Other Antibacterials

Nitrofurantoin

Clindamycin

Vancomycin

Lincosamides

binds to 50S subunit → blockage of peptide translocation (transpeptidation) → inhibition of peptide chain elongation →inhibition of bacterial protein synthesis (bacteriostatic effect)

• CNS penetration: poor

• Route of elimination: both renal and biliary

• Clinical use

  • Anaerobes, such as Clostridium perfringens, Bacteroides spp. (clindamycin is less effective against Bacteroides than other anaerobic species)

    • Aspiration pneumonia

    • Lung abscesses

    • Oral infections

  • Group A streptococcus: especially invasive infections

  • Partially effective against gram-positive aerobes

    • Can be used in MRSA infections

    • Not effective against Enterococci

  • Babesia (together with quinine) [45]

• Special considerations: cross-resistance with macrolides

• GI upset (e.g., diarrhea)

• Pseudomembranous colitis

• Fever

• Teratogenicity [46]

• Contraindications: cautious use in pregnant patients during the 1st trimester and in breastfeeding patients

Glycopeptide

• Bind terminal D-ala-D-ala of cell-wall precursor peptides → inhibition of cell wall synthesis (peptidoglycan formation) → bacterial death (bactericidal effect against most gram-positive bacteria)

• Bacteriostatic against C. difficile

only when there is increased permeability of the meningeal vessels (i.e., with meningeal inflammation)

renal (via glomerular filtration)

especially effective against multidrug-resistant organisms

• Is effective against a wide range of gram-positive bacteria only

• MRSA

• S. epidermidis

• Enterococci (if not vancomycin resistant enterococci)

• C. difficile (causing pseudomembranous colitis): administered orally

• Intravenous administration

  • Nephrotoxicity

  • Ototoxicity/vestibular toxicity

  • Thrombophlebitis

  • Vancomycin flushing reaction: an anaphylactoid reaction caused by rapid infusion of vancomycin

    • Nonspecific mast cell degranulation → rapid release of histamine

    • Symptoms

      • Diffuse flushing of the skin, pruritus mainly of the upper body

      • Muscle spasms and pain in the back and chest

      • Possible hypotension and dyspnea [18]

    • Can be prevented by slowing the rate of infusion and pretreating with antihistamines

  • DRESS syndrome [19]

  • Neutropenia [20]

  • Dysgeusia and gastrointestinal side effects (e.g., nausea, vomiting, abdominal pain)

• Oral administration: predominantly dysgeusia and gastrointestinal side effects

• Contraindications: Consider use in pregnant women only if the benefits outweigh the risks.

• Mechanisms of resistance

  • Modification of amino acid D-Ala-D-Ala to D-Ala-D-Lac: occurs mainly in Enterococcus (e.g., E. faecium, less in E. faecalis)

  • Beta-lactamase resistant

Nitrofurans

reduced by bacterial nitroreductases to reactive metabolites → bind to bacterial ribosomes → impaired metabolism, impaired synthesis of protein, DNA, and RNA → cell death (bactericidal effect

primarily renal , small amounts in feces

• Urinary tract pathogens

  • Gram-positive: Enterococci, Staphylococcus saprophyticus, group B streptococcus, Staphylococcus aureus, Staphylococcus epidermidis

  • Gram-negative: E. coli, Enterobacter spp., Shigella spp., Salmonella spp., Citrobacter spp, Neisseria spp, Bacteroides spp., Klebsiella spp.

• Not effective against Pseudomonas and/or Proteus

• Clinical indications include:

  • Treatment and prophylaxis of acute uncomplicated UTIs (e.g., urethritis, cystitis)

  • Asymptomatic bacteriuria or symptomatic UTI in pregnant women

  • Should not be used in (suspected) pyelonephritis because nitrofurantoin does not achieve adequate concentration in renal tissue

• Adverse effects

  • Pulmonary fibrosis

  • Hemolytic anemia in patients with G6PD deficiency

  • GI upset

  • Reversible peripheral neuropathy

• Contraindications

  • Children < 1 month of age

  • Breastfeeding women

  • Women at 38–42 weeks' gestation or during delivery

  • Hepatic dysfunction

  • Renal dysfunction with a creatinine clearance < 60 mL/min