01 Cell Wall and Membrane

• Ringed planet: beta-lactam ring
• Death Coccus wall: peptidoglycan cell wall with repeating D-alanyl- D-alanine oligopeptides
• Planetary Building Project worker: penicillin binding protein (PBP) forms peptidoglycan cross-links
• Inactivated PBP worker: beta-lactam antibiotics covalently bind PBPs → the space worker
• Bacterialcidal

This particular group is characterized by its four-membered, nitrogen-containing beta-lactam ring at the core of their structure, which is key to the mode of action of this group of antibiotics.

PBPs are all involved in the final stages of the synthesis of peptidoglycan

Purple pencil: penicillin

• Purple coccoid space stations: activity against gram positive organisms (e.g. Staph and Strep)
• Red bandana: penicillin V treats streptococcal pharyngitis
• Heart-shaped planet Sydenhaam: penicillin V or G treats rheumatic fever
• Emperor Viridans: Strep viridans
• Bicuspid hat: penicillin G treats left-sided endocarditis caused by Strep viridans and Strep bovis
• A galactic baby: intrapartum penicillin G prophylaxis for Group B strep (Strep agalactiae)
• Israeli flag: activity against Actinomyces israelii
• Perforated spacesuit: activity against Clostridium perfringens
• Space dog: activity against Pasteurella multocida infected dog bite wounds
• Red gloves and boots: single dose of benzathine penicillin G treats Syphilis (Treponema pallidum)
• Meningitis mohawk: penicillin G treats Neisseria meningitidis..

• V-winged ship: penicillin V
• Acid nebula: oral penicillin V is acid stable
• Royal G-shaped hairdo: penicillin G
• Ivy: penicillin G administered IV..

• Beta guard: beta-lactamase resistance
• Circular shape: beta-lactamases expressed by plasmid genes..

• IgE missiles: Type-1 (IgE mediated) hypersensitivity reaction
• Exploding asteroids: drug-induced autoimmune hemolytic anemia
• IgG missile on surface: positive direct Coombs test
• Blue star clusters in kidney nebula: drug-induced interstitial nephritis..

Nafcillin, oxacillin, methicillin & dicloxacillin

• Protective armor: bulky R-groups prevent beta-lactamase binding.
• Staff pencil: nafcillin
• Ox horns: oxacillin

• Red hump: empiric treatment for skin and soft tissue infections (e.g. folliculitis, abscesses)
• Tricuspid pyramids: treats Staph endocarditis
• Fish bones: treats Staph osteomyelitis

• Altered wall builder: altered penicillin binding proteins (PBPs) resistant to beta-lactam
• Merciless dark lord MRSA: methicillin resistant Staph aureus (MRSA)

Ampicillin, amoxicillin, piperacillin, ticarcillin

• Piper: piperacillin
• Tiger stripes: ticarcillin
• Amp: ampicillin
• Ammo box: amoxicillin

• Red color: improved activity against gram negative bacteria
• Prism: broad spectrum
• Still binds PBP via beta lactam

• Open mouth: amoxicillin - oral bioavailability
• Ivy: ampicillin - IV administration

• Space stations: staph, strep
• Red bandana: amoxicillin and ampicillin treat streptococcal pharyngitis
• Plugged ears: amoxicillin treats otitis media and sinusitis caused by Strep pneumoniae, Haemophilus influenzae, Moraxella catarrali
• Rusty chest plate: amoxicillin and ampicillin treat pneumonia caused by Strep pneumoniae, Haemophilus influenzae
• H wing ship: activity against Haemophilus influenzae
• Helicopter: amoxicillin is part of the triple therapy (with clarithromycin and a PPI) for Helicobacter pylori infection
• Robin of Ixodes: amoxicillin treats Lyme disease caused by Borrelia burgdorferi
• Spleen hole: amoxicillin prophylaxis against encapsulated bacteria (e.g. Strep pneumoniae and Haemophilus influenzae) in asplenic patients
• Amoxicillin prophylaxis before dental procedures in patients at high risk for endocarditis

Ampi:

• Diplococcus rock drums: ampicillin treats Enterococcus infections
• Set list: ampicillin treats meningitis caused by Listeria monocytogenes
• Activity against gastrointestinal and urinary tract gram negative rods (e.g. E coli)

Also some GI bugs

• Knocked over amp: ampicillin resistant strains of Enterococcus due to beta-lactamase production
• Beta bouncer: sensitivity to beta-lactamases

To counter resistance:

• Distracting clarinet: clavulanate - beta-lactamase inhibitor
• Back to back tambourines: tazobactam and sulbactam - beta- lactamase inhibitors

• Trampled liver spot: drug induced liver injury
• Red lights: antibiotic induced rash in the setting of viral illness (e.g. Epstein-Barr virus -infectious mononucleosis)

• Gas mask: piperacillin and ticarcillin treat anaerobic infections
• Mona Lisa: piperacillin and ticarcillin treat Pseudomonas infections

Cephalosporin

• Activity goes from gram positive to gram negative

• Binds PBP
• Ineffective beta lasers: Beta lactamase ineffective

1st Gen

• 1st General Lex: 1st generation cephalosporins include cephalexin and cefazolin
• Flex: cephalexin
• Fez: cefazolin

• Purple coccoid space stations: activity against gram positive organisms (e.g. Staph and Strep) (1st gen)
• Puffy red gloves and patches: treats cellulitis, abscesses caused by Staph and Strep (1st gen)
• Red bandana: treats Strep pharyngitis (1st gen)
• Red bladder cup: activity against gram negative UTI bugs (e.g. Proteus, E coli, Klebsiella)
• surgical instruments: cefazolin for surgical prophylaxis

2nd Gen

• 2nd General Fox: 2nd generation cephalosporins include cefuroxime, cefotetan, cefoxitin
• Furious: cefuroxime
• Tea cup: cefotetan
• Fox: cefoxitin

• Some red space stations: same coverage as 1st gen with extended gram negative coverage
• Red hens: activity against Haemophilus influenzae, Neisseria, Serratia (HENS)

3rd Gen

• 3rd General Taz: 3rd generation cephalosporins include ceftriaxone, cefotaxime, and ceftazidim
• 3 axes: ceftriaxone and cefotaxime
• Taz: ceftazidime

• Mostly red space stations: extended gram negative coverage beyond 2nd gen
• Mohawk helmet: empiric treatment for meningitis (3rd gen)
• H-wing ship: activity against Haemophilus influenzae
• Rusty chest plate: treats community and hospital acquired pneumonia
• Mona Lisa: ceftazidime treats Pseudomonas infections
• Emperor Viridans: ceftriaxone treats endocarditis caused by Strep viridans and HACEK organisms
• Activity against gram negative GI bugs (e.g. Salmonella, Shigella)
• Dripping chandelier: single dose of IM ceftriaxone is first line treatment for gonorrhea
• Robin of Ixodes: ceftriaxone treats Lyme disease caused by Borrelia burgdorferi

4th Gen

• 4th General Prime: 4th generation cephalosporins include cefepime

• Prism: broad spectrum
• Mona Lisa: Pseudomonas
• Red and purple space stations: broad spectrum (4th gen)
• Mohawk helmet: cefepime treats bacterial meningitis

5th Gen

• 5th General Tara: 5th generation cephalosporins include ceftaroline

• Prism: broad spectrum
• Lord MRSA: ceftaroline treats MRSA infections

Monobactam and Carbopenem

• Ringed planet: beta-lactam ring
• Unfinished Death Coccus: binds PBPs halting peptidoglycan wall synthesis

• One eyed AZ-3M: monobactam - aztreonam
• One eyed android: Monobactam has single beta lactam ring
• Bellows: monobactam has activity against aerobic gram negative rods
• Red rod robot: monobactam has activity against aerobic gram negative rods
• Ineffective beta guard: monobactams are resistant to beta- lactamases

Activity only against gram negative and aerobic

• Mona Lisa: monobactams and carbapenems treat Pseudomonas infections
• Red mohawk helmet and rusty lungs: monobactam treats serious systemic infections with gram negative pathogens (e.g. meningitis, pneumonia, sepsis)
• Pencil wound: monobactams can be used in patients with a h/o penicillin allergy

• Hover car: carbapenems - imipenem, ertapenem, meropenem, doripenem
• prism: carbapenems are broad spectrum
• gas mask: carbapenems treat anaerobic infections (e.g. pneumonia, intra-abdominal infections)
• ineffective rainbow beta guard: monobactams are resistant to extended spectrum beta- lactamases

• “when others fail”: use carbapenems with bugs resistant to other available treatments
• mohawk helmet: carbapenems treat bacterial meningitis

• Amy: imipenem

• Cilastin oil: cilastin inhibits dehydropeptidase in renal tubules preventing the degradation of imipenem

• Mud puddle: GI side effects of carbapenems
• Rust spots: carbapenem may cause skin rash
• Shaking: imipenem lowers the seizure threshold

Vancomycin

• Purple coccoid temples: activity against gram positive bacteria (e.g. Staph, Strep)
• Ivy: IV administration

• Altered wall builder: altered penicillin binding proteins (PBPs) resistant to beta-lactams like penicillin
• Temple wall hieroglyphs: inhibition of cell wall synthesis by directly binding D-alanyl-D- alanine oligopeptides
• Ineffective altered wall builder: altered PBPs ineffective against vancomycin
• Shooting arrows: vancomycin resistanct to beta lactamase

• Golden staff: Staph aureus
• No mercy pharaoh: activity against methicillin resistant Staph aureus (MRSA)
• Meningitis mohawk: CNS penetration - activity against penicillin- resistant Strep pneumo (PRSP)
• Fish bones: bone penetration - treats MRSA osteomyelitis
• Nurse: activity against nosocomial MRSA infections (e.g. hospital acquired pneumonia)
• Biofilm on lines and valves: activity against Staph epidermidis
• heart shaped headpiece: empiric treatment of endocarditis
• Diplococcus rock drums: activity against Enterococcus
• Temple of flowing chocolate: oral vancomycin treats Clostridium difficile colitis

• D-LAC hieroglyph: altered peptidoglycan structure (D-ALA-D-LAC) confers resistance to vancomycin

Vancomycin is frequently used synergistically with aminoglycosides for treatment of penicillin-resistant enterococcal infections. Vancomycin resistance (mediated by plasmids or transposons) can develop when bacterial proteins serving as ligases alter the D-alanyl D-alanine cell wall precursors, which are the targets of vancomycin. VanA ligase replaces D-alanyl D-alanine with D-alanine D-lactate, thereby preventing vancomycin binding.

• Red statue: red man syndrome due to histamine release
• Beehive: mast cell
• Blue vines: thrombophlebitis
• Broken ear: ototoxicity
• Falling kidney: nephrotoxicity
• Slingshot native in dress: Drug reaction with eosinophilia and systemic symptoms (DRESS syndrome)
• Undulating sand dunes: monitor plasma levels

Daptomycin

• POLICE DEPT: DAPTomycin
• Purple wall of protesters: activity against gram positive cell wall (e.g. Staph, Strep, Enterococcus)
• Taser: inserts lipid tail into membrane to depolarize cell

• Resisting van: activity against vancomycin resistant bacterial strains
• Diplococcus rock drums: activity against Enterococcus
• No mercy pharaoh: activity against methicillin resistant Staph aureus (MRSA)
• “It’s in our blood”: treats MRSA bacteremia
• Tricuspid peaks: treats Staph endocarditis
• Protective rusty chest plate: ineffective for pneumonia

• Chicken leg bite: myopathy
• CrisPy chicKen: monitor creatinine phosphokinase (CPK) levels