Flagyl & Cipro

A pharmD working as an infectious diseases specialists told me that doses for amoxicillin have crept up because of resistance patterns of S. pneumoniae. When I started in retail in '87, amoxil 500mg tid was the max you'd see in community practice. First time I saw 1g tid, I thought the dr screwed up.

VA Hopeful Dr said:

I had thought that at 40 kgs we switched to adult doses.

Not that this is a common occurrence, but I just gave cipro-flagyl for cellulitis s/p rottweiler bite. Apparently that's recommended if they fail augmentin.

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WVUPharm2007 said:

Is it? I'm too lazy to look it up. I know that 4g is the max dose, I'm just trying to rationalize it. I'm sure one of our dorky "look at how smart I am" types will find out for us lickity split. I have seen a few cases of 1000mg qid in adults in my life.

Otherwise, I'm fine with being super aggressive with some antibiotics. Like amoxil. What's the worst that will happen? Epic diarrhea?

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Pharmavixen said:

A pharmD working as an infectious diseases specialists told me that doses for amoxicillin have crept up because of resistance patterns of S. pneumoniae. When I started in retail in '87, amoxil 500mg tid was the max you'd see in community practice. First time I saw 1g tid, I thought the dr screwed up.

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Amoxicillin -

Max for kids for AOM or sinusitis is: 2g per day, period.
Max for adults for sinusitis is: 3g per day, period.

The only other reason to do 1g po tid is chronic salmonella infection, typhoid fever, or some other weird disease I don't know.

You can go more with amox/clav - definitely possible to hit 4g of amox content with those.

In the end, nothing happens with even 4g of amox on board per day for 14 days.

pinipig523 said:

Amoxicillin -

Max for kids for AOM or sinusitis is: 2g per day, period.
Max for adults for sinusitis is: 3g per day, period.

The only other reason to do 1g po tid is chronic salmonella infection, typhoid fever, or some other weird disease I don't know.

You can go more with amox/clav - definitely possible to hit 4g of amox content with those.

In the end, nothing happens with even 4g of amox on board per day for 14 days.

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as predicted

WVUPharm2007 said:

as predicted

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Someone's gotta balance out your laziness.

xiphoid2010 said:

Wait, I thought it was bactrim + clinda.

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Sanford's suggests augmentin or if pen allergic/failure then cipro + flagyl. We ended up changing flagyl to clinda for some extra gram+ coverage,

WVUPharm2007 said:

Is it? I'm too lazy to look it up. I know that 4g is the max dose, I'm just trying to rationalize it. I'm sure one of our dorky "look at how smart I am" types will find out for us lickity split. I have seen a few cases of 1000mg qid in adults in my life.

Otherwise, I'm fine with being super aggressive with some antibiotics. Like amoxil. What's the worst that will happen? Epic diarrhea?

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Next peds dehydration admission because of AGE is getting the diagnosis of epic diarrhea.

Also around here we're seeing more Bactrim being prescribed because of decreased resistance compared to Cipro.

VA Hopeful Dr said:

Sanford's suggests augmentin or if pen allergic/failure then cipro + flagyl. We ended up changing flagyl to clinda for some extra gram+ coverage,

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Clinda does a good job covering viridans streps and oral anaerobes, which is why ENT loves it. There is little reason to go to flagyl unless you are worried about anaerobes further down the GI tract like bacteroides and c.diff.

xiphoid2010 said:

wait, i thought it was bactrim + clinda.

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You're right for Peds, but cipro + Flagyl/clinda would work too in adults.

and now for some facts:

1. Dogs constitue 85-90% of animal bite wounds (cats are 5-10% and humans are 2-3%)

2. Majority of human bites are closed fist injuries, aka "fight bites" and should always be treated as a potential infxn per hopkins guide

3. For the years 1990-2003, there were 30 total documented cases of rabies infection in the US.... 28 of those cases were caused by BAT bites

4. Cat scratch fever (Bartonella henselae) sends ~2000 people to the hospital per year in the US

5. and lastly...

p-rog said:

and now for some facts:

1. Dogs constitue 85-90% of animal bite wounds (cats are 5-10% and humans are 2-3%)

2. Majority of human bites are closed fist injuries, aka "fight bites" and should always be treated as a potential infxn per hopkins guide

3. For the years 1990-2003, there were 30 total documented cases of rabies infection in the US.... 28 of those cases were caused by BAT bites

4. Cat scratch fever (Bartonella henselae) sends ~2000 people to the hospital per year in the US

5. and lastly...
View attachment 16399

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I saw a NASTY case of cellulitis from a fight bite in the ED a couple of weeks ago. Hand was swollen about 4 times the size of the other one with pus leaking out of the knuckles. Lymphangitis up to the shoulder. Of course, the guy said that he "fell down the stairs a few days ago and sprained my wrist". Right.

VA Hopeful Dr said:

Next peds dehydration admission because of AGE is getting the diagnosis of epic diarrhea.

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Please tell me you'll put that in the H&P.

In my area- ive got docs prescribing 2500 to 3000 for kids and I go through bottles and bottles of liquid.. and I questioned the dr and he gets all defensive asking DO you think im Overdosing the kid, have I seen the patient... and when the kid comes in.. he looks fine, his mom says he has sinusitis or a ear infection but instead of giving ear drops the kid got 4 chewable 250 tabs three times a day... sinusitis i gave the mom 19 mls of 400mg/5ml twice a day... its getting worse and the kids both had bad case of diarrhea and would not eat anything afraid he will have to go to the bathroom all day

pinipig523 said:

Amoxicillin -

Max for kids for AOM or sinusitis is: 2g per day, period.
Max for adults for sinusitis is: 3g per day, period.

The only other reason to do 1g po tid is chronic salmonella infection, typhoid fever, or some other weird disease I don't know.

You can go more with amox/clav - definitely possible to hit 4g of amox content with those.

In the end, nothing happens with even 4g of amox on board per day for 14 days.

Click to expand...

Pharmavixen said:

It's a bit out of date, but our docs have used Cipro + Flagyl for diabetic foot infections, covering off your anaerobes, Pseudomonas, gm -ves, as well as staph + strep. However, cipro is unreliable against staph + strep these days, and resistance of Pseudomonas to cipro is increasing. A more rational combo, that I am encouraging, is cipro + clinda.

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Clindamycin is largely bacteriostatic isn't it? I feel like a bacteriostatic antibiotic is not too synergistic with a bactericidal antibiotic such as ciprofloxacin. Although I'm a little new to the subject.

Grizaholic17 said:

Clindamycin is largely bacteriostatic isn't it? I feel like a bacteriostatic antibiotic is not too synergistic with a bactericidal antibiotic such as ciprofloxacin. Although I'm a little new to the subject.

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If my memory serves, it's can be either static or cidal depending on the concentration. It covers gram positives and anaerobes, but has no gram negative activity.

It is a ribosomal inhibitor, is sometimes added to cell-wall antibiotic (I've seen with vanc and beta-lactams) to inhibit toxin production in severe cellulitis and necrotizing fasciitis.

It's famous for causing c.diff in high doses, probably because it's immune and takes over when clinda takes out other anaerobes.