Indications
Bacteriostatic antimicrobials, a term generally used to describe antimicrobials that function via inhibition of bacterial protein synthesis, have many indications in medicine according to their mechanisms of action. Due to merely inhibiting further growth of bacteria, bacteriostatic antimicrobials require a functioning host immune system to fully clear overgrowth. Due to this effect, however, observational studies have shown that there is a lower incidence of toxic shock and more tolerable side effect profiles.[1][2][3][4] The following classes and specific antimicrobials are generally bacteriostatic: tetracyclines, macrolides, clindamycin, trimethoprim/sulfamethoxazole, linezolid, and chloramphenicol. However, the routine clinical use of chloramphenicol has fallen out of favor in recent years because of side effects.
The indications for tetracycline antimicrobials are extremely broad. As one of the oldest classes of antimicrobials, tetracyclines have demonstrated good activity against gram-positive, gram-negative, atypical, and spirochete bacteria.[5][6] While older tetracyclines (tetracycline, doxycycline) have significant resistance developed in more common pathogens, they retain good activity against atypical pathogens.[3][5][6] However, newer agents within this class (tigecycline) are seeing increasing use in the treatment of multiresistant pathogens due to low rates of resistance.[3] Additionally, due to their wide spectrum of activity and predictable and comparatively tolerable toxicity profile, these agents are popular in the outpatient setting.[3]
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The indications for macrolide antimicrobials are dependent upon the specific macrolide antimicrobial in question. There are three primary antimicrobials within this class: erythromycin, clarithromycin, and azithromycin.[7][8] Erythromycin has poor activity against gram-negative and anaerobic organisms. However, it is extremely effective against atypical pathogens and has some activity against Neisseria spp. Clarithromycin has a similar spectrum of activity to erythromycin, with additional activity against some staph and strep species.[8][9] Azithromycin generally has less activity against most common gram-positive and negative pathogens, but it demonstrates higher efficacy against atypical agents.[9][8]
Clindamycin is an antimicrobial that has gained many indications. In a 1996 review of the literature concerning the drug, indications for it include the following uses: skin and soft tissue infections (including diabetic foot), osteomyelitis and septic arthritis, recurrent streptococcal pharyngitis, anaerobic lung infections, and as an alternative for intra-abdominal and pelvic infections.[9] However, it has poor activity in the bloodstream and is not a recommended therapy in septic patients or those with most gram-negative infections.[9][10][11]
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Trimethoprim/sulfamethoxazole previously saw use as the primary outpatient antimicrobial for a wide variety of infections. However, due to the emergence of widespread resistance, it has lost its utility for empiric coverage of infection in the outpatient setting.[12] Currently, trimethoprim/sulfamethoxazole indications include the treatment of uncomplicated cystitis in patients without recent antimicrobial use, hospitalization, or recurrent UTI in the past year, as well as empiric treatment of non-bloody infectious diarrhea.[12] Due to high resistance in strep and staph species, it is no longer the recommended agent in respiratory or skin/soft tissue infection.
Additionally, trimethoprim/sulfamethoxazole is one of the agents of choice to prevent HIV/AIDS-associated infections, specifically pneumocystis pneumonia (P. jiroveci). Its recommendations include its use as a prophylactic agent in patients with CD4 count less than 200 cells/microliter.[12]
Linezolid, first gaining widespread use in the 2000s, has broad activity against most gram-positive organisms.[13][14][15] Due in large part to its expense, as well as efforts to protect it against developing resistance at large, its primary use is for the treatment of multi-drug resistant gram-positive infections. It has poor activity against gram-negative and anaerobic bacteria, and clinicians should not use it in these settings. Additionally, due to its limited spectrum of activity, it should not be used as an empiric antimicrobial.
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