillin, 119 00:07:58.959 --> 00:08:01.560 taso backdam which is also known zocin. Again, this one has the best 120 00:08:01.560 --> 00:08:05.759 coverage for pseudomonas of the two, and then tick our sillin clavilanate still cover 121 00:08:05.800 --> 00:08:09.839 pseudomonis, but not as well as pip tazo. So there's not really any 122 00:08:11.000 --> 00:08:13.879 specific high old indications. I would say to know for these, but just 123 00:08:13.920 --> 00:08:18.800 be aware, particularly when peudomonis is suspected, like in hospital acquired pneumonia. 124 00:08:18.959 --> 00:08:22.120 This class is going to be utilized, particularly piptazo It can also be used 125 00:08:22.120 --> 00:08:26.439 in some severe soft tissue infections and trebdominal infections as well. So what are 126 00:08:26.480 --> 00:08:30.319 the ad rs? What are the adverse drug reactions that you need to know 127 00:08:30.360 --> 00:08:33.120 for the penicillin class in general, So just a few that I would focus 128 00:08:33.159 --> 00:08:37.639 on. One is their hypersensitivity reaction, because of all the drug classes, 129 00:08:37.840 --> 00:08:43.559 penicilla is the class most associated with hypersensitivity reactions. Second one is some of 130 00:08:43.600 --> 00:08:48.240 the hematologic reactions you can see in this class, So thrombostopenia, neutropenia, 131 00:08:48.440 --> 00:08:54.200 immune mediated hemolytic anemia, all possible in the beta lactam class in general, 132 00:08:54.480 --> 00:09:00.360 but particularly with the penicillin antibiotics. And then finally GI problems. Now this 133 00:09:00.440 --> 00:09:03.559 is non specific because all antibiotic classes can cause GI problems, but in the 134 00:09:03.600 --> 00:09:07.279 penicillin class there's a couple of main culprits to look out for. That's going 135 00:09:07.320 --> 00:09:11.879 to be ampicillin, amoxis cillin, which are known for causing diarrhea, particularly 136 00:09:13.120 --> 00:09:16.639 augmented, which remember is the combo of amoxysillin clavilane. Penicillan has the highest 137 00:09:16.639 --> 00:09:20.679 incidence of diarrhea of all the penicillin. So be aware when you're prescribing that 138 00:09:20.720 --> 00:09:24.360 medication of your patients if you can maybe just give them playing amoxis cillina instead 139 00:09:24.360 --> 00:09:28.200 of augmentin, you'll be doing them a big favor, all right. So 140 00:09:28.240 --> 00:09:31.679 that's our penicillans are the main things that you need to know for those. 141 00:09:31.840 --> 00:09:35.279 Let's move on to our cephalosporins. All right. Well, the cephalosporons always 142 00:09:35.279 --> 00:09:39.679 seem to give people problems, but I've come up with a few mnemonics that 143 00:09:39.720 --> 00:09:43.720 I think will help you with these, So hopefully that'll be helpful to help 144 00:09:43.720 --> 00:09:46.000 you to remember the cephalosporins the way you need to know about them. All 145 00:09:46.080 --> 00:09:50.559 right, So before we jump into the cephalosporins, I want to review an 146 00:09:50.559 --> 00:09:54.200 easy way to remember the coverage for cephalosporins, particularly, they're gram negative verse 147 00:09:54.200 --> 00:09:58.399 gram positive coverage. So as a general rule, as the cephalosporin generations go 148 00:09:58.480 --> 00:10:05.000 on from first to second to third to fourth, they lose gram positive coverage 149 00:10:05.000 --> 00:10:07.799 and they gain gram negative coverage. It's not one hundred percent accurate, and 150 00:10:07.840 --> 00:10:11.559 in every case there are some exceptions. But as a general rule, if 151 00:10:11.600 --> 00:10:15.080 you remember this fear exams with the cephalist borns, as the generations go on 152 00:10:15.120 --> 00:10:20.720 from first to fourth, they lose gram positive coverage and they gain negative coverage. 153 00:10:20.720 --> 00:10:24.679 So in general, first generation is really good at covering gram positive, 154 00:10:24.799 --> 00:10:28.639 not so good at gram negative, and fourth generation really good gram negative coverage 155 00:10:28.879 --> 00:10:33.600 but not so good at covering gram positive. Fifth generation doesn't really follow these 156 00:10:33.679 --> 00:10:35.840 rules. It's kind of really great at gram positive. So don't worry about 157 00:10:35.840 --> 00:10:41.159 fifth generation. But first to fourth, remember that your first generation is going 158 00:10:41.200 --> 00:10:43.759 to be really good at gram positive, your fourth is going to be really 159 00:10:43.799 --> 00:10:46.159 good at gram negative, so loses gram negative as goes on. The way 160 00:10:46.159 --> 00:10:48.320 that I used to remember that, it seems so simple, but then when 161 00:10:48.360 --> 00:10:52.200 you're having an exam question, you've a thousand things in your head and you 162 00:10:52.240 --> 00:10:54.200 see a first generation and you're like, wait, is this the one that's 163 00:10:54.240 --> 00:10:56.639 good at gram negative gram positive. So the way that you remember that, 164 00:10:58.200 --> 00:11:01.159 as you know, in the Olympics or anytime you have like some kind of 165 00:11:01.240 --> 00:11:05.919 race or whatever, they have those podiums where you have the person standing in 166 00:11:05.000 --> 00:11:09.200 first place. They're standing in the little boxes that says like first place, 167 00:11:09.279 --> 00:11:13.000 second place, third place, etc. Well, the person in first place, 168 00:11:13.159 --> 00:11:18.240 aka your first generation person in first place is super positive they got first 169 00:11:18.240 --> 00:11:24.000 place. They're so happy, they're so positive, they're almost completely absent of 170 00:11:24.039 --> 00:11:28.399 any negative feelings at all. That's because your first generation covers gram positive but 171 00:11:28.600 --> 00:11:33.600 very little GRAM negative. The person in third and fourth generation, they are 172 00:11:33.679 --> 00:11:37.279 not very positive at all. They're mostly negative because they're like almost in last 173 00:11:37.279 --> 00:11:41.279 place, third and fourth place. They're very negative but very little positive. 174 00:11:41.320 --> 00:11:46.080 They're not happy they did not get first place. So as you go on 175 00:11:46.159 --> 00:11:48.919 from first, second, third, and fourth, you're losing that positive feeling 176 00:11:48.960 --> 00:11:54.799 because you're going further on in the places, and you're gaining negative feelings because 177 00:11:54.799 --> 00:11:58.000 you're further on in the placement. So that's how you used to remember it. 178 00:11:58.000 --> 00:12:01.559 It's just a simple way to kind of remember with the cephalisborns as far 179 00:12:01.559 --> 00:12:03.559 as their coverage as a general rule. All right, so let's go ahead 180 00:12:03.600 --> 00:12:07.519 and get started with the generations. We'll start with our first generation Cephalis born. 181 00:12:09.039 --> 00:12:11.639 That's going to include cephalexin which the brand name is Keflex. That's your 182 00:12:11.720 --> 00:12:16.960 po variety, and then cephazolin, which is known as anseff. That's the 183 00:12:16.000 --> 00:12:22.039 brand name and that's your IV. So these have really good gram positive coverage. 184 00:12:22.039 --> 00:12:26.440 Like I just went over so staff strap skin infections. It does have 185 00:12:26.480 --> 00:12:30.279 some mild gram negative coverage like free coli, proteus, clepsi yellow, but 186 00:12:30.360 --> 00:12:33.320 the main usephere first gens. What they do best is gram positive organisms. 187 00:12:33.840 --> 00:12:39.320 Remember you're on the first place podium. You're super positive. You got first 188 00:12:39.320 --> 00:12:43.360 place. You're covering gram positive really well, so high old indications. There's 189 00:12:43.399 --> 00:12:48.279 really two things that I think you should know, skin infections and surgical prophylaxis. 190 00:12:48.320 --> 00:12:54.919 So skin infections MSSA, So all of your skin infections involving staff fulliculitis, 191 00:12:54.919 --> 00:13:01.159 peronnikia MSSA, be thinking of your first gens particular or lead with sephyluxin, 192 00:13:01.240 --> 00:13:05.679 which is your oral antibiotic of this class. Surgical prophyloxis is the second 193 00:13:05.720 --> 00:13:09.000 thing I think you should know cephozolin. So when you do your surgical rotations, 194 00:13:09.039 --> 00:13:11.480 you'll hear this before every every single surgery. Two grams of antef on 195 00:13:11.519 --> 00:13:16.879 board. It's basically the most commonly used antibiotic for surgical prophyloxis. So know 196 00:13:16.000 --> 00:13:22.000 that for sefazolon. So again two things skin infections, MSSA, methyslin, 197 00:13:22.039 --> 00:13:26.440 susceptible stephorius. You should be thinking that with your first gens, particularly selection 198 00:13:26.639 --> 00:13:31.200 cephalexin and then surgical prophyloxis one hundred percent cephyzolin. All right, So those 199 00:13:31.200 --> 00:13:35.720 are your first gens, not allowed to know their second generation sef oxyten, 200 00:13:35.879 --> 00:13:39.559 sefuroxen, cepiclo, cefot tm. So that's a lot, a lot of 201 00:13:39.559 --> 00:13:43.039 weird names. How you're going to remember that those are all your second generation. 202 00:13:43.320 --> 00:13:48.600 So what you remember is you think of two furry fox drinking tea on 203 00:13:48.639 --> 00:13:54.679 the floor. Again, two furry fox drinking tea on the floor. So 204 00:13:54.080 --> 00:14:00.279 two arry helps you remember your second generation furry. That helps you remember rock 205 00:14:00.320 --> 00:14:07.200 seam fox. That's sefoxytin drinking t cefot tan on the floor, sefa cloor. 206 00:14:07.799 --> 00:14:11.399 So that helps you remember again the meds that are in this class. 207 00:14:11.080 --> 00:14:15.799 Two furry fox drinking tea on the floor. Remember that you remember your second 208 00:14:15.799 --> 00:14:20.159 gen cephalosporins. So compared to first gen, weaker gram positive coverage, but 209 00:14:20.399 --> 00:14:26.840 broader gram negative coverage picks up coverage for enterobacter Icia. It also does and 210 00:14:26.879 --> 00:14:31.279 this is the key. Have anaerobic coverage, good anaerobic coverage for basically all 211 00:14:31.279 --> 00:14:35.960 the Cephalis sporins. So first gens have better gram positive coverage. Third gens 212 00:14:35.960 --> 00:14:39.159 are going to have better gram negative coverage. So the second gens are kind 213 00:14:39.159 --> 00:14:41.159 of like the forgotten middle child. But the key, like I said, 214 00:14:41.399 --> 00:14:45.840 for your second gens is their anaerobic coverage, and that's with sef oxytin and 215 00:14:45.879 --> 00:14:52.200 cefo t tan particularly good for your pelvic infections and trabdominal infections. That's what 216 00:14:52.279 --> 00:14:54.960 you'll normally see them test it on. So for high old indications, they 217 00:14:56.000 --> 00:15:00.759 do have indications for covering UTIs, they have indications for covering resp praetory infections 218 00:15:00.799 --> 00:15:03.240 line disease second line to doxy. But for the sake of an exam, 219 00:15:03.360 --> 00:15:09.159 what you'll need to focus on is the intrabdominal and pelvic infections involving your anaerobes 220 00:15:09.240 --> 00:15:11.200 like bacteroids. When it comes to second gens, that's what you're going to 221 00:15:11.240 --> 00:15:13.919 be tested on. That's what I would focus on. So again, HYLD 222 00:15:13.960 --> 00:15:20.039 indications intrabdominal and pelvic infections, cefottan and sefoxyten really good for PID for pelvic 223 00:15:20.080 --> 00:15:26.720 inflammatory disease. There is some resistance seen in cephottan from B for jealous so 224 00:15:26.840 --> 00:15:30.840 for intrabdominal infections might not be the best choice anymore. But remember for PID, 225 00:15:31.240 --> 00:15:33.679 Cephottan and sefoxyten have really good coverage. So that's what you should focus 226 00:15:33.720 --> 00:15:37.559 on for your second gens. I wouldn't worry about anything else because really that's 227 00:15:37.559 --> 00:15:41.159 what they have best coverage of, and that's what you'll probably see on an 228 00:15:41.200 --> 00:15:43.879 exam question. All right, So moving on to our third generation cephalosporins. 229 00:15:43.879 --> 00:15:50.399 That's sef triaxone, cefotaxin, ceftazidine, some others in this class, sef 230 00:15:50.440 --> 00:15:52.960 podoxine, but really those are the three that ever seemed to come up. 231 00:15:52.960 --> 00:15:56.279 Those are the ones that I would focus on. So how do you remember 232 00:15:56.320 --> 00:16:00.600 them? You remember, if you try taxing me, you won't get a 233 00:16:00.639 --> 00:16:03.720 dime. You can try taxing me, but you won't get a dime, 234 00:16:03.039 --> 00:16:07.480 so you can try that. Sef triaxone also try helps you remember your third 235 00:16:07.480 --> 00:16:14.679 generation taxing cefotaxim, but you won't get a dime. Seftazidine again, so 236 00:16:14.720 --> 00:16:18.879 you can try taxing me, but you won't get a dime. Triaxone. 237 00:16:18.919 --> 00:16:23.080 Also try third generation taxing sefotaxime, but you won't get a dime seftazidine. 238 00:16:23.159 --> 00:16:29.120 All right, So these have really excellent gram negative coverage, including pseudomonus. 239 00:16:29.120 --> 00:16:33.200 With seftazidine, gram positive coverage is decreased. Remember you're in third place. 240 00:16:33.279 --> 00:16:37.600 You're pretty negative at this point, not very positive. Some antibiotics in this 241 00:16:37.639 --> 00:16:41.559 class, like seftazidine, have virtually no gram positive coverage at all. Your 242 00:16:41.600 --> 00:16:48.240 third gends mainly about your gram negatives and pseudomonis. With seftazidine, it's important 243 00:16:48.240 --> 00:16:51.879 to remember that seftazidim has pseudomonus coverage because that always seem to come up. 244 00:16:52.480 --> 00:16:55.879 And I have another another mnemonic for you to remember that. So if you 245 00:16:56.000 --> 00:16:57.960 sue me, you won't get a dime. If you sue me, you 246 00:16:59.000 --> 00:17:03.600 won't get a dime. So sue helps you remember sue domonas you won't get 247 00:17:03.639 --> 00:17:07.839 a dime seftazidine. So if you sue me pseudomonas, you won't get a 248 00:17:07.880 --> 00:17:12.240 dime seftazidine. So that helps you remember seftazidine only third gen that covers pseudomonas. 249 00:17:12.640 --> 00:17:17.720 What are your high old indications gonococcal infections. That's really big. SEF 250 00:17:17.720 --> 00:17:23.480 triaxon meningitis. So your third generation cephalosporins cefotaxim, sef triaxone are the beta 251 00:17:23.519 --> 00:17:30.200 lactems of choice and impure treatment of meningitis generally combined with other antibiotics for their 252 00:17:30.240 --> 00:17:34.279 synergistic effect. And then community acquired pneumonia hospitalized. All right, those are 253 00:17:34.279 --> 00:17:40.559 your high old indications. Now, fourth generation this is very simple. Last 254 00:17:40.559 --> 00:17:42.759 two generations are really easy with your cephalisporons because there's only a couple of meds. 255 00:17:42.880 --> 00:17:48.759 So fourth generation ceph apem, that's the only fourth generation cephalosporin. Nice 256 00:17:48.759 --> 00:17:52.920 and easy. What a sephapem cover gram negative including pseudomonas, which is really 257 00:17:52.920 --> 00:17:57.599 important. It has very limited gram positive coverage basically just for MSSA, but 258 00:17:57.680 --> 00:18:03.680 remember gram negative pseudomonus. That's the key, all right, So you get 259 00:18:03.720 --> 00:18:07.799 some gram negative coverage, little gram positive coverage mainly for staff. But remember 260 00:18:07.839 --> 00:18:11.960 pseudomonis. So there's not a lot to know about cephapeine basically, just that 261 00:18:11.000 --> 00:18:15.119 it's a fourth generation sephless sporin and it has good coverage against pseudomonis. That's 262 00:18:15.160 --> 00:18:19.400 all i'd remember. How do you remember that. So instead of remembering cephapeam, 263 00:18:19.640 --> 00:18:25.279 remember SEP four peam. So instead of cephapeem, remember se four peem. 264 00:18:25.359 --> 00:18:29.359 The number four that helps you remember it's a fourth generation cephalis sporin. 265 00:18:29.880 --> 00:18:34.880 And then it helps remember Pseudomonis, which has four syllables, so pseudomonas four 266 00:18:36.279 --> 00:18:40.519 four syllables. That helps you remember coverage of pseudomonis. So again instead of 267 00:18:40.559 --> 00:18:45.519 cephapem, remember SEF four peam. Fourth generation selphless sporin four also stands for 268 00:18:45.559 --> 00:18:48.279 the four syllables that are in Pseudomonis. Helps you remember that it covers pseudomonis. 269 00:18:48.359 --> 00:18:51.680 Those are the two things that I've remembered for it, I wouldn't worry 270 00:18:51.680 --> 00:18:55.720 about anything else, all right, Next generation, fifth generation Sef Tarolin. 271 00:18:56.160 --> 00:18:57.799 It's another easy one. It's really the only one you need to know. 272 00:18:57.839 --> 00:19:03.279 If you're outside of the US. There's another fifth generation Cephalis born called Sef 273 00:19:03.400 --> 00:19:06.799 Tobra Paul here in the States that we just have Sef tarrolein. So that's 274 00:19:06.799 --> 00:19:10.519 all you need to know Sef Tarlen. The main thing is that it's the 275 00:19:10.519 --> 00:19:14.400 only sephless sporn that covers mersa. That's all I would focus on MRSA. 276 00:19:14.680 --> 00:19:17.359 It's the unique thing about it. It's the primary use for the drug, 277 00:19:17.519 --> 00:19:19.359 and that's what you're going to be tested on. So again, two things, 278 00:19:19.359 --> 00:19:22.240 just like in the fourth gend that you need to know for this one. 279 00:19:22.680 --> 00:19:25.200 Two things that you need to know. Sef Tarlene, it's a fifth 280 00:19:25.240 --> 00:19:29.359 generation sephless born. And then two it covers Mursa. So how do you 281 00:19:29.359 --> 00:19:33.920 remember that? So instead of remembering Sef Tarolene, remember Sef Starlene. So 282 00:19:33.960 --> 00:19:37.960 instead of Sef Tarlene, remember Sef Starolene. And then when you think of 283 00:19:38.000 --> 00:19:41.200 a star, how many sides does a star have? It has five? 284 00:19:41.279 --> 00:19:45.720 That helps you remember your fifth generation sephless born. And then when you look 285 00:19:45.720 --> 00:19:48.279 out into the stars, what's the closest planet you can sometimes see and that's 286 00:19:48.319 --> 00:19:53.559 Mars. And what is Mars rearranged? Mars is just Mursa rearranged, the 287 00:19:53.680 --> 00:19:59.119 letters rearranged, So mrs A M A R S. That's just those letters 288 00:19:59.119 --> 00:20:02.599 of Mars rear arranged. So that helps you remember Merca coverage. So again, 289 00:20:03.200 --> 00:20:07.400 Sef Tarolin, just remember star Alene. Think of a star, five 290 00:20:07.440 --> 00:20:10.759 sides to a star, fifth generation sephless born. And then when you look 291 00:20:10.759 --> 00:20:12.519 at into the stars. You can see Mars, which is our closest planet. 292 00:20:12.880 --> 00:20:17.079 Mars is just MRSA. The letters rearranged. That helps you remember this 293 00:20:17.119 --> 00:20:19.359 is the only sephileis sporning that has MERCA coverage. You're done. Those are 294 00:20:19.359 --> 00:20:25.160 your sephless sporns. Let's keep moving on with our mono backdam. So monobacktam 295 00:20:25.279 --> 00:20:29.519 as trion m that's the only one as trionam, and this does not have 296 00:20:29.599 --> 00:20:32.920 a lot to know about it. There's really just one thing. So mono 297 00:20:32.960 --> 00:20:38.640 backdams as trionam cover gram negatives only including pseudomonas, so basically just gram negative 298 00:20:38.680 --> 00:20:45.160 aerobes, no gram positives. So obviously you know MERSA doesn't cover anaerobes gram 299 00:20:45.200 --> 00:20:48.960 negatives only including pseudomonas, although there's actually a pretty significant rate of resistance in 300 00:20:49.039 --> 00:20:53.720 most institutions against it, so normally need to utilize impure double coverage. So 301 00:20:53.799 --> 00:20:57.240 mono backdam's the main thing about this one. This is what you need to 302 00:20:57.279 --> 00:21:03.519 remember about as trionam. No cross reactivity with other beta lactam antibiotics. You 303 00:21:03.559 --> 00:21:07.039 can give it if they have a penicillin allergy or a selphless sporin allergy, 304 00:21:07.119 --> 00:21:10.920 it's the main thing you need to know and possibly the only thing you need 305 00:21:10.960 --> 00:21:15.640 to know for this medication as trion Am, as far as exam questions just 306 00:21:15.839 --> 00:21:18.559 exist for this one thing and the vignette. They're going to give you a 307 00:21:18.559 --> 00:21:22.839 patient that has a severe anaphylactic reaction to penicillin, for instance, and then 308 00:21:22.880 --> 00:21:26.119 they're going to say which antibiotic class would you give them for their infection. 309 00:21:26.319 --> 00:21:29.000 They're going to have a bunch of beta lactam class antibiotics. They're going to 310 00:21:29.039 --> 00:21:30.640 give you cephless sporins in there, they're going to give you penicillans, and 311 00:21:30.680 --> 00:21:33.480 then as tree andam is going to be in there, and that's going to 312 00:21:33.519 --> 00:21:37.440 be your answer. So remember no cross reactivity with other beta lactam antibiotics. 313 00:21:37.839 --> 00:21:41.440 Little fyi here, though, I don't think they'll be evil to you on 314 00:21:41.480 --> 00:21:44.400 the exam and do this to you. But as treonam, like I said, 315 00:21:44.640 --> 00:21:48.559 you can use it in sephless sporon allergies penicillin allergies, but the exception 316 00:21:48.279 --> 00:21:53.240 is seftazidine. They share a similar side chain. So again I don't think 317 00:21:53.240 --> 00:21:56.920 they're going to be cruel and do this to you. But in real life, 318 00:21:56.000 --> 00:22:00.480 remember that, so you can give them in pay with penicillona sepfhless sporin 319 00:22:00.559 --> 00:22:06.000 allergies. The exception is seftazidine. Remember that similar side chain, so that 320 00:22:06.039 --> 00:22:11.079 can trigger the same allergic reaction. And then we know that seftazidim is a 321 00:22:11.119 --> 00:22:14.440 third generation sefhless sporn. How do you how do we know that? Remember, 322 00:22:14.440 --> 00:22:17.920 if you try taxing me, you won't get a dime seftazidimee. And 323 00:22:17.920 --> 00:22:21.400 then we also know seftazidim also cover pseudomonus because if you try suing me, 324 00:22:21.680 --> 00:22:25.319 you won't get a dime. All right, Just trying to reiterate that, 325 00:22:25.319 --> 00:22:27.400 so you remember that the other thing too. I don't think this is as 326 00:22:27.440 --> 00:22:32.799 important, but as tree and am also doesn't cause any renal toxicity, so 327 00:22:32.799 --> 00:22:36.319 you can use this in patience with renal insufficiency. I don't think it's as 328 00:22:36.359 --> 00:22:38.400 important, but just a little extra thing for you to know, all right, 329 00:22:38.480 --> 00:22:44.720 Moving right along to our carbon penem. So that's immopenem selastin meropenem and 330 00:22:44.920 --> 00:22:52.200 ertepenem just an fi immopenem unlike merropenam and ertepenem. It's never administered alone. 331 00:22:52.240 --> 00:22:55.359 As you can see, I said it's immopendum selastin. That combo, it 332 00:22:55.400 --> 00:22:59.559 always gets combined with selastin. The reason is because if you give it by 333 00:22:59.559 --> 00:23:03.839 itself, that actually gets inactivated by the proximal renal tubule and it can lead 334 00:23:03.880 --> 00:23:07.480 to necrosis of the proximal tubule. So you'll always see this carbon penum combined 335 00:23:07.599 --> 00:23:12.319 with selastin. All right, so what do carbon pendums cover. They're extremely 336 00:23:12.440 --> 00:23:18.759 broad spectrum antibiotics. They cover a lot so gram positive, gram negative, 337 00:23:18.920 --> 00:23:23.400 including your espl organisms, pseudomonas, anaerobes. So these are about as broad 338 00:23:23.720 --> 00:23:30.359 spectrum as antibiotics get. They cover everything, like I said, gram positive, 339 00:23:30.359 --> 00:23:36.200 gram negative, including those extended spectrum beta lactomass pseudomonas, although there's one 340 00:23:36.200 --> 00:23:40.279 exception I'll get to in a minute. They cover anaerobes including beef jellous. 341 00:23:41.119 --> 00:23:42.839 This is another one where it's just easy to remember what they don't cover, 342 00:23:44.240 --> 00:23:48.200 and really that's just MERSA and your atypicals. Otherwise you can pretty much use 343 00:23:48.279 --> 00:23:52.359 these for anything else. And that's why in practice you're not going to do 344 00:23:52.599 --> 00:23:56.279 that, because really broad spectrum drugs should rarely be used because they breed resistance. 345 00:23:56.400 --> 00:24:02.240 These are basically your silver bullet. They're used for severe infections where you 346 00:24:02.319 --> 00:24:04.240 don't know what the bug is. The person's crashing, they're dying, so 347 00:24:04.279 --> 00:24:07.759 you just have to throw everything at them. You can't be concerned with the 348 00:24:07.880 --> 00:24:11.000 resistance and everything else, so you're not going to use these often. Now, 349 00:24:11.039 --> 00:24:17.599 I mentioned before these cover Pseudomonus within exception, so that exception is ertapenem. 350 00:24:17.680 --> 00:24:21.759 Ertapenem does not cover pseudomonus. It's the only carbon pendum that does not. 351 00:24:22.519 --> 00:24:25.240 And I actually had a question on this in school, which I think 352 00:24:25.319 --> 00:24:27.799 was kind of cruel, but anyways, I used to remember that ertapenem is 353 00:24:27.799 --> 00:24:33.200 the exception to the rule where all other carbon penums cover pseudomonus. It's the 354 00:24:33.240 --> 00:24:37.160 only one that does not. And ertapenem is the only carbon penum that starts 355 00:24:37.200 --> 00:24:41.359 with an E. So when you see E, remember that means exception because 356 00:24:41.359 --> 00:24:44.920 it's the exception to the rule that are all carbon pendums cover pseudomonus, it 357 00:24:45.000 --> 00:24:48.039 does not. It's the exception, only one that starts with an Eerdepenem. 358 00:24:48.119 --> 00:24:52.400 Remember that as far as is your adverse drug reactions for this CNS toxicity. 359 00:24:52.440 --> 00:24:56.480 So they can lower seizure threshold, particularly with immapenem. That's really all I 360 00:24:56.480 --> 00:24:59.200 would know for those that's the end of your beta lactam. So you're going 361 00:24:59.240 --> 00:25:02.279 to get a lot of question from those, So know those pretty well beta 362 00:25:02.319 --> 00:25:06.640 lactums of course, penicillin, cephalis porins, carbopenams, mono backdamps. Let's 363 00:25:06.720 --> 00:25:10.920 keep moving a longer. We're going to go onto our aminoglycosides. That's gentomycin, 364 00:25:11.000 --> 00:25:18.160 tobermycin, mcacent neomycin, streptomycin. So these cover gram negatives including pseudomonis, 365 00:25:18.640 --> 00:25:22.440 little to no gram positive coverage, no anaerobic coverage, basically just gram 366 00:25:22.519 --> 00:25:27.200 negatives for your aminoglycosides. There's not really any high old indications that memorize for 367 00:25:27.200 --> 00:25:33.880 aminoglycosides. There's really few instances where you use these as monotherapy fort with systemic 368 00:25:33.880 --> 00:25:37.000 immeno glycosides. Not your drops I'm talking about like for your infections, but 369 00:25:37.279 --> 00:25:42.960 really just two instances where you use these as monotherapy with systemic amminoglycosides. That's 370 00:25:44.000 --> 00:25:48.240 two laurmia in plague. So not exactly your high yield diseases. You can 371 00:25:48.359 --> 00:25:52.599 use it for its synergistic effect with other drugs and endocarditis, but over all, 372 00:25:52.720 --> 00:25:56.000 the highest yield thing about amminoglycosides is actually their adverse drug reactions. I 373 00:25:56.039 --> 00:26:00.680 remember being asked about in clinical rotations about this on exam USTs. This is 374 00:26:00.720 --> 00:26:03.519 probably the most important thing to remember. So adverse drug reactions you need to 375 00:26:03.519 --> 00:26:10.640 remember. These drugs can be both autotoxic and nephrotoxic, so autotoxicity aminoglycoside induced 376 00:26:10.640 --> 00:26:15.799 autotoxicity can result in vestibular or cochlear damage and then nephrotoxicity. Ten to twenty 377 00:26:15.799 --> 00:26:22.519 percent of patients can experience some degree of nephrotoxicity with these meds. In most 378 00:26:22.559 --> 00:26:26.319 cases, aminoglycoside nephrotoxicity is actually reversible though much Obviously it's a good thing, 379 00:26:26.640 --> 00:26:30.000 all right, So how do you remember the main things that you need to 380 00:26:30.039 --> 00:26:37.039 know about your aminoglycosides. So all of your memno glycosides end in ci N, 381 00:26:37.240 --> 00:26:41.839 so gentomycin tobermycin, I'm a casin ci N. They all end in 382 00:26:41.960 --> 00:26:44.759 I know there's other classes that also end in ci N. You just kind 383 00:26:44.759 --> 00:26:48.720 of have to be familiar with these ones and remember for thisneumonic to work. 384 00:26:48.440 --> 00:26:52.359 But remember they all end in ci N. So what does ci N stand 385 00:26:52.359 --> 00:26:56.079 for? Cion stents For a couple of things. One it stands for coverage 386 00:26:56.079 --> 00:27:00.200 includes negatives because that helps you remember. This is basically just covering your gram 387 00:27:00.319 --> 00:27:04.279 negative organisms. So ci N stands for coverage includes negatives, gram negative organisms, 388 00:27:04.480 --> 00:27:10.240 and then ci N also stands for cruscious incus and nephrons. Remember incas 389 00:27:10.279 --> 00:27:14.000 is one of your auditory oscles that helps you remember your autotoxicity. And then 390 00:27:14.079 --> 00:27:15.640 nephrons, of course you know, is the functional unit of the kidney. 391 00:27:15.720 --> 00:27:19.279 Helps remember the nephrotoxicity that can happen in these drugs. Remember all of your 392 00:27:19.319 --> 00:27:23.759 drugs and in cin in this class, coverage includes negatives. This is mainly 393 00:27:23.759 --> 00:27:29.599 covering gram negatives and then crushes incas and nephrons because you can cause autotoxicity and 394 00:27:29.640 --> 00:27:34.200 nephrotoxicity with this drug class. All right, moving on to our tetracyclines doxis 395 00:27:34.200 --> 00:27:40.119 cycling, tetracycline, minnocyclines. So a few different meds in the tetracycline class, 396 00:27:40.160 --> 00:27:42.880 but basically this is the doxycycling show. Most things you need to know 397 00:27:42.920 --> 00:27:48.680 about the tetracyclines will be about doxy, so make that your focus. This 398 00:27:48.720 --> 00:27:52.160 is another one that has a pretty broad spectrum of activity gram negatives gram positives, 399 00:27:52.160 --> 00:27:59.000 including mersa atypicals, and then you're weird stuff. So weird stuff, 400 00:27:59.039 --> 00:28:03.279 what's that? Well, anytime you have some odd organism or unusual pathogen, 401 00:28:03.359 --> 00:28:06.559 we should be thinking about using a tetracycline. So vibrio, brucella, Q 402 00:28:06.720 --> 00:28:11.279 fever, anthrax, line disease, they're all covered by tetracyclines. Usually, 403 00:28:11.279 --> 00:28:15.039 of course it's going to be doxy. So for your high yeld indications, 404 00:28:15.079 --> 00:28:18.400 it's really just doxy that can that you have to focus on. There's not 405 00:28:18.480 --> 00:28:22.480 a lot of high old indications for mentocycline and tetracycline. Mentocycline is mainly just 406 00:28:22.599 --> 00:28:26.720 used for acne. So the three things that you need to know for a 407 00:28:26.799 --> 00:28:30.440 doxy are rocky mountain, spotted fever, chlamydia, and lime disease. Those 408 00:28:30.440 --> 00:28:34.200 are your high heeled indications. Of course there's other things that doxies used for, 409 00:28:34.240 --> 00:28:37.920 but these are the ones that always seem to come up in a vignette. 410 00:28:37.200 --> 00:28:41.279 So chlamydia doxy is now first line for chlamydia. Used to be a 411 00:28:41.319 --> 00:28:45.720 zithromycin, but due to superior efficacy we see with doxy compared to a zithro 412 00:28:47.079 --> 00:28:49.480 the guidelines have changed and now doxy is going to be your first line. 413 00:28:49.480 --> 00:28:53.920 One hundred milligrams bid seven days for your first line treatment for chlamydia Rocky Mountain 414 00:28:53.920 --> 00:28:59.440 spotted fever first line. Pretty much all patients are going to get doxe. 415 00:28:59.480 --> 00:29:03.240 Even in young children. You're gonnay for Rocky Mountain spoted fever, You're gonna 416 00:29:03.240 --> 00:29:07.640 give doxy. Just a heads up Rocky Mountain spotted fever treatment in pregnancy. 417 00:29:07.880 --> 00:29:11.839 It used to be chlorine. Fennocole used to be your first line, but 418 00:29:11.079 --> 00:29:15.279 now that's even being replaced with doxy. If you look at the updated guidelines, 419 00:29:15.319 --> 00:29:18.240 so Rocky Mountain spotted fever pretty much doxy all the way. Lime disease 420 00:29:18.920 --> 00:29:26.039 first line, non pregnant adults and children and older children with lime disease kids 421 00:29:26.119 --> 00:29:29.880 under eight, the guidelines are kind of muddy. You'll be taught less than 422 00:29:30.039 --> 00:29:33.200 eight with lime disease, you're gonna give them moxycillon, and then over eight 423 00:29:33.200 --> 00:29:36.839 you're gonna give them DOXE. I'd probably learn it that way for the boards 424 00:29:36.839 --> 00:29:38.039 and for your exams, But if you look at the guidelines, that really 425 00:29:38.039 --> 00:29:41.319 depends on the stage of the infection the child has. So if it's just 426 00:29:41.480 --> 00:29:45.480 cutaneous disease. Normally you'll just give them moxicillin, but there's any signs of 427 00:29:45.519 --> 00:29:52.559 neurologic involvement, you can preferably use doxy. And actually, the American Academy 428 00:29:52.559 --> 00:29:56.079 of Pediatric supports the use of doxycycling for children under eight as long as it's 429 00:29:56.079 --> 00:29:59.960 administered for less than twenty one days, which in doxy is the case. 430 00:30:00.680 --> 00:30:04.119 So again, the three high old indications you're gonna remember for doxycycling are gonna 431 00:30:04.119 --> 00:30:07.079 be chlamydia, Rocky Mountain spotted fever, and lime disease. So how do 432 00:30:07.119 --> 00:30:11.559 you remember that? Well, what you do is you think of sitting on 433 00:30:11.640 --> 00:30:14.799 a dock by the sea, like a nice seafood restaurant, and a dock 434 00:30:14.880 --> 00:30:18.960 by the sea eating clams and Rocky Mountain oysters with a squeeze of lime. 435 00:30:19.559 --> 00:30:26.039 So you're sitting on a dock by the sea, doc sea cycling, eating 436 00:30:26.119 --> 00:30:32.039 clams, chlamydia, and Rocky Mountain oysters Rocky Mountain spotted fever with a squeeze 437 00:30:32.079 --> 00:30:36.440 of lime over the top. And that's your lime disease. If you know 438 00:30:36.480 --> 00:30:38.920 what Rocky mount oysters are, they are not seafood, but it helps the 439 00:30:40.000 --> 00:30:44.319 pneumonic work. So remember again, you're high held indications for doxy. If 440 00:30:44.039 --> 00:30:47.640 you think of sitting on a dock by the sea, doc sea cycling, 441 00:30:47.759 --> 00:30:52.319 eating clams, chlamydia, and Rocky Mountain oysters, Rocky Mountain spotted fever with 442 00:30:52.359 --> 00:30:56.599 a squeeze of lime over the top lime disease. Don't forget. Doxy can 443 00:30:56.640 --> 00:30:59.640 also be used in community acquired pneumonia. But as far as the high yeld 444 00:30:59.680 --> 00:31:00.359 ones, like I said, the ones that always seem to come up, 445 00:31:00.359 --> 00:31:03.480 those are the three that I would focus on. There are also some high 446 00:31:03.519 --> 00:31:08.000 old adverse drug reactions, so teeth discoloration. It can inhibit bone growth in 447 00:31:08.119 --> 00:31:14.839 children, So tetracycline antibiotics have been associated with permanent tooth discoloration and children under 448 00:31:14.839 --> 00:31:18.200 eight years of age if used repeatedly or for prolonged courses, which this does 449 00:31:18.240 --> 00:31:22.119 not occur in adults, and then tetracyclines may also deposit in bone and effect 450 00:31:22.279 --> 00:31:26.559 growth, which is why we're cautious using this drug in children for a long 451 00:31:26.599 --> 00:31:30.599 periods of time. They can also have impaired absorption when you take them with 452 00:31:30.599 --> 00:31:34.559 certain minerals and in acids like aluminum, calcium, iron, magnesium, so 453 00:31:34.640 --> 00:31:38.960 certain vitamins or dairy products when taken at the same time as tetracyclines, can 454 00:31:40.160 --> 00:31:42.440 chilate with the antibiotic and impair its absorptions. So remember that again that's going 455 00:31:42.480 --> 00:31:45.240 to be like aluminum, calcium, iron, magnesium, So you just want 456 00:31:45.240 --> 00:31:49.119 to warn your patients about this before starting the antibiotic. Normally it's good to 457 00:31:49.119 --> 00:31:52.799 put it on your actual prescription when you send it off to the pharmacy. 458 00:31:52.960 --> 00:31:56.039 Do not take these at the same time because of the impaired absorption and then 459 00:31:56.079 --> 00:32:01.720 photosensitivity. So there's other classes that can cause photosensitivity reactions, but it seems 460 00:32:01.759 --> 00:32:07.000 to most commonly come up in questions about the tetracyclines. So the effect can 461 00:32:07.119 --> 00:32:10.480 range from a mild red rash to blistering on areas exposed to the sun. 462 00:32:10.519 --> 00:32:14.119 So you just also want to warn your patients about this as well. Those 463 00:32:14.160 --> 00:32:15.640 are the main things that seem to come up with that class. Let's move 464 00:32:15.640 --> 00:32:20.759 on to our fluoroquinolons. So the first thing to know about fluoroquinolans is you're 465 00:32:20.799 --> 00:32:23.319 generally going to avoid using it in your run of the mill infections. So 466 00:32:23.400 --> 00:32:29.759 like RYANU sinew sitis uncomplicated UTIs, the risks outweigh the benefits, So keep 467 00:32:29.799 --> 00:32:32.359 that in mind when you're practicing. Don't give cipro for a simple UTI when 468 00:32:32.400 --> 00:32:37.039 you could just just as easily given macrobid, which is nitrofur intoine. Save 469 00:32:37.119 --> 00:32:42.480 these class for your more complicated infections. So the drugs that are in this 470 00:32:42.519 --> 00:32:46.400 class are going to be ciprofloxysin, levofloxisin, moxifloxis and those are the three 471 00:32:46.559 --> 00:32:50.799 that you need to know. Let's go over each individual one and talk about 472 00:32:50.839 --> 00:32:52.880 a little bit that you need to know with each one. So moxifloxis in 473 00:32:52.960 --> 00:33:00.640 this is called a quote unquote respiratory fluoroquinolone. So moxi in addition to floxysin 474 00:33:00.720 --> 00:33:05.359 are considered respiratory fluoroquinolans. This isn't like an official thing, but this is 475 00:33:05.400 --> 00:33:08.960 kind of generally what they're known as. The reason is because both of these 476 00:33:09.039 --> 00:33:14.440 drugs in this class are active against the most common respiratory pathogens including Strep. 477 00:33:14.480 --> 00:33:19.720 Numo, homophilus, influenza, monexella, and that's why you call them unofficially 478 00:33:19.720 --> 00:33:25.000 are respiratory fluoroquinolones. Moxifloxysin has the best grand positive coverage of all of the 479 00:33:25.000 --> 00:33:30.279 three that we're going to go over also has really good coverage of your atypicals 480 00:33:30.319 --> 00:33:34.480 and your anaerobes. Maxi of the fluoroquinolones, is really the only one with 481 00:33:34.559 --> 00:33:37.960 decent anaerobic coverage, and because of this, it can actually be used for 482 00:33:37.160 --> 00:33:43.559 some intrabdominal infections, but it's really kind of limited due to the resistance among 483 00:33:43.640 --> 00:33:46.359 the bacteroid species, so it's not the best option, but it can be 484 00:33:46.440 --> 00:33:52.319 used as an alternative to ampicillin, soul backdam in aspiration ammonia for its good 485 00:33:52.319 --> 00:33:55.279 anaerobic coverage. So remember that, I'd say, of the three fluoroquinolans, 486 00:33:55.279 --> 00:33:59.400 this is probably going to be the one you're asked about the least. Most 487 00:33:59.480 --> 00:34:02.799 questions from my experience are about cipro and levofloxysin. But if you're asked something 488 00:34:02.839 --> 00:34:07.240 about Moxie, it's probably going to be related to its coverage of anaeropes. 489 00:34:07.240 --> 00:34:10.679 So remember that about Moxi is its anaerobic coverage that's unique in this class, 490 00:34:12.119 --> 00:34:15.760 So levofloxysin. This is another quote unquote respiratory fluoroquinolone. As we went over 491 00:34:15.800 --> 00:34:22.480 with MOXI, the big difference between Moxie and levofloxysin is levofloxysin also has activity 492 00:34:22.519 --> 00:34:25.480 in the urinary tract, so it can be used as an alternative to ciprofloxysin 493 00:34:25.559 --> 00:34:31.119 in some cases for pylonephritis your complicated UTIs where MOXI cannot MOXI has It are 494 00:34:31.159 --> 00:34:37.039 truly no urine activity, so levo floxysin has really good Gram positive coverage. 495 00:34:37.039 --> 00:34:42.320 It has coverage of atypicals levofloxysin As far as coverage, it's kind of in 496 00:34:42.360 --> 00:34:46.039 the middle. MOXI has better Gram positive coverage. Cipro has the best Gram 497 00:34:46.119 --> 00:34:51.519 negative coverage. Levofloxysin's kind of hanging out in the middle. It does have 498 00:34:51.719 --> 00:34:55.199 really good strepnumal coverage, though better than moxi, which is why it can 499 00:34:55.239 --> 00:35:00.199 be used as monotherapy in a community acquired pneumonia, although we try not to 500 00:35:00.920 --> 00:35:06.599 use it for pneumonia to prevent fluoroquinolone resistance among the respiratory pathogens and like it 501 00:35:06.679 --> 00:35:09.440 went over before, lever floxusin also does have similar coverage as seen in cipro. 502 00:35:09.599 --> 00:35:16.440 For your complicated UTIs complicated like acute cystitis pylonephritis, cipron Levo can kind 503 00:35:16.440 --> 00:35:21.559 of be used interchangeably, all right. That moves us onto our ciprofloxus in, 504 00:35:21.559 --> 00:35:23.320 our last drug in this class that will go over. This is a 505 00:35:23.440 --> 00:35:30.119 quote unquote urinary fluoroquinolone, so it's first line for pylonephritis your complicated UTIs. 506 00:35:30.519 --> 00:35:34.320 Ciprofloxusin is the only fluoroquinolone with a P in it. So that'll help me. 507 00:35:34.400 --> 00:35:38.159 Remember that as soon as you see your pepe stuff pylona fhritus UTIs prostatitis 508 00:35:38.199 --> 00:35:42.719 in your older males, you're going to be using cipro generally as your first 509 00:35:42.760 --> 00:35:45.559 line. A lot of people think the reason we don't use cipro for our 510 00:35:45.599 --> 00:35:51.039 respiratory tract infections like pneumonia is that it doesn't penetrate the lungs, but that's 511 00:35:51.079 --> 00:35:54.480 actually not the case. It's just that cipro has lesser activity against our grand 512 00:35:54.480 --> 00:35:59.920 positive organisms, in particular strep pneumo, and that's the reason we don't use 513 00:35:59.920 --> 00:36:04.320 it for most respiratory infections and reserve that from Maxi and levofloxicin, which have 514 00:36:04.400 --> 00:36:08.559 really great gram positive coverage. All right, So cipro best gram negative coverage 515 00:36:08.599 --> 00:36:14.440 of all of the fluoroquinolones, including the best coverage of pseudomonis. Pseudomonis has 516 00:36:14.480 --> 00:36:19.400 the best gram negative coverage of the fluoroquinolones, including the best pseudomonus coverage. 517 00:36:19.400 --> 00:36:23.800 Remember that so remember again as a quick recap, moxifloxysin best gram positive coverage, 518 00:36:23.840 --> 00:36:29.559 the only one with anaeroba coverage. Cipro best gram negative coverage including pseudomonis 519 00:36:29.639 --> 00:36:31.480 and levo floxysens. Kind of in the middle, but it has really good 520 00:36:31.480 --> 00:36:37.280 strep pneumo coverage. What are your high yeld indications pylonophritis with cipro and levofloxisin. 521 00:36:37.840 --> 00:36:44.119 Your complicated UTIs cipro and levofloxicin. Remember, if this is an uncomplicated, 522 00:36:44.199 --> 00:36:46.800 healthy patient, you're going to be sticking to bactrum or macrobit, which 523 00:36:46.840 --> 00:36:52.280 is nitroferent tone prostetitis, cipro or levo phloxicin. It can be used as 524 00:36:52.280 --> 00:36:58.480 impiric therapy in your older patients and then community acquire pneumonia, levofloxisin, moxifloxisin. 525 00:36:58.880 --> 00:37:01.239 These can be used as monotherapy, but generally reserve for your patients with 526 00:37:01.280 --> 00:37:06.840 comorbidities, older patients or other problems as far as adverse drug reactions, the 527 00:37:06.960 --> 00:37:10.320 fluoroquinolones have a bunch of adverse drug reactions that are possible. GI of course, 528 00:37:10.400 --> 00:37:14.199 is the most common as in most antibiotics, but we're going to focus 529 00:37:14.199 --> 00:37:16.000 on the ones that always seem to come up on exam questions and the more 530 00:37:16.159 --> 00:37:21.320 unique ones. And really there's three. First one is QT prolongation, so 531 00:37:21.440 --> 00:37:24.960 fluoroquino loans can prolong the QT interval, potentially leading to torsades, so we 532 00:37:25.000 --> 00:37:30.679 avoid this class and patients taking QT prolonging drugs or patients with long QT syndrome 533 00:37:30.960 --> 00:37:36.239 or other risk factors for rhythmias. The other one comes up a lot as 534 00:37:36.320 --> 00:37:40.320 tendinopathy or tendon rupture, So fluoroquinol loans can cause tendonopathy and tendin rupture. 535 00:37:40.519 --> 00:37:44.800 Most common sites is going to be your Achilles tendon, so always be careful 536 00:37:44.840 --> 00:37:47.679 to tell your patients avoid vigorous exercise, will on the medication, and have 537 00:37:47.800 --> 00:37:52.400 them alert you of any signs of tendinopathy, pain swelling, etc. And 538 00:37:52.400 --> 00:37:57.800 then they can also and this one's pretty interesting, they can precipitate a myocinic 539 00:37:57.880 --> 00:38:01.199 crisis. So fluoroquinolones actually have a black box warning for use and patients with 540 00:38:01.280 --> 00:38:08.639 Mystenia gravis because they have neuromuscular blocking activity which can precipitate a mystinic crisis. 541 00:38:08.840 --> 00:38:12.760 Remember that I did have that on an exam question. All right, so 542 00:38:12.800 --> 00:38:16.559 that's your floroquinolones. Let's move onto our macrolides, including a zithromycin, chlorithromycin, 543 00:38:16.760 --> 00:38:21.199 erythromycin. They cover a lot of things, so they cover gram negatives, 544 00:38:21.480 --> 00:38:24.719 gram positives, and they cover your atypicals. This class has pretty broad 545 00:38:24.760 --> 00:38:31.119 spectrum of activity. A zithromycin in particularly in particular, is going to have 546 00:38:31.400 --> 00:38:35.400 the it's really going to be your drug of choice for most of your atypical 547 00:38:35.519 --> 00:38:38.400 organisms. But remember they cover a lot of things, gram negatives, gram 548 00:38:38.440 --> 00:38:45.280 positives, atypicals, high yield associations. Chlamydia with a zithromycin. But remember, 549 00:38:45.880 --> 00:38:47.880 like I spoke about before, this used to be your first line treatment 550 00:38:47.880 --> 00:38:52.079 for chlamydia. But new evidence is showing the efficacy of doxy is superior, 551 00:38:52.320 --> 00:38:55.679 So most guidelines are saying doxy for us a zithro as a second line option, 552 00:38:57.000 --> 00:38:59.559 but it's still a good one to know in practice because the thing about 553 00:38:59.599 --> 00:39:02.360 giving is zithro for chlamydia is it's one dose. So if you have a 554 00:39:02.400 --> 00:39:06.000 patient you feel it is going to be non compliant and it's not going to 555 00:39:06.039 --> 00:39:09.159 take the doxi for seven days, a zithro is a good option. It 556 00:39:09.199 --> 00:39:12.599 maybe second line you may not have as good of coverage, but if you 557 00:39:12.599 --> 00:39:15.159 feel like the patient's not going to take the full course anyways, you can 558 00:39:15.199 --> 00:39:17.119 give them one dose of a zithro. You always have to keep that in 559 00:39:17.159 --> 00:39:20.719 mind. So on the exam question, the choice is probably gonna be doxy. 560 00:39:20.800 --> 00:39:23.960 But just remember in real life these little things for clinical practice. Another 561 00:39:24.000 --> 00:39:30.280 thing that it covers that you're probably going to hear about is Microbacterium avium complex, 562 00:39:30.760 --> 00:39:36.239 so a zithromycinchlora from mycense. So your macrolides are the cornerstone of antimicrobacterial 563 00:39:36.440 --> 00:39:39.880 therapy for MAC treatment and prophyloxis in your HIV patients with MAC. This is 564 00:39:39.960 --> 00:39:45.800 usually combined with or a fampin or a famb top. But just remember Microbacterium 565 00:39:45.800 --> 00:39:50.400 avium complex MAC. When you want to treat MAC, you use a macrolide, 566 00:39:50.400 --> 00:39:52.920 So remember that remember to treat MAC, you're going to use a mac 567 00:39:53.039 --> 00:40:00.000 rolide. Community acquired pneumonia also is zithromycinchlorithromycin. So for both your typical organisms 568 00:40:00.039 --> 00:40:05.360 like strap numo as well as your atypicals like microplasma pneumonia, macrolides are your 569 00:40:05.400 --> 00:40:12.239 first line option, particularly azithomycin for your atypicals. Remember also gastroparesis with erythromycin 570 00:40:12.360 --> 00:40:17.239 because erythromycin increases gastric motility. It's uses another option in addition to your meticlopromide. 571 00:40:17.440 --> 00:40:22.039 And then the last one I think you should remember is your COPD bacterial 572 00:40:22.119 --> 00:40:27.719 exascerbations. So in chronic bronchitis bacterial exascerbations, macro lines would generally be your 573 00:40:27.719 --> 00:40:32.559 first line men to treat, and selected patients with severe COPD with frequent exascerbations, 574 00:40:32.599 --> 00:40:37.960 macrolides can actually be used prophylactically to prevent exascerbations. Normally you're going to 575 00:40:37.960 --> 00:40:40.880 see your zythromycin used in that case. As far as your adverse drug reactions, 576 00:40:40.920 --> 00:40:45.840 there's a few QT prolongation, so all macrolides have been associated with QT 577 00:40:45.960 --> 00:40:50.840 interval prolongation. Before giving one of these meds, make sure that the patient's 578 00:40:50.880 --> 00:40:53.320 not at risk for trsades taking any other meds that can prolong the QT interval. 579 00:40:53.679 --> 00:40:57.920 They do have some pretty prominent GI side effects, so a number of 580 00:40:58.159 --> 00:41:01.119 different GI problems associated with ACO lines. Of course you're running the middle diarrhea 581 00:41:01.119 --> 00:41:05.039 and abdominal pain we see in all the classes. But then you also have 582 00:41:05.079 --> 00:41:09.840 a possibility of a patotoxicity with a zithro and a cute cholie static hepatitis, 583 00:41:09.880 --> 00:41:15.320 particularly with arrhythromycin. And then finally they do have a cytochrome P for fifty 584 00:41:15.360 --> 00:41:20.079 inhibition, so you have to look out for your drug to drug interactions other 585 00:41:20.159 --> 00:41:22.800 drugs that they may be taking, like statins, warfare and digoxin. All 586 00:41:22.880 --> 00:41:25.639 right, let's move on to our last class and wrap this up, and 587 00:41:25.760 --> 00:41:30.480 that's going to be vencomycin. So venko myycin is an important one. I 588 00:41:30.559 --> 00:41:34.039 covered a lot of classes, but not a lot of individual meds, but 589 00:41:34.119 --> 00:41:36.360 venco comes up a lot, so I think it's important for you to know 590 00:41:36.440 --> 00:41:42.320 this one. So venko myycin has really good grand positive coverage, specifically MRSA. 591 00:41:42.400 --> 00:41:45.639 That's what you really need to know. So for your high old indications 592 00:41:45.639 --> 00:41:49.039 for vanco, Venco's not actually used for a lot. It's mainly two things 593 00:41:49.039 --> 00:41:52.360 that you need to know really well for Venco, and that's MRSA and c 594 00:41:52.599 --> 00:41:57.119 DIFF. So MRSA, that's the big one. Venco and MRSA are synonymous. 595 00:41:57.159 --> 00:41:59.800 As soon as you hear venko, be thinking MRSA. The other high 596 00:42:00.079 --> 00:42:05.039 indication is c DIFF. And what's interesting about this is that we use po 597 00:42:05.199 --> 00:42:08.960 venco to treat c DIFF, so we give venco by mouth. Vancomycin is 598 00:42:08.960 --> 00:42:13.800 almost always given intravenously. We don't usually give venko po because it has a 599 00:42:13.920 --> 00:42:17.079 really poor GI absorption, But the exception is when we're treating c DIFF. 600 00:42:17.119 --> 00:42:21.239 We don't want vanco to get systemically absorbed, but we don't care about that. 601 00:42:21.280 --> 00:42:23.360 We just want to kind of have it sit in the gut and because 602 00:42:23.360 --> 00:42:28.440 that's where the C DIF infection is. So that's why we give venko po 603 00:42:28.599 --> 00:42:30.920 for treating C DIFF. And this is really the only case that you'll give 604 00:42:31.000 --> 00:42:35.559 venco micn po. Otherwise you're always for merca and everything else, you're giving 605 00:42:35.559 --> 00:42:37.880 it intravenously. Now, as far as your adverse drug reactions, this is 606 00:42:37.920 --> 00:42:43.119 another one where there's some high old things. So first thing is Redman syndrome. 607 00:42:43.400 --> 00:42:45.159 It's not really called Redman syndrome anymore. That's what you're gonna hear it 608 00:42:45.159 --> 00:42:52.840 called, but it's really officially called venkomycin induced infusion reaction associated with rash, 609 00:42:52.880 --> 00:42:55.440 So let's just continue to call it Redman's syndrome. So this is something unique 610 00:42:55.440 --> 00:43:00.119 with VANKO, and like most unique things, it's often tested on. Basically, 611 00:43:00.119 --> 00:43:04.519 if you infuse vanco too quickly, you'll get this confluent or this blotchy 612 00:43:04.639 --> 00:43:07.760 rash that covers the trunk, the extremities the head of the neck can be 613 00:43:07.760 --> 00:43:12.159 pretty dramatic and all you avoid this just simply by infusing it slowly. A 614 00:43:12.239 --> 00:43:15.000 couple other high yield things as far as your audiverse drug reactions. Autotoxicity, 615 00:43:15.119 --> 00:43:20.039 this is more common in your older patients generally consider to be reversible in most 616 00:43:20.480 --> 00:43:25.000 cases. And then nephrotoxicity, so Venco can be nephrotoxically into que kidney injury, 617 00:43:25.440 --> 00:43:30.719 more common when it's co administered with other nephrotoxic agents like loop diuretics IVY, 618 00:43:30.719 --> 00:43:36.360 contract IVY, contrast die amphotericin B, etc. So Venco is a 619 00:43:36.360 --> 00:43:40.000 few high yield ADRs and indications. How do you remember the things that you 620 00:43:40.039 --> 00:43:44.159 need to know for venco? So what I came up with is as soon 621 00:43:44.199 --> 00:43:49.039 as you see vancomycin VA n coomycin, I want you to think of a 622 00:43:49.159 --> 00:43:52.199 van, So vancomycin, think of a van and think of a van with 623 00:43:52.400 --> 00:43:59.039 chrome hubcaps, like chrome rims, like those big pimped out chrome rims on 624 00:43:59.079 --> 00:44:02.079 it. So I want you to think of vancomycin and think of a pimped 625 00:44:02.079 --> 00:44:07.599 out van with chrome rims driving by. And chrome is spelled cr O, 626 00:44:08.039 --> 00:44:13.760 M SO CRM. That stands for c DIFF. The R stands for Redman 627 00:44:13.920 --> 00:44:19.000 syndrome and renal toxicity, the O and chrome stands for autotoxicity. And then 628 00:44:19.239 --> 00:44:24.679 the M in chrome stands for MRSA, so MRCA covers. Remember again chrome 629 00:44:24.760 --> 00:44:29.679 hubcaps. That's going to stand for C DIFF, Redman syndrome, renal toxicity, 630 00:44:29.760 --> 00:44:34.599 autotoxicity, and then MRSA. All right, So one last time you 631 00:44:34.639 --> 00:44:37.639 see vancomycin, think of a van, pimped out chrome rims, crom c 632 00:44:37.840 --> 00:44:43.639 dif Redman syndrome, renal toxicity, autotoxicity, MRSA. That's vancomycin. That's 633 00:44:43.639 --> 00:44:45.159 all you need to know. All right. Let's wrap it up with five 634 00:44:45.239 --> 00:44:49.320 quick questions and we will be done with our antibiotics. So question one, 635 00:44:49.679 --> 00:44:54.280 patient with penicillin allergy can safely be given Which class of betolactam antibiotics with no 636 00:44:54.440 --> 00:44:59.679 risk of cross reactivity? Remember that's going to be as trion m your mono 637 00:44:59.719 --> 00:45:05.039 back damn class, So that spatolactum has no cross reactivity with penicillin or cephalosporins, 638 00:45:05.119 --> 00:45:08.280 except for the little exception I went over with ceftazidine that we discussed earlier. 639 00:45:08.639 --> 00:45:13.679 Question two, A patient being treated from MERSA with ivannibiotics begins to develop 640 00:45:13.719 --> 00:45:17.559 a red rash crosses head, neck, thorax and extremities as the IV anibiotic 641 00:45:17.679 --> 00:45:22.320 is being administered. Which antibiotic is this patient likely receiving, So he's likely 642 00:45:22.360 --> 00:45:27.599 receiving vencomycens or treating mersa. It's really only a number of meds to begin 643 00:45:27.639 --> 00:45:30.480 with. Then we see he's developing a rash as the IV antibiotic is being 644 00:45:30.480 --> 00:45:36.039 administered, which we know is normally caused by venkomycin. That's our Redman syndrome, 645 00:45:36.559 --> 00:45:39.199 and that's if this medication is administered too quickly, they may develop that 646 00:45:39.800 --> 00:45:45.119 confluent or blotchy rash spread throughout the body. Question three, which is the 647 00:45:45.159 --> 00:45:49.760 only medication in the carbon penum class that does not cover pseudomonis. So carbon 648 00:45:49.800 --> 00:45:52.360 penum class which men does not cover pseudomonis. That is going to be our 649 00:45:52.480 --> 00:45:58.239 exception, our exception with an E that is e ORed apenem. So remember 650 00:45:58.760 --> 00:46:00.280 in our carbon penum class, the only one that starts with an E. 651 00:46:00.440 --> 00:46:06.079 That's our exception to the rule that all carbon panams cover pseudomonas. Urda panem 652 00:46:06.239 --> 00:46:09.280 is that exception. It does not cover pseudomonas. Question for which medication is 653 00:46:09.360 --> 00:46:15.320 first line to treat chlamydia, Rocky Mountain spotted fever and lime disease. That 654 00:46:15.440 --> 00:46:17.719 was going to be doxy cycling. Don't forget you're sitting on a dock by 655 00:46:17.719 --> 00:46:22.519 the sea, doxycycling eating clams, chlamydia, Rocky Mountain oysters, Rocky mounted 656 00:46:22.559 --> 00:46:27.519 spotted fever with a squeeze of lime, lime disease. All right. Last 657 00:46:27.559 --> 00:46:34.119 question, which fifth generation cephalosporin has coverage against MRSA. So remember that's going 658 00:46:34.199 --> 00:46:38.440 to be septaroline aka se staroline. Star has five sides. Look up into 659 00:46:38.480 --> 00:46:42.400 the stars. What's the closest planning you see mars, which is just MURSA 660 00:46:42.519 --> 00:46:45.639 rearranged? All right, So that was your antibiotics. I hope that was 661 00:46:45.719 --> 00:46:49.239 helpful. As always, thank you so much for the support. Good Luck 662 00:46:49.360 --> 00:46:52.559 on your pants, your pandory rs, and good luck in PA school