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Antimicrobial Spectrum of Activity Visual Learning Exercises (“Flower Diagrams”)
This work is licensed under the Creative Commons Attribution-NonCommercial- ShareAlike 4.0 International License. Noncommerical use with author attribution is expressly encouraged. Modification and distribution of modified versions is allowed for noncommerical use. To view a copy of this license, visit sa/4.0/ If using other media please copy and paste this figure for attribution: Conan MacDougall
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Gram-positive Gram-negative
Staphylococci Strep & Enterococci Enterobacteriaceae GN cocci & coccobacilli AmpC producers anaerobes Low resistance High resistance Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae N. meningitidis Staph aureus (MSSA) -An alternative method of understanding and comparing spectra of activity is the “flower diagram”. Common organisms are displayed on the slide in different sectors based on their characteristics: Gram-positive organisms on the left, Gram-negatives on the right. The organisms are arranged out from the center according to their degree of resistance: organisms that tend to display little resistance are closer to the center than organisms that tend to be more resistant (there are of course some exceptions). We can visualize which organisms an antibacterial has activity against by circling it; we can add a further degree of subtlety by the use of shading: when the circle is darker, the drug has better activity compared to a lighter shading. Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae Wondercillin N. meningitidis Staph aureus (MSSA) -In this example, “Wondercillin” has good activity against methicillin-susceptible Staphylococcus aureus but no activity against methicilin-resistant Staph aureus. Its spectrum includes some activity against Enterococcus faecalis, but at a somewhat lower level (as indicated by the lighter shading). It has no activity against the other organisms on the figure, including any Gram-negative organisms. -If this works for you as a learning tool, great. If not, don’t worry. You won’t be asked to fill these in on a test! Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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EXERCISE 1: Penicillin G
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae PCN G N. meningitidis Staph aureus (MSSA) -Let’s take a moment to review where we are in terms of spectrum of activity. Use the flower diagram to indicate the spectrum of activity of penicillin G. (You’ll get an “official” diagram filled out later.) Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae PCN G N. meningitidis Staph aureus (MSSA) -Let’s take a moment to review where we are in terms of spectrum of activity. Use the flower diagram to indicate the spectrum of activity of penicillin G. (You’ll get an “official” diagram filled out later.) Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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EXERCISE 2: Nafcillin
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae Nafcillin N. meningitidis Staph aureus (MSSA) -Now try it for nafcillin. Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae Nafcillin N. meningitidis Staph aureus (MSSA) -Now try it for nafcillin. Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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EXERCISE 3: Aminopenicillins (Ampicillin/Amoxicillin)
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae Ampicillin Amoxicillin N. meningitidis Staph aureus (MSSA) -Let’s review the relative activity of the aminopenicillins and antipseudomonal penicillins. Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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Gram-positive Gram-negative
12 Gram-positive Gram-negative Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae Ampicillin Amoxicillin N. meningitidis Staph aureus (MSSA) -Let’s review the relative activity of the aminopenicillins and antipseudomonal penicillins. Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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EXERCISE 4: Beta-lactamase Inhibitor Combinations (ampicllin/sulbactam & amoxicillin/clavulanate, piperacillin/tazobactam)
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Gram-positive Gram-negative
14 Gram-positive Gram-negative Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae Ampicillin/sulbactam Amoxicillin/clavulanate N. meningitidis Staph aureus (MSSA) -How do the beta-lactam/beta-lactamase inhibitor combination aminopenicillins differ in spectrum of activity? Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae Ampicillin/sulbactam Amoxicillin/clavulanate N. meningitidis Staph aureus (MSSA) -How do the beta-lactam/beta-lactamase inhibitor combination aminopenicillins differ in spectrum of activity? Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae Piperacillin/ tazobactam N. meningitidis Staph aureus (MSSA) -What organisms does piperacillin/tazobactam cover? What are the holes in its spectrum? Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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Gram-positive Gram-negative
17 Gram-positive Gram-negative Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae Piperacillin/ tazobactam N. meningitidis Staph aureus (MSSA) -What organisms does piperacillin/tazobactam cover? What are the holes in its spectrum? Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae Cefazolin N. meningitidis Staph aureus (MSSA) -Let’s take a moment to review where we are in terms of spectrum of activity for the 1st- and 2nd-generation cephalosporins. -Try and fill out the flower diagram for cefazolin. Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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EXERCISE 5: First-generation Cephalosporins (cefazolin/cephalexin)
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae Cefazolin N. meningitidis Staph aureus (MSSA) -Let’s take a moment to review where we are in terms of spectrum of activity for the 1st- and 2nd-generation cephalosporins. -Try and fill out the flower diagram for cefazolin. Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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EXERCISE 6: Second-generation Cephalosporins (cefuroxime, cefoxitin/cefotetan)
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae Cefuroxime N. meningitidis Staph aureus (MSSA) -Now think about how cefuroxime would be similar or different. Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae Cefuroxime N. meningitidis Staph aureus (MSSA) -Now think about how cefuroxime would be similar or different. Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae Cefoxitin Cefotetan N. meningitidis Staph aureus (MSSA) -How are cefoxitin/cefotetan different from cefuroxime? Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes Cefoxitin Cefotetan H. influenzae N. meningitidis Staph aureus (MSSA) -How are cefoxitin/cefotetan different from cefuroxime? Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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EXERCISE 7: Third-generation Cephalosporins (ceftriaxone/cefotaxime, ceftazidime)
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae Ceftriaxone Cefotaxime N. meningitidis Staph aureus (MSSA) -Let’s review the spectrum of activity of the 3rd & 4th generation cephalosporins. Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes Ceftriaxone Cefotaxime H. influenzae N. meningitidis Staph aureus (MSSA) -Let’s review the spectrum of activity of the 3rd & 4th generation cephalosporins. Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae Ceftazidime N. meningitidis Staph aureus (MSSA) Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes Ceftazidime H. influenzae N. meningitidis Staph aureus (MSSA) Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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EXERCISE 9: Fourth & Fifth-generation Cephalosporins (cefepime, ceftaroline)
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae Cefepime N. meningitidis Staph aureus (MSSA) Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes Cefepime H. influenzae N. meningitidis Staph aureus (MSSA) Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae Ceftaroline N. meningitidis Staph aureus (MSSA) Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae Ceftaroline N. meningitidis Staph aureus (MSSA) Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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EXERCISE 10: Monobactams & carbapenems (aztreonam, ertapenem, imi/mero/doripenem)
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae Aztreonam N. meningitidis Staph aureus (MSSA) -Let’s take a moment to review the spectrum of activity of the monobactams and carbapenems. Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae Aztreonam N. meningitidis Staph aureus (MSSA) -Let’s take a moment to review the spectrum of activity of the monobactams and carbapenems. Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae Ertapenem N. meningitidis Staph aureus (MSSA) Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae Ertapenem N. meningitidis Staph aureus (MSSA) Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae Imipenem Meropenem Doripenem N. meningitidis Staph aureus (MSSA) Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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Gram-positive Gram-negative
Enterococcus faecium (VRE) Serratia Enterococcus faecalis Klebsiella pneumoniae E. coli Proteus mirabilis S. pneumoniae Strep pyogenes H. influenzae Imipenem Meropenem Doripenem N. meningitidis Staph aureus (MSSA) Enterobacter spp Bacteroides fragilis Pseudomonas Staph aureus (MRSA)
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