ICU Medication Masterclass & Library
145 complete critical care pharmacotherapy profiles built to the highest medical depth — incorporating visual target mechanisms, spectrum visualizers, PK/PD dynamics, organ failure dosing, stewardship pearls, and claim-level citations.
ICU Antimicrobial Strategy
Choose therapy by syndrome, severity, resistance risk and source control—then narrow from microbiology. Exact doses remain in the medication monographs.
Corticosteroids & Immunomodulation: Which? When? Why?
Comprehensive interactive comparison of Hydrocortisone vs. Methylprednisolone vs. Dexamethasone with relative potency curves, genomic cascade visualizer, and adverse effect maps.
Antipsychotics in the ICU
When antipsychotics may help, when they do not treat delirium, agent selection, QT/torsades risk, extrapyramidal effects, NMS, interactions, monitoring, and stopping therapy.
Bedside pharmacology by ICU problem
Move beyond isolated monographs: compare agents, choose by physiology, then drill into exact dosing and organ-failure handling.
Sedation, Analgesia & Neuromuscular Blockade
Propofol vs dexmedetomidine vs midazolam vs ketamine, opioid strategy, rocuronium/succinylcholine/cisatracurium, organ failure, monitoring and R1→R5 bedside cases.
Vasopressors & Inotropes
Norepinephrine, vasopressin, epinephrine, phenylephrine, dopamine, dobutamine and milrinone compared by receptor profile, shock phenotype and pressure-flow tradeoffs.
Antimicrobial Pharmacology & Stewardship
A pharmacology-first companion to ICU Antimicrobial Strategy: choose empiric therapy by syndrome and resistance risk, then optimize exposure by PK/PD, organ support and source control before narrowing from microbiology.
Anticoagulation, Hemostasis & Emergency Reversal
Choose anticoagulation by indication, organ function and procedural risk; recognize HIT and major bleeding; reverse only when the clinical problem justifies it; and plan re-initiation once hemostasis is achieved.
Neurocritical-Care Medications
Medication choices in neurocritical care are inseparable from physiology: stop seizures without causing secondary hypotension, reduce intracranial pressure while preserving perfusion, and choose titratable blood-pressure therapy without overshoot.
Renal, Electrolyte & Acid–Base Pharmacology
A bedside medication framework for fluid removal, sodium emergencies, potassium shifting/stabilization, acid–base rescue and electrolyte replacement—always distinguishing temporary physiologic manipulation from definitive solute removal or disease treatment.
Endocrine & Metabolic ICU Pharmacology
Endocrine emergencies are protocol-sensitive but physiology-dependent. This masterclass separates insulin strategies for DKA/HHS/hyperkalemia, stress-dose corticosteroids for adrenal crisis, desmopressin for central DI, and the sequencing principles of thyroid emergencies.
Toxicology & Antidotes
A mechanism-first antidote curriculum: stabilize airway/ventilation/circulation, identify the physiologic poison phenotype, use the antidote that changes that mechanism, and arrange enhanced elimination when the toxin can actually be removed.
Cardiovascular Rhythm & Blood Pressure Pharmacology
A bedside cardiovascular-drug curriculum that separates rate control, rhythm control, vasodilation and anti-impulse therapy. The goal is not to memorize drug lists—it is to choose the agent that matches rhythm mechanism, ventricular function, blood pressure, ischemia and the end-organ emergency.
Respiratory & Airway Pharmacology
A severe-airway and pulmonary-vascular drug curriculum: use bronchodilators, corticosteroids, magnesium, epinephrine and inhaled pulmonary vasodilators based on the actual respiratory mechanism rather than escalating every drug for every wheezy or hypoxemic patient.
Obstetric Critical-Care Pharmacology
A maternal-emergency pharmacology curriculum focused on eclampsia, acute severe pregnancy/postpartum hypertension and postpartum hemorrhage. It emphasizes rapid protocolized treatment while preserving the critical-care habit of reassessing airway, shock and competing diagnoses.
Transplant & Immunosuppression Pharmacology
A transplant-ICU medication curriculum centered on the tension between rejection, infection and drug toxicity. It teaches how to interpret calcineurin-inhibitor levels, interactions, AKI and cytopenias without making the dangerous assumption that all immunosuppression should either be continued unchanged or stopped completely.
Hepatology & GI ICU Pharmacology
A cirrhosis/hepatology medication curriculum that separates encephalopathy treatment, portal-pressure control, HRS-AKI vasoconstriction and acute liver-failure antidotal therapy. It emphasizes precipitant/source control and avoids drug-only treatment of syndromes driven by bleeding, infection or hemodynamic failure.
Corticosteroids & Immunomodulation in Critical Illness
A syndrome-first guide to glucocorticoids and selected immunomodulators: distinguish replacement from anti-inflammatory therapy, use steroid-equivalent thinking correctly, and avoid carrying one trial regimen into every ICU diagnosis.
Hematology & Oncologic Emergency Pharmacology
High-stakes drug selection for thrombotic microangiopathy, immune thrombocytopenia, tumor lysis and hyperinflammation—where the correct medication is inseparable from plasma exchange, transfusion strategy, dialysis and trigger control.
Cardiac Arrest & Peri-Arrest Pharmacology
Drug reasoning during cardiac arrest and peri-arrest instability: know which medications can help, which are merely optional, and which routine drugs distract from high-quality CPR, defibrillation and treatment of reversible causes.
Anaphylaxis & Refractory Allergic Emergency Pharmacology
A no-delay pharmacology pathway for anaphylaxis: intramuscular epinephrine first, airway and fluid resuscitation in parallel, then carefully selected infusions/adjuncts for refractory shock or bronchospasm.
ICU Nutrition, Refeeding & Micronutrient Pharmacology
The medication side of ICU nutrition: recognize refeeding risk before calories start, give thiamine when indicated, correct phosphate/potassium/magnesium safely, control glucose without starving the patient, and count non-nutritional calories such as propofol lipid.
ACS & Antiplatelet Pharmacology
A bedside framework for antiplatelet selection in acute coronary syndromes: aspirin plus a P2Y12 inhibitor, PCI context, bleeding risk, oral absorption, drug interactions and when clopidogrel is favored over more potent agents.
Thrombolysis & Reperfusion Pharmacology
A high-risk medication framework for alteplase and tenecteplase across acute ischemic stroke and other reperfusion syndromes. The same fibrinolytic mechanism does not mean the same indication, dose or contraindication set.
🧠 ICU Educational & Spectrum Frameworks
Open only the reference table you need. Every antimicrobial reference table can now be downloaded as PDF.
🦠 Drug-by-Pathogen FrameworkShow table ▼Hide table ▲
Educational Drug-by-Pathogen Framework (IDSA AMR Guidance 2026)
ESBL Enterobacterales
E. coli, K. pneumoniae — syndrome and susceptibility matter
- ✓ Meropenem for severe infection / shock
- ✓ Ertapenem for susceptible non-Pseudomonas infection when clinically stable
- ✓ Cefepime-enmetazobactam (Exblifep): alternative in selected ESBL-E infections; U.S. label is cUTI
- ✕ Ceftriaxone when ESBL resistant
- ✕ Do not assume piperacillin-tazobactam is equivalent to a carbapenem for invasive ESBL infection
KPC-producing CRE
Carbapenem-resistant Enterobacterales — KPC mechanism
- ✓ Meropenem-vaborbactam
- ✓ Ceftazidime-avibactam (Avycaz)
- ✓ Imipenem-cilastatin-relebactam (Recarbrio)
- ✕ Aztreonam alone
- ✕ Polymyxins when an active safer novel beta-lactam is available
- ✕ Routine aminoglycoside monotherapy for invasive disease
NDM / other MBL-producing Enterobacterales
Metallo-beta-lactamase producers
- ✓ Aztreonam-avibactam (Emblaveo) when available
- ✓ Ceftazidime-avibactam + aztreonam when the fixed combination is unavailable
- ✓ Cefiderocol when susceptible
- ✕ Ceftazidime-avibactam alone
- ✕ Meropenem-vaborbactam for NDM
- ✕ Imipenem-relebactam for NDM
OXA-48-like CRE
Serine carbapenemase phenotype
- ✓ Ceftazidime-avibactam (Avycaz)
- ✓ Other agents only when susceptibility/mechanism support them
- ✕ Meropenem-vaborbactam as a mechanism-based default
- ✕ Assuming all carbapenemases respond to the same inhibitor
DTR Pseudomonas aeruginosa
Difficult-to-treat resistant Pseudomonas
- ✓ Ceftolozane-tazobactam
- ✓ Ceftazidime-avibactam
- ✓ Imipenem-cilastatin-relebactam
- ✓ Cefiderocol when susceptibility/site support use
- ✕ Ertapenem
- ✕ Ceftriaxone
- ✕ TMP-SMX
- ✕ Vancomycin
- ✕ Polymyxin as preferred therapy when an active safer beta-lactam exists
CRAB
Carbapenem-resistant Acinetobacter baumannii
- ✓ Sulbactam-durlobactam (Xacduro) + imipenem-cilastatin or meropenem — IDSA 2026 preferred approach
- ✓ If Xacduro is temporarily unavailable: high-dose ampicillin-sulbactam + another active agent
- ✓ Alternative combination components when susceptible: high-dose minocycline, high-dose tigecycline, cefiderocol, polymyxin B
- ✕ Routine carbapenem monotherapy
- ✕ Colistin/polymyxin as preferred therapy when Xacduro is active/available
- ✕ Treating colonization as invasive infection
Stenotrophomonas maltophilia
First decide colonization vs true invasive infection
- ✓ Cefiderocol monotherapy — IDSA 2026 preferred approach for invasive infection, with limited clinical-outcomes evidence
- ✓ Aztreonam-avibactam + a second active agent — alternative
- ✓ Levofloxacin, minocycline, or TMP-SMX as components of combination therapy — alternatives
- ✓ Consider step-down to susceptible single-agent therapy only after clear, sustained clinical improvement
- ✕ Meropenem
- ✕ Imipenem
- ✕ Routine treatment of respiratory colonization
MSSA
Methicillin-susceptible S. aureus
- ✓ Cefazolin
- ✓ Antistaphylococcal penicillin where appropriate
- ✕ Vancomycin as preferred definitive therapy when a beta-lactam is tolerated and isolate is susceptible
MRSA
Site matters
- ✓ Vancomycin (AUC-guided for serious infection)
- ✓ Linezolid for MRSA pneumonia
- ✓ Daptomycin for bacteremia/endovascular infection — NOT pneumonia
- ✕ Daptomycin for primary alveolar pneumonia
- ✕ Cefazolin as MRSA therapy
VRE / resistant Enterococcus
Species, site and susceptibility matter
- ✓ Linezolid
- ✓ High-dose daptomycin in selected bacteremia/endovascular infection when susceptible and specialist-guided
- ✕ Cephalosporins as Enterococcus therapy
- ✕ Assuming all E. faecium remains daptomycin susceptible
Invasive Candidemia
Candida bloodstream infection
- ✓ Echinocandin initial therapy for most critically ill adults
- ✓ Fluconazole step-down when clinically stable and isolate is susceptible
- ✓ Evaluate source control and catheter removal when the catheter is a likely source and removal is feasible
- ✕ Treating respiratory Candida colonization
- ✕ Automatic catheter removal regardless of source/feasibility
Invasive Aspergillosis
Mold-active therapy
- ✓ Voriconazole
- ✓ Isavuconazole
- ✓ Liposomal amphotericin B in selected situations
- ✕ Fluconazole
- ✕ Echinocandin monotherapy as routine first-line definitive therapy
Mucormycosis
Rhizopus, Mucorales — surgery/source control matters
- ✓ Liposomal amphotericin B
- ✓ Isavuconazole
- ✓ Posaconazole as selected step-down/salvage therapy
- ✕ Fluconazole
- ✕ Echinocandin monotherapy
Severe Influenza
Hospitalized / ICU influenza
- ✓ Oseltamivir enterally as standard first-line therapy when susceptible
- ✓ Consider longer duration in prolonged severe disease/immunocompromise
- ✕ Routine doubling to oseltamivir 150 mg twice daily
- ✕ Delaying antiviral therapy while waiting for confirmatory testing in a compatible severe syndrome
⚖️ High-Yield Antimicrobial Comparison MatricesShow table ▼Hide table ▲
High-Yield Antimicrobial Comparison Matrices
| Agent | Best Mechanism/Role | Useful Against | Key Gaps | ICU Pearl |
|---|---|---|---|---|
| Ceftazidime-avibactam (Avycaz) | KPC / OXA-48-like CRE; selected DTR Pseudomonas | KPC, OXA-48-like; many DTR Pseudomonas | NDM/other MBL alone | For MBL producers, pair avibactam protection with aztreonam or use a preferred MBL-active alternative. |
| Meropenem-vaborbactam | KPC-producing CRE | KPC Enterobacterales | NDM/MBL; OXA-48-like not its strength | Excellent KPC option; do not generalize all carbapenemases. |
| Imipenem-cilastatin-relebactam (Recarbrio) | KPC and selected DTR Pseudomonas | KPC; some DTR Pseudomonas | NDM/MBL; OXA-48-like | Mechanism and susceptibility still matter. |
| Aztreonam-avibactam (Emblaveo) | NDM/other MBL-producing Enterobacterales | Many MBL + co-produced serine β-lactamases | Not a universal Acinetobacter drug | FDA label is narrower than the IDSA 2026 AMR role. |
| Cefiderocol | MBL CRE / selected DTR Pseudomonas | Many NDM/MBL CRE; DTR Pseudomonas | Variable CRAB performance; resistance can emerge | Reserve for resistant phenotypes where its spectrum matters. |
| Ceftolozane-tazobactam | DTR Pseudomonas | Many difficult Pseudomonas isolates | Carbapenemase-producing CRE not its core role | One of the most important modern antipseudomonal options. |
| Cefepime-enmetazobactam (Exblifep) | ESBL-E / selected AmpC+ESBL | Many ESBL Enterobacterales | Not a universal CRE drug | U.S. FDA label is cUTI; IDSA guidance discusses broader selected ESBL use. |
📍 Site Matters — Tissue Penetration MatrixShow table ▼Hide table ▲
Site Matters — Tissue Penetration Matrix
Central Nervous System / Meninges
- ✓ Ceftriaxone (meningitis dosing)
- ✓ Meropenem (meningitis dosing)
- ✓ Ampicillin (Listeria coverage)
- ✓ Acyclovir (HSV encephalitis)
- ✓ Fluconazole (good CSF exposure)
- ✕ Echinocandins — poor CSF penetration
- ✕ Daptomycin — not a CNS workhorse
- ✕ Ertapenem — not a meningitis drug
Lungs / Alveolar Lining Fluid
- ✓ Linezolid — high ELF exposure
- ✓ Levofloxacin
- ✓ Cefepime / ceftazidime
- ✓ Meropenem
- ✓ Ceftolozane-tazobactam
- ✓ Ceftazidime-avibactam (Avycaz)
- ✕ Daptomycin — inactivated by pulmonary surfactant
- ✕ Aminoglycosides as monotherapy — poor ELF exposure
- ✕ Tigecycline is not a preferred bacteremia drug despite tissue penetration
Urinary Tract / Kidney
- ✓ Ceftriaxone / cefepime when susceptible
- ✓ TMP-SMX
- ✓ Aminoglycosides
- ✓ Ertapenem
- ✓ Cefepime-enmetazobactam (Exblifep) — FDA cUTI indication
- ✓ Plazomicin — FDA cUTI indication
- ✕ Echinocandins — poor urinary concentrations
- ✕ Tigecycline / eravacycline — not preferred for UTI
- ✕ Polymyxin B — poor urinary exposure compared with colistin/CMS
Bloodstream / Endovascular
- ✓ Cefazolin for MSSA
- ✓ Vancomycin (AUC-guided) for MRSA
- ✓ Daptomycin for susceptible MRSA/VRE bacteremia
- ✓ Carbapenem or active novel beta-lactam for susceptible invasive Gram-negative disease
- ✕ Tigecycline — low serum exposure
- ✕ Eravacycline — not a bacteremia drug
- ✕ Oral fosfomycin — not for bacteremia
Intra-abdominal / Deep Tissue
- ✓ Piperacillin-tazobactam
- ✓ Meropenem / ertapenem
- ✓ Ceftriaxone + metronidazole
- ✓ Eravacycline (cIAI label)
- ✓ Tigecycline in selected susceptible resistant infections
- ✕ Aminoglycoside monotherapy
- ✕ Vancomycin alone for polymicrobial intra-abdominal sepsis
- ✕ Agents without anaerobic coverage when anaerobes are part of the syndrome
Bone / Joint / Prosthetic Material
- ✓ Cefazolin for MSSA
- ✓ Vancomycin for MRSA
- ✓ Daptomycin or linezolid in selected resistant Gram-positive infection
- ✓ Rifampin may be used only as part of selected staphylococcal prosthetic-material regimens
- ✕ Rifampin monotherapy — rapid resistance
- ✕ Short-course therapy without source control in established hardware infection
Eye / Vitreous
- ✓ Systemic fluoroquinolones have useful ocular penetration in selected syndromes
- ✓ Endophthalmitis usually requires intravitreal therapy directed by ophthalmology
- ✕ Relying on systemic antibiotics alone for acute postoperative endophthalmitis
Mold / Invasive Fungal Disease
- ✓ Voriconazole — invasive aspergillosis
- ✓ Isavuconazole — aspergillosis / mucormycosis
- ✓ Liposomal amphotericin B — mucormycosis and broad mold salvage
- ✓ Posaconazole — prophylaxis and selected salvage/step-down
- ✕ Fluconazole for Aspergillus or Mucorales
- ✕ Echinocandin monotherapy for mucormycosis
| Medication | Class / Role | Preferred / Why I Choose It | Caution / Why I Avoid It | Bedside Pearl |
|---|---|---|---|---|
| Amikacin Aminoglycosides | Aminoglycoside Antibiotic | ✓ Extremely potent bactericidal agent against resistant Gram-negative bacilli, maintaining susceptibility when organisms are resistant to Gentamicin and Tobramycin. | ✕ High risk of acute tubular necrosis (nephrotoxicity) with prolonged exposure or high trough levels. | Differentiate FDA Product-Label Conventional Dosing (15 mg/kg/day divided q8–12h per DailyMed) from Critical Care Extended-Interval Dosing (15–20 mg/kg q24h) and Critical-Care PK Loading Strategies (25–30 mg/k… |
| Anidulafungin Echinocandins | Echinocandin Antifungal Agent | ✓ First-line preferred initial antifungal therapy for candidemia and invasive candidiasis in critically ill septic patients. | ✕ Poor urinary tract penetration: Ineffective for Candida pyelonephritis or cystitis. | Candida recovered from blood should be considered clinically significant and evaluated as candidemia rather than dismissed as contamination. Immediate antifungal therapy is indicated. If a central venous cathe… |
| Cefepime Cephalosporins | 4th-Generation Cephalosporin Antibiotic | ✓ Preferred carbapenem-sparing option for many invasive infections caused by Enterobacter cloacae complex, Klebsiella aerogenes, and Citrobacter freundii at moderate risk of clinically signif… | ✕ Cefepime-Induced Neurotoxicity (CIN): Encephalopathy, nonconvulsive status epilepticus (NCSE), and myoclonus in unadjusted renal failure. | If an ICU patient on Cefepime develops unexplained altered mental status, myoclonus, or a slowed EEG with triphasic waves, suspect Cefepime-Induced Neurotoxicity (CIN)! Immediately adjust dose for CrCl or hold… |
| Ceftriaxone Cephalosporins | 3rd-Generation Cephalosporin Antibiotic | ✓ First-line empiric coverage for severe Community-Acquired Pneumonia (CAP) in combination with Macrolide/Doxycycline. | ✕ Ceftriaxone is not a reliable treatment for Pseudomonas aeruginosa or Acinetobacter baumannii. | Never mix routine infection dosing (1–2 g q24h) with CNS bacterial meningitis dosing (2.0 g IV q12h) — high meningeal drug levels are required to overcome the blood-brain barrier. |
| Daptomycin Lipopeptides | Cyclic Lipopeptide Antibiotic | ✓ Rapidly bactericidal alternative to vancomycin for MRSA bacteremia and right-sided infective endocarditis; agent selection depends on source, MIC/susceptibility, prior therapy, renal functi… | ✕ Do not use daptomycin for typical alveolar pneumonia: pulmonary surfactant inhibits its antibacterial activity. This is a lack-of-efficacy limitation rather than a classic toxicity-based co… | Do not select daptomycin to treat an alveolar pneumonia because surfactant markedly reduces its activity. It remains useful for susceptible Gram-positive bloodstream/endovascular and selected deep infections; … |
| Ertapenem Carbapenems | Group 1 Carbapenem Antibiotic | ✓ Targeted once-daily therapy (1.0 g IV q24h) for confirmed ESBL Enterobacterales infections (UTI, cIAI, bacteremia) in stable patients or outpatient step-down. | ✕ CRITICAL EXAM & CLINICAL TRAP: Has no clinically reliable activity against Pseudomonas aeruginosa or Acinetobacter baumannii — inappropriate for empiric ICU shock coverage when Pseudomonas … | Carbapenem ≠ automatically antipseudomonal! Never select Ertapenem as empiric therapy for VAP or septic shock where Pseudomonas coverage is mandatory. Furthermore, in severe septic shock with hypoalbuminemia, … |
| Linezolid Oxazolidinones | Oxazolidinone Antibiotic | ✓ Guideline-supported option for MRSA HAP/VAP; ATS/IDSA supports either linezolid or vancomycin, with selection individualized to renal function, blood counts, interacting serotonergic drugs,… | ✕ Serotonin-toxicity and adrenergic-interaction risk: linezolid is a reversible, nonselective MAO inhibitor. Avoid or closely manage important serotonergic combinations when feasible and titr… | Linezolid is an important option for MRSA pneumonia and achieves good epithelial-lining-fluid exposure; vancomycin is also guideline-supported, so do not claim universal superiority. Daptomycin is not indicate… |
| Liposomal Amphotericin B Polyenes | Polyene Antifungal Agent (Liposomal Formulation) | ✓ Guideline-preferred first-line therapy for mucormycosis, generally at liposomal amphotericin B doses of at least 5 mg/kg/day, combined with urgent surgical management when feasible. | ✕ CRITICAL MEDICATION SAFETY WARNING: Amphotericin B formulations are not interchangeable mg-for-mg. Confusing a conventional deoxycholate product with a lipid/liposomal regimen can produce a… | Never substitute amphotericin B formulations mg-for-mg. Verify the complete product/formulation and indication-specific dose before prescribing, dispensing, and administration; fatal overdoses have occurred wh… |
| Meropenem Carbapenems | Group 2 Antipseudomonal Carbapenem Antibiotic | ✓ Preferred therapy for invasive ESBL-producing Enterobacterales infections such as bloodstream infection, particularly in critical illness; MERINO supports carbapenem preference over piperac… | ✕ Inactivated by carbapenemases (KPC, NDM, VIM, OXA-48). | Use prolonged/extended infusion when PK/PD optimization is important (e.g., critical illness, augmented clearance, or higher MIC pathogens) and adjust for renal/CRRT clearance. BLING III supports better clinic… |
| Metronidazole Nitroimidazoles | Synthetic Nitroimidazole Antimicrobial | ✓ Potent bactericidal activity against Bacteroides fragilis and obligate intra-abdominal anaerobes. | ✕ No clinically useful activity against aerobic Gram-negative bacilli (E. coli, Klebsiella, Pseudomonas) or Gram-positive aerobes. | AVOID UNNECESSARY DUPLICATE ANAEROBIC COVERAGE! Adding Metronidazole to Piperacillin-Tazobactam or Meropenem usually provides unnecessary duplicate anaerobic coverage without additional therapeutic benefit whi… |
| Piperacillin–Tazobactam Penicillins | Antipseudomonal Penicillin & Beta-Lactamase Inhibitor | ✓ First-line empiric monotherapy for HAP/VAP, intra-abdominal sepsis, and febrile neutropenia when Pseudomonas is suspected. | ✕ Observational studies have reported more creatinine-defined AKI with vancomycin plus piperacillin-tazobactam, but causality is uncertain; the randomized ACORN trial found no significant dif… | Use an institutionally validated prolonged/extended-infusion regimen when PK/PD optimization is desired, with renal/CRRT adjustment. Do not switch piperacillin-tazobactam to cefepime solely because of an assum… |
| Trimethoprim–Sulfamethoxazole (TMP-SMX) Folate Synthesis Inhibitors | Sulfonamide & Folate Antagonist Combination | ✓ Important Stenotrophomonas-active agent: Current IDSA 2026 guidance identifies Cefiderocol monotherapy as the preferred initial approach for invasive S. maltophilia infection (supporting cl… | ✕ High incidence of severe hyperkalemia in ICU patients due to trimethoprim amiloride-like ENaC potassium channel block (heightened in CKD, AKI, ACEi/ARB/MRA use). | Express weight-based TMP-SMX doses by the trimethoprim (TMP) component. For invasive Stenotrophomonas maltophilia, current IDSA 2026 guidance identifies Cefiderocol monotherapy as the preferred initial approac… |
| Vancomycin Glycopeptides | Glycopeptide Antibiotic | ✓ A standard empiric anti-MRSA option when the syndrome and local epidemiology warrant MRSA coverage (for example selected HAP/VAP, severe sepsis with MRSA risk, purulent/NSTI syndromes, or s… | ✕ Nephrotoxicity risk rises with excessive vancomycin exposure (especially AUC above the recommended range), duration, critical illness and other nephrotoxic exposures. Observational studies … | For serious suspected/confirmed MRSA infection in a critically ill patient, use an actual-body-weight loading strategy when rapid target attainment is needed (2020 consensus: commonly 20–35 mg/kg, maximum 3 g)… |
| Acyclovir Antivirals | Antiviral nucleoside analogue | ✓ Empiric treatment of suspected HSV encephalitis while PCR is pending. | ✕ AKI/crystal nephropathy and neurotoxicity, especially if not renally adjusted. | In unexplained encephalopathy on acyclovir with AKI, consider drug neurotoxicity as well as viral progression. |
| Ganciclovir Antivirals | Antiviral nucleoside analogue | ✓ Severe CMV disease when IV therapy is needed. | ✕ Neutropenia/thrombocytopenia, renal accumulation, reproductive toxicity. | CBC and renal function are part of the dose—not optional monitoring. |
| Fluconazole Azoles | Triazole antifungal | ✓ Step-down from echinocandin when susceptible and clinically stable. | ✕ QT prolongation, hepatotoxicity, CYP interactions, resistance in non-albicans Candida. | Do not choose fluconazole empirically for an unstable ICU candidemia patient when azole resistance is plausible. |
| Micafungin Echinocandins | Echinocandin antifungal | ✓ Empiric/initial therapy for unstable candidemia. | ✕ Hepatic enzyme elevation; limited urinary/CSF penetration. | Echinocandins are excellent bloodstream drugs but poor choices for Candida UTI because active urinary concentrations are low. |
| Voriconazole Azoles | Triazole antifungal | ✓ First-line invasive aspergillosis. | ✕ Visual/neurotoxicity, hepatotoxicity, QT effects, photosensitivity, extensive CYP interactions. | TDM is not optional trivia in prolonged/severe invasive aspergillosis—it can materially change efficacy and toxicity. |
| Ceftazidime-Avibactam Novel beta-lactams | Cephalosporin / beta-lactamase inhibitor | ✓ Preferred option for KPC and OXA-48-like CRE; one preferred option for DTR Pseudomonas. | ✕ Resistance can emerge during therapy; renal under/overdosing during changing kidney function. | For NDM/MBL organisms, ceftazidime-avibactam alone is inadequate—pair avibactam protection with aztreonam or use an appropriate alternative. |
| Ceftolozane-Tazobactam Novel beta-lactams | Cephalosporin / beta-lactamase inhibitor | ✓ Preferred agent for DTR Pseudomonas pneumonia in 2026 IDSA guidance. | ✕ Resistance may emerge; renal dosing errors are common. | Do not use ceftolozane-tazobactam simply because an ESBL is present—reserve novel agents when narrower options work. |
| Meropenem-Vaborbactam Novel beta-lactams | Carbapenem / beta-lactamase inhibitor | ✓ Preferred KPC CRE option with low reported resistance emergence relative to some alternatives. | ✕ Renal accumulation, beta-lactam neurotoxicity/seizure risk; no activity against MBLs. | Carbapenemase mechanism matters—KPC, NDM and OXA-48 are not interchangeable labels. |
| Cefiderocol Novel beta-lactams | Siderophore cephalosporin | ✓ Preferred option for NDM-producing Enterobacterales; preferred monotherapy for invasive Stenotrophomonas maltophilia in IDSA 2026 despite limited clinical-outcomes evidence; alternative for… | ✕ Mortality imbalance signal in early pathogen-focused trial; resistance/heteroresistance; mechanism-specific interpretation required. | Cefiderocol is not “the strongest antibiotic”; reserve it for resistant Gram-negative phenotypes where its unique spectrum matters. |
| Aztreonam Monobactams | Monobactam beta-lactam | ✓ Useful beta-lactam option in selected severe beta-lactam allergy and as the MBL-stable partner in aztreonam-avibactam strategies. | ✕ Narrow spectrum; resistance from co-produced serine beta-lactamases unless protected by avibactam. | For NDM infection, “aztreonam is stable to NDM” is only half the story—co-produced ESBL/AmpC often still destroys unprotected aztreonam. |
| Gentamicin Aminoglycosides | Aminoglycoside antibiotic | ✓ Selected resistant Gram-negative infection or specific synergy indications. | ✕ Nephrotoxicity, irreversible ototoxicity, neuromuscular blockade. | Aminoglycoside dosing without TDM in an unstable ICU patient is not precision therapy. |
| Azithromycin Macrolides | Macrolide antibiotic | ✓ Atypical coverage in severe CAP. | ✕ QT prolongation, hepatotoxicity, GI effects; resistance limits monotherapy for pneumococcus. | When QT is already markedly prolonged or the patient has multiple QT-prolonging drugs, reassess whether azithromycin is the best atypical agent. |
| Levofloxacin Fluoroquinolones | Fluoroquinolone antibiotic | ✓ Oral/IV bioequivalence and atypical coverage when appropriate. | ✕ QT prolongation, tendinopathy, neuropathy, dysglycemia, CNS effects, aortic-risk warnings, C. difficile. | Do not use fluoroquinolone convenience to override local susceptibility or toxicity risk. |
| Imipenem-Cilastatin-Relebactam Novel beta-lactams | Carbapenem / dehydropeptidase-I inhibitor / beta-lactamase inhibitor | ✓ A preferred option in 2026 IDSA guidance for invasive KPC-producing Enterobacterales when susceptible. | ✕ Relebactam does not inhibit NDM/VIM/IMP metallo-beta-lactamases and should not be assumed active against OXA-48-like producers. | Do not select a novel beta-lactam by the label ‘CRE’ alone—identify the carbapenemase when possible and confirm AST. KPC, MBL and OXA-48-like phenotypes require different drug choices. |
| Sulbactam-Durlobactam Novel beta-lactams | Penicillin-binding antibacterial / beta-lactamase inhibitor | ✓ Preferred therapy for invasive CRAB when available, combined with a carbapenem. | ✕ Do not use as monotherapy for invasive CRAB; MBLs such as NDM are not inhibited. | Do not rank antimicrobials as simply 'stronger' or 'weaker': match the drug to the organism, resistance mechanism, infection site, source control and achievable exposure. |
| Aztreonam-Avibactam Novel beta-lactams | Monobactam / beta-lactamase inhibitor | ✓ Preferred option for NDM-producing Enterobacterales in current IDSA guidance; an alternative for invasive Stenotrophomonas maltophilia, preferably initially combined with a second active ag… | ✕ Do not assume all MBL organisms are susceptible; confirm AST and syndrome. | Do not rank antimicrobials as simply 'stronger' or 'weaker': match the drug to the organism, resistance mechanism, infection site, source control and achievable exposure. |
| Cefepime-Enmetazobactam Novel beta-lactams | Fourth-generation cephalosporin / beta-lactamase inhibitor | ✓ Option when susceptibility and resistance mechanism make its ESBL/AmpC coverage useful. | ✕ Reserve newer agents when narrower established beta-lactams are adequate; not a universal CRE drug. | Do not rank antimicrobials as simply 'stronger' or 'weaker': match the drug to the organism, resistance mechanism, infection site, source control and achievable exposure. |
| Ampicillin-Sulbactam Penicillins | Aminopenicillin / beta-lactamase inhibitor | ✓ Useful for aspiration-related polymicrobial infection when antibiotics are indicated and for susceptible mixed infections; CRAB role is now secondary/bridge. | ✕ Do not treat it as preferred definitive therapy for invasive CRAB when sulbactam-durlobactam is available. | Do not rank antimicrobials as simply 'stronger' or 'weaker': match the drug to the organism, resistance mechanism, infection site, source control and achievable exposure. |
| Cefazolin Cephalosporins | First-generation cephalosporin | ✓ Excellent definitive therapy for susceptible MSSA in many syndromes and useful perioperatively. | ✕ Not adequate for MRSA, Pseudomonas, enterococci or CNS infection without syndrome-specific evidence. | Do not rank antimicrobials as simply 'stronger' or 'weaker': match the drug to the organism, resistance mechanism, infection site, source control and achievable exposure. |
| Clindamycin Protein-synthesis inhibitors | Lincosamide | ✓ Adjunct for toxin suppression in invasive group A streptococcal or clostridial disease when clinically appropriate. | ✕ High C. difficile risk and resistance limit indiscriminate empiric use. | Do not rank antimicrobials as simply 'stronger' or 'weaker': match the drug to the organism, resistance mechanism, infection site, source control and achievable exposure. |
| Isavuconazole Antifungals | Triazole antifungal | ✓ Important alternative mold-active azole, particularly when voriconazole interactions/toxicity or mucormycosis matter. | ✕ Major CYP3A interactions remain; susceptibility and syndrome determine choice. | Do not rank antimicrobials as simply 'stronger' or 'weaker': match the drug to the organism, resistance mechanism, infection site, source control and achievable exposure. |
| Posaconazole Antifungals | Triazole antifungal | ✓ Useful mold-active prophylaxis and selected treatment/salvage option. | ✕ Numerous CYP3A interactions; oral suspension and delayed-release tablet are not pharmacokinetically interchangeable. | Do not rank antimicrobials as simply 'stronger' or 'weaker': match the drug to the organism, resistance mechanism, infection site, source control and achievable exposure. |
| Minocycline Tetracyclines | Tetracycline | ✓ Alternative combination component for invasive CRAB when susceptible; IDSA 2026 notes that fewer than half of CRAB isolates may test susceptible using the revised CLSI breakpoint. | ✕ Avoid assuming tetracycline susceptibility from class alone; limited urinary concentrations and bacteremia evidence constrain use. | Do not rank antimicrobials as simply 'stronger' or 'weaker': match the drug to the organism, resistance mechanism, infection site, source control and achievable exposure. |
| Tigecycline Tetracyclines | Glycylcycline | ✓ Selected deep-tissue/intra-abdominal resistant infections when susceptibility and PK fit. | ✕ Not suggested for bloodstream or urinary infections caused by CRE because serum/urinary exposures are inadequate; nausea and mortality warning matter. | Do not rank antimicrobials as simply 'stronger' or 'weaker': match the drug to the organism, resistance mechanism, infection site, source control and achievable exposure. |
| Eravacycline Tetracyclines | Fluorocycline | ✓ Useful for selected complicated intra-abdominal resistant infections when susceptibility and source control fit. | ✕ Do not extrapolate to UTI or bloodstream infection; resistance mechanism and MIC matter. | Do not rank antimicrobials as simply 'stronger' or 'weaker': match the drug to the organism, resistance mechanism, infection site, source control and achievable exposure. |
| Polymyxin B Polymyxins | Polymyxin | ✓ Possible combination component when preferred CRAB options are unavailable/resistant and susceptibility supports use. | ✕ Nephrotoxicity, neurotoxicity and narrow therapeutic window make newer active beta-lactams preferable when available. | Do not rank antimicrobials as simply 'stronger' or 'weaker': match the drug to the organism, resistance mechanism, infection site, source control and achievable exposure. |
| Colistin (CMS) Polymyxins | Polymyxin prodrug | ✓ Occasional salvage option, particularly urinary infection because CMS is renally converted/excreted. | ✕ High nephrotoxicity and complex PK; do not substitute dosing units across products/countries. | Do not rank antimicrobials as simply 'stronger' or 'weaker': match the drug to the organism, resistance mechanism, infection site, source control and achievable exposure. |
| Oseltamivir Antivirals | Neuraminidase inhibitor | ✓ Core ICU influenza therapy; start promptly even when illness began >48 h earlier in hospitalized severe disease. | ✕ Absorption requires enteral access; resistance or malabsorption may require specialist alternatives. | Do not rank antimicrobials as simply 'stronger' or 'weaker': match the drug to the organism, resistance mechanism, infection site, source control and achievable exposure. |
| Ceftazidime Cephalosporins | Third-generation antipseudomonal cephalosporin | ✓ Narrower definitive antipseudomonal option when susceptible and cefepime/piperacillin-tazobactam are not preferred. | ✕ Resistance can emerge; weak Gram-positive coverage makes it unsuitable for many empiric monotherapy scenarios. | Do not rank antimicrobials as simply 'stronger' or 'weaker': match the drug to the organism, resistance mechanism, infection site, source control and achievable exposure. |
| Ampicillin Penicillins | Aminopenicillin | ✓ High-value narrow therapy for Listeria CNS infection and susceptible enterococcal disease. | ✕ Do not use when beta-lactamase/resistance makes exposure ineffective. | Do not rank antimicrobials as simply 'stronger' or 'weaker': match the drug to the organism, resistance mechanism, infection site, source control and achievable exposure. |
| Penicillin G Penicillins | Natural penicillin | ✓ Definitive narrow therapy when organism and syndrome support it. | ✕ High-dose formulations carry sodium/potassium load and require renal/neurotoxicity awareness. | Do not rank antimicrobials as simply 'stronger' or 'weaker': match the drug to the organism, resistance mechanism, infection site, source control and achievable exposure. |
| Tobramycin Aminoglycosides | Aminoglycoside | ✓ Selected resistant Gram-negative infections or synergistic indications when susceptibility and PK favor it. | ✕ Avoid prolonged empiric use when safer active beta-lactams are available. | Do not rank antimicrobials as simply 'stronger' or 'weaker': match the drug to the organism, resistance mechanism, infection site, source control and achievable exposure. |
| Fosfomycin IV Other antibacterials | Phosphonic-acid antibacterial | ✓ Labeled IV option for adult cUTI/acute pyelonephritis due to susceptible E. coli or K. pneumoniae when fosfomycin is appropriate. | ✕ Do not generalize the U.S. cUTI indication to pneumonia, bacteremia, or other MDR infections without a specific evidence-supported rationale; each 6-g vial contains 1980 mg sodium and QT/el… | Do not rank antimicrobials as simply 'stronger' or 'weaker': match the drug to the organism, resistance mechanism, infection site, source control and achievable exposure. |
| Plazomicin Aminoglycosides | Aminoglycoside | ✓ Selected complicated UTI/CRE scenarios when susceptibility supports and preferred beta-lactams are unsuitable. | ✕ Nephrotoxicity and TDM burden; generally not preferred over safer active novel beta-lactams. | Do not rank antimicrobials as simply 'stronger' or 'weaker': match the drug to the organism, resistance mechanism, infection site, source control and achievable exposure. |
| Remdesivir Antivirals | Nucleotide analogue antiviral | ✓ Selected hospitalized or immunocompromised COVID-19 patients when antiviral therapy is indicated. | ✕ Not a substitute for syndrome-appropriate immunomodulation/supportive care; benefit falls when viral replication is no longer the dominant problem. | Do not rank antimicrobials as simply 'stronger' or 'weaker': match the drug to the organism, resistance mechanism, infection site, source control and achievable exposure. |
| Foscarnet Antivirals | Pyrophosphate analogue antiviral | ✓ Important salvage antiviral when polymerase resistance or intolerance limits ganciclovir/acyclovir. | ✕ Major nephrotoxicity and electrolyte toxicity; use ID/transplant pharmacy oversight. | Do not rank antimicrobials as simply 'stronger' or 'weaker': match the drug to the organism, resistance mechanism, infection site, source control and achievable exposure. |
| Rezafungin Echinocandins | Long-acting echinocandin antifungal | ✓ Once-weekly IV dosing can be useful when rezafungin is an appropriate echinocandin option and the labeled limited/no-alternative criterion is met. | ✕ Do not present it as routine first-line replacement for established echinocandins: U.S. approval is specifically for patients with limited or no alternative options. | The long half-life explains weekly dosing, but the U.S. label is deliberately narrow; verify indication, source control, susceptibility, and whether a better-established alternative exists. |
Amikacin
Amikacin Sulfate
Potent concentration-dependent aminoglycoside for severe MDR Gram-negative bacilli and Pseudomonas aeruginosa — requires distinguishing Product-Label Conventional Dosing from Critical Care Extended-Interval PK Strategies, therapeutic drug monitoring (TDM), and ototoxicity/nephrotoxicity vigilance.
Anidulafungin
Anidulafungin
First-line echinocandin for candidemia and invasive candidiasis in critically ill patients — features unique non-enzymatic spontaneous chemical degradation, with no dosage adjustment required for renal or hepatic impairment per prescribing information.
Cefepime
Cefepime Hydrochloride
Zwitterionic 4th-generation antipseudomonal cephalosporin with useful activity against susceptible Pseudomonas and many AmpC-producing Enterobacterales; it is one accepted option for syndromes such as HAP/VAP or febrile neutropenia when local susceptibility and patient factors fit, but carries important neurotoxicity risk with excess exposure or renal dysfunction.
Ceftriaxone
Ceftriaxone Sodium
Workhorse 3rd-generation cephalosporin with strong Gram-negative and pneumococcal coverage, dual biliary/renal clearance, and high CNS penetration at 2g IV q12h for bacterial meningitis.
Daptomycin
Daptomycin
Rapidly bactericidal cyclic lipopeptide used for selected MRSA bacteremia/right-sided endocarditis and VRE infections; monitor CPK and do not use it to treat typical alveolar pneumonia because pulmonary surfactant markedly inhibits its activity.
Ertapenem
Ertapenem Sodium
Once-daily Group 1 carbapenem for ESBL Enterobacterales, cIAI, and cUTI in stable patients — NOT an antipseudomonal agent, and requires caution in severe septic shock / hypoalbuminemia due to altered protein binding.
Linezolid
Linezolid
Synthetic oxazolidinone active against MRSA and VRE, with excellent oral bioavailability and useful lung penetration. Standard labeling does not mandate renal dose adjustment, but renal dysfunction and prolonged exposure increase metabolite accumulation and thrombocytopenia risk; close blood-count monitoring and selective TDM are reasonable in high-risk ICU patients.
Liposomal Amphotericin B
Amphotericin B Liposome for Injection
Broadest-spectrum fungicidal polyene for Mucormycosis, invasive Molds, and Cryptococcus — significantly less nephrotoxic than conventional amphotericin B, but FORMULATIONS ARE NOT INTERCHANGEABLE MG-FOR-MG.
Meropenem
Meropenem Sodium
Ultra-broad-spectrum antipseudomonal Group 2 carbapenem for severe ESBL Enterobacterales, MDR Pseudomonas aeruginosa, intra-abdominal sepsis, and post-neurosurgical meningitis.
Metronidazole
Metronidazole
Potent obligate anaerobic bactericidal agent for intra-abdominal infections, CNS abscesses, and trichomoniasis — requires avoiding redundant double anaerobic coverage when paired with Pip-Tazo or Meropenem.
Piperacillin–Tazobactam
Piperacillin Sodium and Tazobactam Sodium
Workhorse ICU antipseudomonal penicillin providing broad Gram-negative, Gram-positive, and anaerobic coverage — best administered as an extended 4-hour infusion, but carries synergy for AKI when combined with Vancomycin.
Trimethoprim–Sulfamethoxazole (TMP-SMX)
Trimethoprim and Sulfamethoxazole
Sequential folate pathway inhibitor used for Pneumocystis jirovecii pneumonia (PJP), selected susceptible bacterial infections, Nocardia, and as an active option for Stenotrophomonas maltophilia. Doses are conventionally expressed by the trimethoprim component; major ICU toxicities include hyperkalemia, creatinine elevation from inhibited tubular secretion, true kidney injury, cytopenias, and severe cutaneous reactions.
Vancomycin
Vancomycin Hydrochloride
Parenteral glycopeptide for serious susceptible Gram-positive infections, especially MRSA; in serious invasive MRSA, use an appropriate loading strategy when rapid exposure is needed and AUC-guided monitoring (target AUC24/MIC 400–600 when MIC is assumed 1 mg/L) rather than routine trough-only 15–20 mg/L targeting.
Acyclovir
Acyclovir
IV antiviral essential for HSV encephalitis/disseminated HSV and severe VZV; renal dose adjustment and crystalluria/neurotoxicity are central ICU issues.
Ganciclovir
Ganciclovir sodium
IV anti-CMV drug for severe CMV disease in immunocompromised hosts; major toxicities are marrow suppression and renal accumulation.
Fluconazole
Fluconazole
Excellent-bioavailability azole useful for susceptible Candida step-down and cryptococcal consolidation/maintenance; not reliable for molds.
Micafungin
Micafungin sodium
Echinocandin used for candidemia/invasive candidiasis; the U.S. label requires no renal dose adjustment and no post-hemodialysis supplement.
Voriconazole
Voriconazole
Preferred primary therapy for invasive aspergillosis with nonlinear pharmacokinetics, major interactions and a strong role for TDM.
Ceftazidime-Avibactam
Ceftazidime/avibactam
Key agent for selected CRE and DTR Pseudomonas; active against KPC and OXA-48-like enzymes but not metallo-beta-lactamases by itself.
Ceftolozane-Tazobactam
Ceftolozane/tazobactam
Potent antipseudomonal beta-lactam/beta-lactamase inhibitor, particularly valuable for DTR Pseudomonas pneumonia and other severe infections.
Meropenem-Vaborbactam
Meropenem/vaborbactam
Carbapenem plus boronic-acid beta-lactamase inhibitor, preferred for KPC-producing Enterobacterales but inactive against MBLs and OXA-48-like enzymes.
Cefiderocol
Cefiderocol
Siderophore cephalosporin active against many carbapenem-resistant Gram-negative organisms, including MBL producers. IDSA 2026 also identifies cefiderocol monotherapy as the preferred approach for invasive Stenotrophomonas maltophilia, while acknowledging that this preference is driven mainly by preclinical rather than robust clinical-outcomes data.
Aztreonam
Aztreonam
Gram-negative-only beta-lactam notable for stability to metallo-beta-lactamases; often paired with avibactam activity when MBL producers co-produce serine beta-lactamases.
Gentamicin
Gentamicin sulfate
Concentration-dependent Gram-negative agent with selected synergy uses; nephrotoxicity/ototoxicity and TDM make it a specialist ICU drug.
Azithromycin
Azithromycin
Macrolide used for atypical CAP coverage and selected infectious syndromes; QT and interaction considerations matter in ICU patients.
Levofloxacin
Levofloxacin
Respiratory fluoroquinolone with excellent bioavailability and antipseudomonal activity at higher dosing, balanced against significant class toxicities.
Imipenem-Cilastatin-Relebactam
Imipenem/cilastatin/relebactam
Carbapenem/beta-lactamase-inhibitor option for selected KPC-producing Enterobacterales and susceptible DTR Pseudomonas; relebactam inhibits class A (including KPC) and class C beta-lactamases but not metallo-beta-lactamases or OXA-48-like carbapenemases.
Sulbactam-Durlobactam
sulbactam/durlobactam
FDA-approved as Xacduro for HABP/VABP caused by susceptible A. baumannii-calcoaceticus complex. IDSA 2026 extends its role to preferred therapy for invasive CRAB when combined with imipenem-cilastatin or meropenem; durlobactam protects sulbactam from many class A/C/D beta-lactamases.
Aztreonam-Avibactam
aztreonam/avibactam
FDA-approved as Emblaveo with metronidazole for adults with limited/no alternatives for complicated intra-abdominal infection caused by designated susceptible Gram-negative organisms. Separately, IDSA 2026 recommends aztreonam-avibactam as a preferred option for invasive NDM-producing Enterobacterales; that broader AMR use extends beyond the narrow U.S. labeled indication.
Cefepime-Enmetazobactam
cefepime/enmetazobactam
FDA-approved as Exblifep for adult complicated UTI including pyelonephritis due to designated susceptible organisms. IDSA 2026 also considers cefepime-enmetazobactam an alternative for ESBL-E infections outside the urinary tract; such use should be recognized as guideline-supported use beyond the narrow U.S. cUTI label.
Ampicillin-Sulbactam
ampicillin/sulbactam
Broad beta-lactam/beta-lactamase inhibitor used for susceptible polymicrobial infections; high-dose sulbactam-based therapy is a temporary CRAB bridge only when sulbactam-durlobactam is not immediately available.
Cefazolin
cefazolin
High-value narrow beta-lactam for MSSA and streptococci; often preferred over vancomycin for susceptible MSSA bacteremia after source evaluation.
Clindamycin
clindamycin
Protein-synthesis inhibitor with anaerobic and Gram-positive activity; in ICU practice it is especially valuable as adjunct toxin-suppression therapy for selected invasive GAS/clostridial syndromes.
Isavuconazole
isavuconazonium sulfate
Mold-active triazole used for invasive aspergillosis and mucormycosis; notable for shortening rather than prolonging QT and for fewer cyclodextrin renal-vehicle concerns than IV voriconazole.
Posaconazole
posaconazole
Broad mold-active triazole used mainly for prophylaxis and selected salvage/treatment strategies; formulation-specific absorption and interactions matter.
Minocycline
minocycline
Tetracycline with activity against selected CRAB and Stenotrophomonas isolates; susceptibility testing and infection site are essential.
Tigecycline
tigecycline
Tissue-distributing glycylcycline with activity against many resistant Gram-positive and Gram-negative organisms, including selected CRE/CRAB; low serum/urinary exposure limits bloodstream/UTI use, and the U.S. label does not indicate it for HAP/VAP.
Eravacycline
eravacycline
Fluorocycline approved for complicated intra-abdominal infection with activity against many ESBL/CRE and anaerobic organisms; not a urinary or bloodstream drug.
Polymyxin B
polymyxin B
Toxic salvage Gram-negative agent; IDSA 2026 retains polymyxin B only as an alternative component for selected invasive CRAB, not as preferred routine therapy.
Colistin (CMS)
colistimethate sodium
Colistimethate is the inactive prodrug of colistin; dosing-unit conventions vary and renal replacement profoundly complicates exposure. Reserve for resistant Gram-negative infection when safer active agents are unavailable.
Oseltamivir
oseltamivir
First-line enteral antiviral for hospitalized/critically ill influenza when susceptible; treatment should not be delayed for confirmatory testing when clinical suspicion is high during influenza circulation.
Ceftazidime
ceftazidime
Traditional antipseudomonal cephalosporin useful when susceptibility permits; lacks reliable Gram-positive and anaerobic coverage.
Ampicillin
ampicillin
Narrow beta-lactam important for susceptible Enterococcus faecalis, Listeria monocytogenes and selected streptococcal infections.
Penicillin G
benzylpenicillin
Narrow bactericidal beta-lactam for highly susceptible streptococci, clostridial infections, meningococcal disease and neurosyphilis when appropriate.
Tobramycin
tobramycin
Concentration-dependent aminoglycoside with strong antipseudomonal activity; ICU use requires individualized PK/TDM because nephrotoxicity and altered Vd are common.
Fosfomycin IV
fosfomycin disodium
IV fosfomycin (CONTEPO) is now U.S.-approved for adults with complicated UTI, including acute pyelonephritis, caused by susceptible Escherichia coli or Klebsiella pneumoniae. Do not extrapolate this labeled indication to other MDR syndromes or confuse IV fosfomycin disodium with oral fosfomycin tromethamine.
Plazomicin
plazomicin
Next-generation aminoglycoside active against many aminoglycoside-resistant Enterobacterales; role is limited by nephrotoxicity, availability and lack of activity against MBL-mediated co-resistance patterns in some isolates.
Remdesivir
remdesivir
IV antiviral for selected hospitalized COVID-19 patients; benefit depends on disease stage, oxygen requirement, immune status and current guideline context.
Foscarnet
foscarnet
Toxic IV antiviral for resistant/refractory CMV or acyclovir-resistant HSV/VZV. Nephrotoxicity is the major dose-limiting toxicity: adequate IV hydration, frequent creatinine-based dose adjustment, and close calcium/magnesium/potassium/phosphate monitoring are core parts of therapy.
Rezafungin
rezafungin
Once-weekly IV echinocandin. U.S. labeling (revised July 2026) indicates it for candidemia and invasive candidiasis in adults and patients >=12 years who have limited or no alternative options; the label notes limited clinical safety/efficacy data and no study in Candida endocarditis, osteomyelitis, or meningitis.