1. Dolly Mehta
5-0236

2. Methicillin-resistant Staphylococcus aureus (MRSA)
Vancomycin-Resistant Enterococci (VRE) i.e. E. faecium TB
Superbug: NDM-1 (New Delhi metallo-beta-lactamase
bacteria)

3. Cell Wall Synthesis inhibitors Protein Synthesis inhibitors
Beta-Lactum Non Beta-Lactum
Aminoglycosides
Macrolides
Streptogramins
Lincosamides
Oxazolidinones
Tetracyclines
Chloramphenicol
Penicillins
Cephalosporins
Carbapenams
Azetronam
Vancomycin
Fosfomycin
Cycloserine
Bacitracin
Anti-tuberculosis and Anti-Leprosy (RNA, Cell wall, cell membrane)
(special class of bacteria: Mycobacterium)
Rifampin, Isoniazid, Pyrazinamide, Ethambutol/streptomycin
Amikacin, linezolid, clindamycin
Dapsone

4. Cell Wall Gram Positive Mycobacteium Gram Negative Cell wall AG PG
AG: Arabanioglactan
PG: peptidoglycan
Mycolic acid AG
Cell wall
Cell memb
Mycobacteium
Cell wall

5. Overview of cell wall synthesis
Peptidoglycan
N acetylmuramic acid (NAM)
NAM
N acetylglucosamine (NAG)
NAG
Penta peptide Glycine

6. Bactoprenol (C55-carrier or lipid carrier)
D-ala
L-ala
alanine
racemase
D-ala
D-ala
D-ala
D-ala
D-ala M
UDP
D-glu
L-lys
D-ala-D-ala-ligase
UMP P
NAM
Bactoprenol (C55-carrier or lipid carrier)
NAG P BP M
UDP
L-ala
periplasm
autolysin
NAM
UDP
NAM
NAG
NAG
NAM
NAM
Mur-A
NAG
UDP
NAM
NAM
NAM
Glycosidic bond
Peptide cross link
Peptidoglycan units

7. P P periplasm P BP BP NAG NAM NAG NAM NAG NAM NAM NAM NAG NAM NAM NAM

8. (penicillin binding proteins)BP
periplasm
NAG
NAM
NAG
NAM
NAG
NAM
NAM
Peptide cross link
Transpeptidase
(penicillin binding proteins)
NAM
NAG
NAM
NAG
NAM
NAM
NAM
Glycosidic bond
Transglycolase

9. Cell wall synthesis inhibitors
D-ala
alanine
racemase
D-ala
D-ala
cycloserine
D-ala
D-ala-D-ala-ligase
D-ala
L-ala
D-ala
D-ala
D-ala
D-ala
vancomycin
bacitracin
NAG
UDP
MurA
NAM P
NAM
fosfomycin
Bactoprenol (C55-carrier or lipid carrier)
NAG P P P BP BP
PBP
Beta-lactams
periplasm
Inhibits transglycolase
reaction
NAG
NAM
NAG
NAM
NAG
NAM
NAM
Inhibits
Transpeptidase
reaction
NAM
NAG
NAM
NAG
NAM
NAM
NAM

10. Increased expression of efflux pumps (i.e P. aeruginosa)
Mechanism of resistance for beta-lactums
Reduced penetration to site of action (Penn G); P. aeruginosa (lack porins)
Production of b-lactamase
Increased expression of efflux pumps (i.e P. aeruginosa)
Elaboration of normal penicillin binding proteins (PBPs)

11. Mechanism of Resistance for Vancomycin
modification of the D-Ala-D-Ala binding site in PG building block. D-Ala is replaced by D-lactate. P
NAM P
NAM

12. Case Study
A 55-year-old man is brought to the local hospital emergency department by ambulance. His wife reports that he had been in his normal state of health until 3 days ago when he developed a fever and a productive cough. During the last 24 hours he has complained of a headache and is increasingly confused. His wife reports that his medical history is significant only for hypertension, for which he takes hydrochlorothiazide and lisinopril, and that he is allergic to amoxicillin. She says that he developed a rash many years ago when prescribed amoxicillin for bronchitis. In the emergency department, the man is febrile (38.7°C [101.7°F]), hypotensive (90/54 mm Hg), tachypneic (36/min), and tachycardic (110/min). He has no signs of meningismus but is oriented only to person. A stat chest x-ray shows a left lower lung consolidation consistent with pneumonia. The plan is to start empiric antibiotics and perform a lumbar puncture to rule out bacterial meningitis. What antibiotic regimen should be started to treat both pneumonia and meningitis? Does the history of amoxicillin rash affect the antibiotic choice? Why or why not?

13. b-lactamase Inhibitors Penicillin Cephalosporins Carbapenams
Clavulanic acid
(“suicide inhibitor”)
Sulbactum
Tazobactum
Penicillin
Cephalosporins
Cephalothin
Cefazolin
Cefoxitin,
Cefotetan
cefmetazole
Ceftazidime,
cefoperazone
Cefepime
Carbapenams
Imepenam
(combined with cilastatin; Primaxin)
Meropenam
Etrapenam
Vancomycin
Fosfomycin
Monurol
Penicillin G, Natural
Penicillin V
Repository forms of Penn G:
Wycillin
Bicillin
Penicillinase resistant Penicillin
(anti-staphyloccal penicillins)
(strains not resistant to
methacillin: nafcillin, oxacillin
dicloxacilin)
Ampicillin, Amoxicllin
Ticarcillin : Anti-pesudomonal
(i.v)
Piperacillin
Monobactum
Azteronam
(does not exhibit
cross-allergy with
Penn and Cef
Excluding
ceftazidime)

14. Amoxicillin + clavulanate: Augementin (oral)
Ampicillin + Sulbactam: Unasyn
Piperacillin +Tazobactam: Zosyn
Ticarcillin and Clavulanate: Timentin

15. Carboxypenicillin and Ureidiopenicillin (Tricarcillin, Pipericillin)
Cephalosporins
Carbapenams
Vancomycin
Penicillin G/V
Ist generation i.e. Cefazolin
Imepenam (Primaxin)
Pneumococcal Infections (S. pneumoniae)
Pneumococcal Peumonia/meningitis
(only penicillin sensitive)
Streptococcal Infections
Enterococcal endocarditis (+ ampilcillin)
Meningococcal infections
Syphilis
Actinomycosis
Clostridia Infections
Listeria infections (along with Ampicillin)
Prophylactic: Streptococcal and
rheumatoid fever
Skin and soft tissue infections caused by S aureus, S pyogens;
Surgical prophylaxis
Celluulitis, endocarditis
lower respiratory tract infections
Urinary tract infections (UTI)
Intra-abdominal, gynecological,
skin and soft tissues infections
Methicillin-resistent staph infections:
Peumonia, empyema, endocarditis,Osteolmyelitis
Soft-tissues abscesses
Enterococcal endocardiatis
(+ aminoglycosides in patients with serious penn allergy)
IIIrd generation
Meropenam
All forms of Gonorrhea
Severe form of Lyme disease
Pneumococcal Meningitis (+ vancomycin)
(non-immunocompromised)
Pneumococcal Peumonia
Typhoid
Therapeutic equivalent to Prixamin
Fosfomycin
Etrapenam
uncomplicated UTI (acute cystitis) in women due to susceptible strains of Escherichia coli and Enterococcus faecalis
Abdominal and pelvic infections by Gram +
Aminopenicillin
IVth generation
Otitis media
Dental infection and
endocarditis prophylaxis
Upper respiratory tract infections
Urinary tract infections (UTI)
Listeria monocytogenes
Enterococcal infections
Noscomal infections
Neutrpenia with fever
Ventilator-associated pneumonia
Azteronam
Resembles aminoglycosides
Use for gram – infections in patients with B-lactum allegenicity
Bacitracin
topical
Penicillinase-resistant penicillins (PRPs):
Skin infections: cellulitis, impetigo, erysipelas
Endocarditis, meningitis, and bacteremia from staphylococci
Osteomyelitis and septic arthritis only when the organism is proven sensitive
Amoxicillin + clavulanate: Augementin (oral): low risk febrile patients with neutropenia from cancer therapy, acute otitis in childerns, bite wounds, cellulitis and diabetic foot infections
Ampicillin + Sulbactam: Unasyn: good for Gram+ cocci, Intra-abdominal and pelvic infections
Piperacillin +Tazobactam: Zosyn: Appendicitis (complicated by rupture or abscess) and peritonotis, community and hospital acquired pneumonia, Postpartum endometritis, cellulitis
Ticarcillin and Clavulanate: Timentin: Septicemia, Lower Respiratory Infections, UTI, Intra-abdominal, bone-joint, gynecological, skin and soft tissues infections
Carboxypenicillin and Ureidiopenicillin
(Tricarcillin, Pipericillin)
In Neutropenic patients, Bacteremia, pneumonia,
burns infections, UTI (resistant to Penn G and Ampicillin caused by
Pseudomonas or indole + proteus Infections and
enterobacter strains), Hospital-acquired and ventilator-associated pneumonia

16. Untoward Effects Penicillin’s Vancomycin Cephalosporin’s
Hypersensitivity
(macular rashes and anaphylaxis)
“red neck syndrome”
Ototoxicity (excessive high conc.)
Hypersensitivity ~(0.7%-10%)
Allergy to one penicillin risk to other penicillin's/cephalosporin’s (in clinical setting it is 1%) also cases with low and mild Penicillin allergy are low risk for cephalosporin’s)
Cephalosporin’s
Hypersensitivity
Nephrotoxic increases with
Aminoglycosides
Diarrhea
Intolerance to alcohol (cefotetan, cefoperazone)
Thrombocytopenia/platelet dysfunction and disulfaram-like effect (apparent with these: cefamandole, cefmetazole, cefotetan,and cefoperazone), Vit K deficiency
Penicilloic acid
IgE Abs

17. Protein Synthesizing Machinery
Ribosome
mRNA
tRNA
bacteria has 50S and 30 S subunit which forms 70 S polysome that slides on mRNA
has A, P and E sites for binding with tRNA
forms template for protein synthesis
transcribed from DNA
attaches to 30s ribosomes
brings amino acids
attaches to A, P and E sites of ribosomes

18. uuu cca cau cca aug cca cau
MET
uac P E A
50s
uuu cca cau cca aug cca cau
30s

19. uuu cca cau cca aug cca cau
Pro
uac P E A
Met
uac
uuu cca cau cca aug cca cau

20. uuu cca cau cca aug cca cauP E A
Pro
Met
gga
uuu cca cau cca aug cca cau

21. uuu cca cau cca aug cca cauP E A
Met
Pro
uuu cca cau cca aug cca cau

22. uuu cca cau cca aug cca cau
Aminoglycosides
MET
uac
Binds 30S (irreversible inhibitor of protein synthesis) P E A
50s
uuu cca cau cca aug cca cau
30s

23. uuu cca cau cca aug cca cau
Pro
uac
Tetracycline
Binds reversibly at 30 S ribosomal RNA
Compete with tRNA P E A
Met
uac
uuu cca cau cca aug cca cau

24. Macrolides, Lincosamide, Streptogramins
50S ribosomal RNA
Blocks peptide
translocation to P site P E A
Met
Pro
uuu cca cau cca aug cca cau

25. Chloramphenicol, Clindamycin
50S ribosomal RNA
Inhibit peptidyltransferase P E A
Pro
Met
gga
uuu cca cau cca aug cca cau

26. Oxazolidinones
Inhibits ribosomal complex formation P E A
50s
uuu cca cau cca aug cca cau
30s

27. Aminoglycosides concentration-dependent killing postantibiotic effect
Enter cell through porins but require electron transport
to permeate the inner membrane Energy-Dependent Phase 1(EDP1)
b) Create fissure enhancing AG uptake (EDP2 phase)
Aminoglycosides
concentration-dependent killing
postantibiotic effect
Peak and trough levels of Aminoglycosides
therapeutic
dose is achieved
avoid toxicity
Synergistic killing
Along with beta-lactam or vancomycin

28. Mechanisms of resistance for antibiotics inhibiting protein synthesis
Intracellular penetration
AG, Tet, Mac
Anaerobic conditions
(AG) pH
Efflux pumps (Tet, Mac)
Low affinity of drug for bacterial ribosomes
Modification of the ribosomal binding site
(AG, Tet, Mac)
acetylation, phosphorylation, adenylation of OH or NH2 gr (AG)
Drug Inactivation
Tet: enzyme inactivation
Mac: (hydrolysis by esterase's)

29. Gentamicin Tetracycline Erythromycin Tobramycin Doxycycline
Aminoglycosides
Macrolides
Erythromycin
Azithromycin
Clarithromycin
Ketolide
(Telithromycin)
Tetracyclines
Tetracycline
Doxycycline
Minocycline
Tigecycline
Steptogramins
Quinupristin/dalfopristin
Chloramphenicol
Gentamicin
2-deoxystreptamine
Linocosamides
Clindamycin
Gentamicin
Tobramycin
Amikacin
Streptomycin
Neomycin
Oxazolidinones
Spectinomycin
Linezolid

30. Aminoglycosides Macrolides Tetracycline Chloramphenicol Gentamicin
MUST BE LIMITED
Gentamicin
Tobramycin
Amikacin
Erythromycin,
Chlamydial urogenital infections
(pregnancy)
Chlamydial pneuominia in infants
Diphtheria
Pertussis
Tetanus
prophylaxis of rheumtoid fever
Azithromycin
Legionnaires disease
Lymphogranuloma venereum
Pneumonia by Chlamydia pneumonia
Streptococcal infections
Mycobacterial infections
Toxoplasmosis encephalitis
and diarrhea (in AIDS)
Non specific urethritis
Clarithromycin
Helicobacter pylori infections
Ketolide
Respiratory tract infections (bronchitis, sinusitis)
Community acquired pneumonia
Tetracyclines
Rickettsial infections
Mycoplasma infections
Peumonia, bronchitis, sinusitis caused by Chlamyda peumonia
Brucellosis (along with rifampin or Streptomycin)
Tuleremia
Acne
Doxycycline
Rocky mountain fever
Lymphogranuloma venereum
Trachoma
Anthrax
cholera
Typhoid fever
Bacterial menegitis
Anaerobic infections
(intrabdominal or brain) Rickettsial infections
Brucellosis
(Gentamicin prefered due to
low cost and long experience
Steptogramins
Dalfopristin (Synercid)
(should be reserved for serious infections by multiple-drug-resitant gram+
along with Penn and Cef
for serious UTI, bacteremia, infected burns, osteomyelitis, pneumonia, peritonitis and otitis
along with vancomycin
For bacterial endocarditis
Never than a few days unless required
Never mixed in same solution with Penn as it inactivates
Infections caused by
Vancomycin resistant strains
Noscomal infections (Europe)
Limezoid (Zyvox)
should be reserved for serious infections by multiple-drug-resistant gram+ and vancomycin resistant or multi-drug resistant gram+
Streoptomycin
With Penn for bacterial endocarditis
Tularemia
Plague
Tuberculosis
Clindamycin
Lung abscess and anerobic lung and pleural space infections, encephalitis, vaginal infections
Neomycin: topical
Spectinomycin
gonorrhea or gonorrhea in penicillin-allergic patients

31. Untoward Effects Linezolid Aminoglycosides Macrolides Chloramphenicol
Allergic reactions
(fever, eosinophilia, skin eruptions)
Cholestatic hepatitis
Ketolide
Nausea, vomiting
Visual disturbances
Pseudomembrane colitis
Risk of ventricular arrhythmia
Chloramphenicol
Hematological toxicity
(aplastic aneamia)
Hypersensitity
Gray baby syndrome
Ototoxicity (vestibular or cochlear cells)
(largely irreversible); Ethacrynic acid and
furosemide further aggravate it
Nephrotoxicity (8-26% of cases)
(with cephalosporins)
Neuromuscular blockade
Clindamycin
Diarrhoea
Pseudomembrane colitis (lethal)
Skin rashes
May inhibit neuromuscular transmission or potentiate the effect of neuroblocker agents
Tetracyclines
Gastrointestinal
Pseudomembrane colitis
Photosensitivity
Hepatic toxicity (pregnant woman)
Renal toxicity (less with doxycycline)
Fanconi syndrome with degraded Tet
Permanent teeth discoloration in
children's
Linezolid
Well-tolerated, but myelosuppression has been noted; platelets should be monitored in patients with risk of bleeding or if therapy >2 wks
Palpitation, headache
Dalfopristin
Phelebitis
Raise blood pressure if gibven along with other agents i.e. histamine

32. Erythromycin/clathrimycin/ketolide
Drug Interactions
Chloramphenicol,
Streptogramins
CYP450
Prolong half lives of dicumbarol, warfarin
Antiretroviral protease inhibitors
rifabutin
Erythromycin/clathrimycin/ketolide
CYP3A4
Potentiates the effects of i.e.
Carbamazepine, cotoicosteriods, cyclosporin,
digoxin, warfarin
Linezolid
serotonin syndrome
If given with Serotonergic drugs

33. Case Study
A 19-year-old woman with no significant past medical history presents to her college medical clinic complaining of a 2-week history of foul-smelling vaginal discharge. She denies any fever or abdominal pain but does report vaginal bleeding after sexual intercourse. When questioned about her sexual activity, she reports having vaginal intercourse, at times unprotected, with two men in the last 6 months. A pelvic examination is performed and is positive for mucopurulent discharge from the endocervical canal. No cervical motion tenderness is present. A first-catch urine specimen is obtained to be tested for chlamydia and gonococcus. A pregnancy test is also ordered as the patient reports she "missed her last period." Pending these results, the decision is made to treat her empirically for gonococcal and chlamydial cervicitis. What are two potential treatment options for her possible chlamydial infection? How does her potential pregnancy affect the treatment decision?

34. Case Study
A 45-year-old man with no medical history was admitted to the intensive care unit (ICU) 10 days ago after suffering third-degree burns over 40% of his body. He had been relatively stable until the last 24 hours. Now he is febrile (39.5°C [103.1°F]), and his white blood cell count has risen from 8,500 to 20,000/mm3. He has also had an episode of hypotension (86/50 mm Hg) that responded to a fluid bolus. Blood cultures were obtained at the time of his fever and results are pending. The ICU attending physician is concerned about sepsis and decides to treat with empiric combination therapy directed against Pseudomonas. The combination therapy includes tobramycin. The patient weighs 70 kg (154 lb) and has an estimated creatinine clearance of 90 mL/min. How should tobramycin be dosed using once-daily and conventional dosing strategies? How should each regimen be monitored for efficacy and toxicity?

35. Key facts about TB
Second only to HIV/AIDS as the greatest killer worldwide
In 2010, 8.8 million people fell ill with TB and 1.4 million died from TB.
Over 95% of TB deaths occur in low- and middle-income countries, and it is among the top three causes of death for women aged 15 to 44.
In 2009, there were about 10 million orphan children as a result of TB deaths among parents. 8 infants exposed to TB at Sacramento hospital (just yesterday)
leading killer of people living with HIV causing one quarter of all deaths.
Multi-drug resistant TB (MDR-TB) is present in virtually all countries surveyed.
Millennium Development Goal to reverse the spread of TB by 2015.

36. X Mycobacterium Penicillin Cephallosprins Vancomycin Cell wall
Mycolic acid
Cell wall
Aminoglycosides
Streptomycin(ist line)
Kanamycin AG PG
Amikacin
AG: Arabanioglactan
PG: peptidoglycan
cycloserine
Cell memb
Mycobacterium tuberculosis: slow growing, dormant and aerobic bacterium. Mycolic acids fatty acids provide advantage
Reside in Macrophages
Active TB disease, Mtb complexes are always found in the upper air sacs of the lungs.

37. First-line Therapy Alternative Therapy “RIPE” Rifampin Isoniazid
Pyrazinamde
Ethambutol
Streptomycin
Rifabutin
Alternative Therapy
Fluoroquinolones
(Moxifloxacin, gatifloxacin)
cycloserine
capreomycin
Kanamycin and amikacin
ethionamide
clofazimine
aminosalicyclic acid

38. Inhibitors of cell wall and cell membrane
Ethionamide (alternate)
Isoniazid (INH)
Ethambutol
arabinosyltransferase
Arabinoglycan
Pyrazinamide
pyrazinoic acid
(prodrug)
pyrazinamidase
disrupts mycobacterial cell membrane metabolism and transport functions
(prodrug)
Catalase-peroxidase
(KatG)
KasA
INH
AcpM
Fatty acid Synthase II
Mycolic acid synthesis

39. Targeting mycobacterium DNA or RNA
Rifamycin
Fluoroquinolones
(alternate)
Inhibition of DNA synthesis and supercoling
targets topoisomerase

40. mycobacterium protein synthesis inhibitors
Inhibits folate synthesis:
Aminosalicylic Acid (PAS)
Streptomycin (toxic)
Capreomycin/amikacin (alternate)
Macrolides

41. Experimentsl drugs targeting mycobacterium
TM-207 (R207910)

42. Mechanism of Mycobacterial Resistance
butol)
Alteration of enzyme converting prodrug
Ethionamide
Pyrazinamde, Isoniazid
inactive
active

43. Alteration of target protein structure
Blocks the action of
rifamycin, fluroquinolone, ethambutol, streptomycin, macrolide

44. Multidrug-Resistant Tuberculosis (MDR TB) and Possible Effective Treatments

45. Extensively Drug-Resistant Tuberculosis (XDR TB) Diminishing Options for Treatment

47. Drug Interactions of Rifampin
induces Cytochrome P450
Rifabutin
(can be used)
Increases elimination of several drugs i.e cyclosporine, anticonvulsants
Protease inhibitors

48. Atypical Mycobacteria
Accounts for 10% of non-tuberculous or atypical mycobacterium infections
generally non communicable
less susceptible than M tuberculosis to antituberculous drugs
erythromycin, sulfonamides, or tetracycline, which are not active against M tuberculosis, may be effective

49. Drugs active against atypical Mycobacteria
Species
Clinical Features
Treatment Options
M kansasii 
Resembles tuberculosis
Ciprofloxacin, clarithromycin, ethambutol, isoniazid, rifampin, trimethoprim- sulfamethoxazole
M marinum 
Granulomatous cutaneous disease
Amikacin, clarithromycin, ethambutol, doxycycline, minocycline, rifampin, trimethoprim-sulfamethoxazole
M scrofulaceum 
Cervical adenitis in children
Amikacin, erythromycin (or other macrolide), rifampin, streptomycin (Surgical excision is often curative and the treatment of choice.)
M avium complex 
Pulmonary disease in patients with chronic lung disease; disseminated infection in AIDS
Amikacin, azithromycin, clarithromycin, ciprofloxacin, ethambutol, rifabutin
M chelonae 
Abscess, sinus tract, ulcer; bone, joint, tendon infection
Amikacin, doxycycline, imipenem, macrolides, tobramycin
M fortuitum 
Amikacin, cefoxitin, ciprofloxacin, doxycycline, ofloxacin, trimethoprim-sulfamethoxazole
M ulcerans 
Skin ulcers
Isoniazid, streptomycin, rifampin, minocycline (Surgical excision may be effective

50. Leprosy
Mycobacterium leprae
chronic ID skin, peripheral nerves and mucous membranes (eyes, respiratory tract).
also known as Hansen's disease as bacillus causing it was discovered by G.A. Hansen in 1873.
common in warm, wet areas in the tropics & subtropics.

51. inhibits folate synthesis in bacteria
Multidrug therapy
Sulphones (Dapsones)
inhibits folate synthesis in bacteria
Rifampin
Clofazimine (LAMPRENE) Phenazine dye
binds GC rich mycobacterial DNA; anti-inflammatory

52. Sulphone syndrome: fever, jaundice, malaise
exacerbation of lepromatos leprosy
Untoward Effects
Dapsone
Clofazimine
skin discoloration ranging from red-brown to nearly black

53. Case Study
A 45-year-old homeless man presents to the emergency department complaining of a 2-month history of fatigue, weight loss (10 kg), fevers, night sweats, and a productive cough. He is currently living on the street but has spent time in homeless shelters and prison in the last several years. He reports drinking 2–3 pints of hard alcohol per day for the last 15 years, and also reports a history of intravenous drug use. In the emergency department, a chest x-ray shows a right apical infiltrate. Given the high suspicion for pulmonary tuberculosis, the patient is placed in respiratory isolation. His first sputum smear shows many acid-fast bacilli, and a rapid HIV antibody test returns with a positive result. What drugs should be started for treatment of presumptive pulmonary tuberculosis? Does the patient have a heightened risk of developing medication toxicity? If so, which medication(s) would be likely to cause toxicity?

54. A man is admitted with E. coli bacteremia
A man is admitted with E. coli bacteremia. Which of the following is the most appropriate therapy?
Vancomycin
Linezolid
Quinolones, aminoglycosides, carbapenems, piperacillin, ticarcillin, or aztreonam
Doxycycline
Clindamycin
Oxacillin
A 34-year-old woman presents with facial pain, a discolored nasal discharge, bad taste in her mouth, and fever. On physical examination she has facial tenderness. What is the most appropriate management?
Linezolid
Amoxicillin / clavulanic acid and a decongestant
Gentamycin
Erythromycin and a decongestant

55. Objectives
1. Know the components of bacterial cell wall and basis of protein synthesis.
2.Know the classification of penicillins and cephalosporins according to their chemical structure and their antimicrobial spectrum.
3. Know the mechanism of antimicrobial activity for
penicillins, cephalosporins, bacitracin. cyclosporin. aztreonam, imipenem, vancomycin, aminoglycosides, tetracyclines, macrolides, chloramphenicol, lincosamide, streptogramins, oxazolidinones,.
4. Know the mechanisms of bacterial resistance for antimicrobial drugs.
5. Know the most common adverse effects of the antimicrobial drugs.
6. Know the most common applications of these antibiotics for the treatment of disease.