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Antibiotics -- Everyone's Favorite


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I am at a complete loss for how to study antibiotics.

 

I tried to learn what the drugs cover (gram pos/neg, cocci, anaerobes, etc.) but there are too many exceptions to those rules. They don't cover ALL gram pos, or ALL anaerobes, for example.

Then I tried to learn what bacteria cause what pathology, and the morphology of the bacteria (trying to apply what I'd learned above). Once again, it really wasn't concrete enough. 

I tried to learn each individual pathology and what drugs are used for each, but... well, that's just not going to stick! Plus everyone has different opinions/favorite drugs that they use. 

 

I would love to be able to just pick a favorite from each category and learn them well, and know exactly what I would use for, say, a sore throat (pre-culture). However, for test-taking purposes, when I have to choose just one "best," that isn't going to work either.

 

Every resource I look at says something different, and then of course my professors have yet another opinion as to what is correct. I'm just getting a little overwhelmed, and am hoping I'm not alone in this! Any advice out there?

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I remember feeling the exact same as you in PA school... my program's lectures on infectious disease and antibiotic pharm were AWFUL, and I felt totally overwhelmed.  My working knowledge on this topic was pathetic when I went into rotations.  I'm a few years out from didactic year now, so I'm a little hazy on specifics regarding exam questions / etc, but I can offer some advice that will hopefully be helpful.

 

When it comes to the infectious disease portion of didactic year, in addition to the norm of studying whatever the prof reinforces to you, you should focus on the basics of the classification system of bacteria (see attached) and the classic gram stain/microscopy findings for the most common organisms (don't waste your time learning all of them!).  More specifically, know that gram positive cocci in pairs = strep.  gram pos cocci in clusters = staph.  gram negative rods lactose fermenting most likely = ecoli.  gram neg rods nonfermenter = pseudomonas.  also know chlamydia (intracellular) and gonorrhea (gram neg diplococci).  These will come up repeatedly in exams, and if you ever work as a hospitalist or intensivist they may come up in clinical practice as we adjust our empiric antibiotics based on the preliminary culture/gram stain results, so its definitely good to know.  I think its probably helpful to have a general sense for the rest of common bacteria for whether or not they are gram neg or gram positive, but I wouldn't stress about learning the specific morphology for everything.  

classification-of-grtam-positive-and-neg

 

 

 

When it comes to the antibiotic portion of things, there is quite a bite more to know.  DONT try to learn this at first by memorizing specific antibiotics, instead focus on the characteristics of the classes as a whole and just associate the names of the antibiotics that fall under those classes.  Know the mechanism of actions, overall coverage for the whole class, and unique things to keep in mind (often contraindications / adverse effects), like avoiding flouroquinolones in peds because of risk for tendon rupture.  There are a lot of review charts out there. I remember this one below was recommended to me as a student, its pretty busy and might be a bit too detailed in some areas (coverage specifics) and not detailed enough in others, but maybe worth checking out to see if you like it.  

 

Its also definitely good to have a resource to reference while you are studying these little review-type sheets, so that if you aren't sure or want to learn more you can find the answers to your targeted questions.  My favorite didactic abx reference would be the paperback book "antibiotics simplified" - found on amazon.  Very good book!  

 

I'll try to update this post with more suggestions once I get a bit more free time.  Will check back in a bit...

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Adult:  Above diaphragm (easy, EVERYTHING is viral for the most part except for actual pneumonias):  PCN, PCN allergic -> Ceph. (if rash only and no anaphylaxis, with crossover risk of

           Below diaphragm:  Ask Sanford or Hopkins.  UTI -> nitrofurantoin, FQ (tendonitis warning), +/- TMP/SMX, Augmentin.    

                                          Gyn:  metronidazole and fluconazole

 

 

 

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22 hours ago, SERENITY NOW said:

I remember feeling the exact same as you in PA school... my program's lectures on infectious disease and antibiotic pharm were AWFUL, and I felt totally overwhelmed.  My working knowledge on this topic was pathetic when I went into rotations.  I'm a few years out from didactic year now, so I'm a little hazy on specifics regarding exam questions / etc, but I can offer some advice that will hopefully be helpful.

 

When it comes to the infectious disease portion of didactic year, in addition to the norm of studying whatever the prof reinforces to you, you should focus on the basics of the classification system of bacteria (see attached) and the classic gram stain/microscopy findings for the most common organisms (don't waste your time learning all of them!).  More specifically, know that gram positive cocci in pairs = strep.  gram pos cocci in clusters = staph.  gram negative rods lactose fermenting most likely = ecoli.  gram neg rods nonfermenter = pseudomonas.  also know chlamydia (intracellular) and gonorrhea (gram neg diplococci).  These will come up repeatedly in exams, and if you ever work as a hospitalist or intensivist they may come up in clinical practice as we adjust our empiric antibiotics based on the preliminary culture/gram stain results, so its definitely good to know.  I think its probably helpful to have a general sense for the rest of common bacteria for whether or not they are gram neg or gram positive, but I wouldn't stress about learning the specific morphology for everything.  

classification-of-grtam-positive-and-neg

 

 

 

When it comes to the antibiotic portion of things, there is quite a bite more to know.  DONT try to learn this at first by memorizing specific antibiotics, instead focus on the characteristics of the classes as a whole and just associate the names of the antibiotics that fall under those classes.  Know the mechanism of actions, overall coverage for the whole class, and unique things to keep in mind (often contraindications / adverse effects), like avoiding flouroquinolones in peds because of risk for tendon rupture.  There are a lot of review charts out there. I remember this one below was recommended to me as a student, its pretty busy and might be a bit too detailed in some areas (coverage specifics) and not detailed enough in others, but maybe worth checking out to see if you like it.  

 

Its also definitely good to have a resource to reference while you are studying these little review-type sheets, so that if you aren't sure or want to learn more you can find the answers to your targeted questions.  My favorite didactic abx reference would be the paperback book "antibiotics simplified" - found on amazon.  Very good book!  

 

I'll try to update this post with more suggestions once I get a bit more free time.  Will check back in a bit...

That sounds like the approach I started with. I feel pretty good about MOAs, SE/CI, Black box warnings, etc. I'm at the point where I'm just getting really frustrated with not knowing how to actually treat things (or which of the 3 answers on the exam that technically all cover gram negative enteric bacilli is actually best for this particular one).

 

I'm definitely going to keep working on solidifying what I do know! Any advice on how to move forward? I really appreciate your help, thank you!

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 it sounds like the part you are struggling with is the choice for best empiric antibiotic for a given disease.  I can tell you what I did in PA school for this section... I basically made a table and worked through each disease --> expected bacteria --> empiric abx as listed on my textbooks and used uptodate for cross reference, and it seemed to work well for me.  its helpful to have the other review sheets you made before like the bug X --> drugs sheet, and drug X --> bugs sheet so that you can understand the reasoning behind why the abx are chosen for a given condition (i.e., an abx coverage should overlap with the suspected pathogen).  I can upload the sheet I worked on as a student back in the day - beware that i haven't reviewed this lately for accuracy and it its likely out of date especially for the pneumonia section - but hopefully can at least give you an idea of what i did.

 perhaps part of the confusion point for you is that everyone has different favorites... the reality is that infectious dz and abx is a constantly changing field over time and even has significant practice variation based on local susceptibilities, which is probably why you hear so many different things.  while it is frustrating that everyone seems to have different "favorites" and there is no one objective best, try to just learn the most commonly referenced ones and realize they are all likely viable options - you can reference your choice of uptodate/sanford/johns hopkins for what is most likely the "current best" recommendation (but beware, the test is typically lagging behind the 'current best recommendation').  once you get these detailed out, it becomes mostly memorization skills, so consider things like Anki decks which are really great for this sort of thing.   have the cards list the disease and self quiz the dz --> bugs --> drugs.  soon it will be second nature that you know the most common different treatment options for a given disease, and can tell the antibiotics that just don't fit for a given question.  if specific test questions or situations come up that stump you, just let us know and we can try to work through it.

abx and id rapid review sn1.pdf

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On 11/21/2017 at 5:01 AM, SERENITY NOW said:

 it sounds like the part you are struggling with is the choice for best empiric antibiotic for a given disease.  I can tell you what I did in PA school for this section... I basically made a table and worked through each disease --> expected bacteria --> empiric abx as listed on my textbooks and used uptodate for cross reference, and it seemed to work well for me.  its helpful to have the other review sheets you made before like the bug X --> drugs sheet, and drug X --> bugs sheet so that you can understand the reasoning behind why the abx are chosen for a given condition (i.e., an abx coverage should overlap with the suspected pathogen).  I can upload the sheet I worked on as a student back in the day - beware that i haven't reviewed this lately for accuracy and it its likely out of date especially for the pneumonia section - but hopefully can at least give you an idea of what i did.

 perhaps part of the confusion point for you is that everyone has different favorites... the reality is that infectious dz and abx is a constantly changing field over time and even has significant practice variation based on local susceptibilities, which is probably why you hear so many different things.  while it is frustrating that everyone seems to have different "favorites" and there is no one objective best, try to just learn the most commonly referenced ones and realize they are all likely viable options - you can reference your choice of uptodate/sanford/johns hopkins for what is most likely the "current best" recommendation (but beware, the test is typically lagging behind the 'current best recommendation').  once you get these detailed out, it becomes mostly memorization skills, so consider things like Anki decks which are really great for this sort of thing.   have the cards list the disease and self quiz the dz --> bugs --> drugs.  soon it will be second nature that you know the most common different treatment options for a given disease, and can tell the antibiotics that just don't fit for a given question.  if specific test questions or situations come up that stump you, just let us know and we can try to work through it.

abx and id rapid review sn1.pdf

This is a fantastic resource, thank you!! You're entirely right, it's the empirics that are getting me. It's hard when every professor (there are 7 of them), and textbook (3-4 that I use consistently) give a different preference for empiric tx, and then I have to figure out which is the "test question" answer. This is a great compilation, I really appreciate your willingness to share!! 

 

Have you found that this corresponds well to what you actually use in the "Real World"?

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in general, i think the majority of abx listed on my review are still considered appropriate options, but like i said, in the 'real world' there is wide practice variation based on local susceptibility patterns / hospital antibiograms.  if people don't want to figure out local susceptibilities, they often will just default to up to date if they want the current best recommendation on a macro scale... so i'd still recommend you take the time to cross check 

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Here's an antibiotic chart I made in PA school. Definitely not comprehensive, but might be helpful.

For what it's worth, I've been working in ER for a month and if you ask 3 different people their antibiotic preferences for the same condition, you'll often get 3 different answers. PA school is a lot of rote memorization and 1st lines, 2nd lines...but in real life everyone practices so differently from one another

Antibiotic Drugs.docx

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On 11/27/2017 at 4:45 PM, EMEDPA said:

Serenity- I like your chart.

I really liked this text to simplify abx and other meds when I was a student:

https://www.amazon.com/Clinical-Pharmacology-Made-Ridiculously-Simple/dp/1935660004

 

This book series is amazing.  I've read the pharm, pathophys, physiology, anatomy, micro and ortho ones so far.  You can read through them quickly in a few days if you're cramming, but they are excellent adjuncts throughout a class as well. 

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On 12/5/2017 at 9:50 PM, EMEDPA said:

you would probably like the secrets series then for rotations.

one for each rotation, I bought them all:

obgyn secrets, surgical secrets, emergency med secrets, etc

I have my general surgery rotation next semester and I read "Surgical secrets" last month.  It really was quite good.  I enjoyed the format.  I am currently about halfway through "First Aid for the Surgery Clerkship" to get a good review before january.  I'm a quick reader, and I enjoy it, so in my free time I just read books like these.  Haha.

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