Anti-microbial drugs (cell wall inhibitors, cell membrane inhibitors, nucleic acid or DNA inhibitors, protein synthesis inhibitors, folate synthesis inhibitors, anti tubercular drug, anti malarial drug, anti helminthes drugs, anti protozoal drufs) adverse effects comparison chart with mnemonics
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Anti-Microbial Drugs - Adverse Effects Comparison Chart with Mnemonics
Below is a complete, exam-ready reference organized by drug class, mechanism, key adverse effects, and memory aids.
1. CELL WALL INHIBITORS
Beta-Lactams (Penicillins, Cephalosporins, Carbapenems, Monobactams)
| Drug/Class | Key Adverse Effects |
|---|---|
| Penicillins (all) | Hypersensitivity/anaphylaxis, urticaria, maculopapular rash, interstitial nephritis, hemolytic anemia, C. difficile colitis, seizures (high dose/renal failure) |
| Ampicillin/Amoxicillin | All the above + mononucleosis rash (EBV) - "Ampicillin + mono = rash guaranteed" |
| Nafcillin | Neutropenia, interstitial nephritis |
| Oxacillin | Hepatitis |
| Piperacillin-tazobactam | AKI when combined with vancomycin |
| Cephalosporins (1st-4th gen) | Cross-allergy with penicillin (<1%), C. diff, disulfiram-like reaction (MTT-containing: cefoperazone, cefotetan - alcohol = flushing/nausea/vomiting) |
| Ceftriaxone | Biliary pseudolithiasis (sludge), hyperbilirubinemia in neonates |
| Carbapenems | Seizures (imipenem > others), C. diff, GI upset |
| Aztreonam (monobactam) | Generally safe; no cross-reactivity with penicillin |
| Vancomycin | Red man syndrome (histamine release, NOT allergy - slow down infusion), nephrotoxicity, ototoxicity, thrombophlebitis |
Mnemonics:
"PACH-SIN" - Penicillin adverse effects: P - Penicillin allergy/Anaphylaxis A - Ampicillin+EBV = Rash C - C. difficile colitis H - Hemolytic anemia S - Seizures (high dose) I - Interstitial nephritis (nafcillin/oxacillin = nephritis/hepatitis) N - Neutropenia (nafcillin)
Cephalosporins - "DISH" rule: Disulfiram-like (MTT group), Increase INR, Serum sickness, Hypersensitivity
Vancomycin - "RED MAN VAN": Red man syndrome, Ear toxicity (ototoxicity), Drug nephrotoxicity, Marrow (thrombophlebitis)
2. CELL MEMBRANE INHIBITORS
| Drug | Key Adverse Effects |
|---|---|
| Polymyxin B / Colistin | Nephrotoxicity (dose-limiting), neurotoxicity (paresthesias, apnea), neuromuscular blockade |
| Daptomycin | Myopathy/CPK elevation (hold statins!), eosinophilic pneumonia, peripheral neuropathy. Inactivated by surfactant - NOT for pulmonary infections |
| Amphotericin B | Nephrotoxicity (azotemia, renal tubular acidosis), hypokalemia, hypomagnesemia, infusion reaction (fever/chills/rigors = "shake-and-bake"), anemia |
Mnemonics:
Daptomycin - "DUMP it in the muscle, not the lung": Do not use in pneumonia (surfactant inactivates), Up CPK (myopathy), Marrow (eosinophilic pneumonia), P - peripheral neuropathy
Amphotericin B = "Ampho-terrible": Nephrotoxicity, K+ loss (hypokalemia), Mg2+ loss, Fever/chills/rigors on infusion, Anemia
3. NUCLEIC ACID / DNA INHIBITORS (Fluoroquinolones)
| Drug | Key Adverse Effects |
|---|---|
| Fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin) | Tendinitis/tendon rupture (Achilles - black box warning), peripheral neuropathy, CNS effects (hallucinations, anxiety, insomnia, seizures, confusion), QT prolongation (moxifloxacin > others), phototoxicity, GI (nausea/vomiting/headache), cartilage damage in children, C. diff colitis |
| Metronidazole (DNA strand breaker) | Metallic taste, peripheral neuropathy, disulfiram-like reaction with alcohol, headache, nausea, seizures (high dose) |
| Nitrofurantoin | Pulmonary fibrosis (chronic use), peripheral neuropathy, hemolysis (G6PD deficiency), hepatotoxicity |
Mnemonics:
Fluoroquinolones = "FQTPCA" F - Fluoroquinolones → Tendinitis/tendon rupture (Achilles) P - Peripheral neuropathy C - CNS (seizures, hallucinations, insomnia) A - Arrhythmia (QT prolongation, moxifloxacin)
- Phototoxicity + Cartilage damage (avoid in children/pregnant)
Metronidazole - "METAL flag": Metallic taste, Excessive alcohol = disulfiram, Tingling (neuropathy), Avoid in first trimester, Leuckoencephalopathy (high dose)
Nitrofurantoin - "NitroFire in Lungs": N - Neuropathy, F - Fibrosis (pulmonary), H - Hemolysis (G6PD), L - Liver toxicity
4. PROTEIN SYNTHESIS INHIBITORS
30S Ribosomal Subunit Inhibitors
| Drug | Key Adverse Effects |
|---|---|
| Aminoglycosides (gentamicin, tobramycin, amikacin, streptomycin) | Ototoxicity (cochlear = hearing loss + vestibular = balance), Nephrotoxicity (proximal tubule), neuromuscular blockade |
| Tetracyclines (doxycycline, minocycline) | Photosensitivity, GI disturbance, esophageal ulceration (take with water), teeth discoloration/enamel hypoplasia + bone growth suppression (children <8yrs, pregnancy), hepatotoxicity (IV), Fanconi syndrome (outdated tetracycline), minocycline = vestibular toxicity + drug-induced lupus |
50S Ribosomal Subunit Inhibitors
| Drug | Key Adverse Effects |
|---|---|
| Macrolides (erythromycin, azithromycin, clarithromycin) | GI (nausea/vomiting - erythromycin worst, acts as motilin agonist), QT prolongation (azithromycin, clarithromycin), cholestatic jaundice (erythromycin estolate), CYP450 inhibition (clarithromycin > erythromycin), ototoxicity (high dose) |
| Clindamycin | C. difficile pseudomembranous colitis (most notorious), diarrhea, hepatotoxicity |
| Chloramphenicol | Gray baby syndrome (neonates - premature baby lacks glucuronyl transferase), aplastic anemia (idiosyncratic), dose-dependent bone marrow suppression, optic neuritis |
| Linezolid | Thrombocytopenia, serotonin syndrome (MAO inhibitor - avoid with SSRIs/SNRIs/triptans), peripheral/optic neuropathy (prolonged use), lactic acidosis |
| Streptogramins (quinupristin-dalfopristin) | Myalgia, arthralgia, hyperbilirubinemia, CYP3A4 inhibition |
| Oxazolidinones (linezolid, tedizolid) | As above for linezolid |
Mnemonics:
Aminoglycosides = "OTAN": Ototoxicity (cochlear + vestibular), Tubular necrosis (nephrotoxicity), Anesthesia potentiation (NM blockade), Neuromuscular blockade. "MEAN" drugs: Myoneural block, Ear damage, Acute kidney, Nephrotoxicity
Tetracyclines - "TEETH": T - Teeth staining (children <8) E - Esophageal ulceration E - Enamel hypoplasia T - Teratogenic (avoid pregnancy) H - Hepatotoxicity + Photosensitivity
Chloramphenicol - "GRAY CAP": G - Gray baby syndrome R - RBC aplasia (aplastic anemia - idiosyncratic) A - Aplastic anemia Y - (colored urine) C - CYP interactions A - Anemia (dose-dependent) P - Peripheral neuritis + Optic neuritis
Linezolid - "STALL": S - Serotonin syndrome T - Thrombocytopenia A - Acidosis (lactic) L - Leucopenia/anemia L - Linitis (neuropathy)
Clindamycin - "C. diff Clinda": #1 classic cause of Clostridium difficile colitis (also "CLINDA = Colitis Lingers IN Diarrhea Always")
5. FOLATE SYNTHESIS INHIBITORS
| Drug | Key Adverse Effects |
|---|---|
| Sulfonamides (sulfamethoxazole, sulfadiazine) | Hypersensitivity (rash, Stevens-Johnson syndrome/toxic epidermal necrolysis), crystalluria/nephrotoxicity (drink plenty of water!), hemolytic anemia (G6PD deficiency), kernicterus (neonates - displace bilirubin from albumin), bone marrow suppression, photosensitivity, drug-induced lupus |
| Trimethoprim (TMP) | Megaloblastic anemia (folate antagonist - add leucovorin), hyperkalemia, elevated serum creatinine (blocks tubular secretion, not true GFR decrease) |
| TMP-SMX (Co-trimoxazole) | All of the above combined |
| Dapsone | Hemolytic anemia (G6PD deficiency), methemoglobinemia, peripheral neuropathy, agranulocytosis |
Mnemonics:
Sulfonamides = "SHCK-M": S - SJS/Stevens-Johnson Syndrome H - Hemolytic anemia (G6PD) C - Crystalluria K - Kernicterus (neonates) M - Myelosuppression
Trimethoprim - "TMP = Thins My Platelets/Potassium raises": Blocks dihydrofolate reductase → megaloblastic picture; raises K+ and creatinine
Dapsone - "DAPS = Dye-blue blood": Dapsone → methemoglobinemia (bluish blood), hemolysis in G6PD, Agranulocytosis, Peripheral neuropathy, Sulfa allergy cross-reactivity (debated)
6. ANTI-TUBERCULAR DRUGS (First-Line: RIPE)
| Drug | Key Adverse Effects | Classic Mnemonic |
|---|---|---|
| Rifampicin (RIF) | Orange/red discoloration of body fluids (urine, tears, sweat), hepatotoxicity, thrombocytopenia, flu-like syndrome (intermittent use), potent CYP450 inducer (drug interactions with OCP, warfarin, HIV drugs) | "RIPE" for TB |
| Isoniazid (INH) | Peripheral neuropathy (pyridoxine/B6 deficiency - give B6 prophylaxis), hepatotoxicity (age-dependent), drug-induced lupus (anti-histone Ab), seizures (high dose), sideroblastic anemia | |
| Pyrazinamide (PZA) | Hepatotoxicity (most hepatotoxic), hyperuricemia → gout/arthralgia, GI upset, polyarthralgia | |
| Ethambutol (EMB) | Optic neuritis (red-green color blindness, decreased visual acuity - check baseline vision; reversible if caught early), hyperuricemia |
Second-line TB drugs:
| Drug | Key Adverse Effects |
|---|---|
| Streptomycin | Ototoxicity (vestibular > cochlear), nephrotoxicity |
| Cycloserine | CNS toxicity (psychosis, seizures, depression) - "Cyclo-psycho" |
| Ethionamide | GI intolerance, hepatotoxicity, neurotoxicity |
| Kanamycin/Amikacin | Ototoxicity, nephrotoxicity |
| Bedaquiline | QT prolongation, hepatotoxicity |
| Linezolid | Serotonin syndrome, thrombocytopenia, optic neuropathy |
Mnemonics:
RIPE side effects - "RIPE-HOP": R - Red body fluids + CYP inducer (Rifampicin) I - INH = neuropathy (give B6) + Isoniazid lupus P - PZA = hyperuricemia (gout) + Hepatotoxicity E - Ethambutol = Eye toxicity (optic neuritis)
Isoniazid - "INH PLANS": P - Peripheral neuropathy (B6 deficiency) L - Lupus drug-induced A - Age-dependent hepatitis N - Neuropathy (sideroblastic anemia) S - Seizures
Pyrazinamide - "PZA HURTS joints": Hyperuricemia + Arthralgia + Hepatotoxicity (most hepatotoxic first-line TB drug)
Ethambutol - "EMB = Eye Must Be checked": Optic neuritis (reversible if caught early, irreversible if missed)
7. ANTI-MALARIAL DRUGS
(From Tintinalli's Emergency Medicine, Table 159-4)
| Drug | Minor Toxicity | Major Toxicity | Key Point |
|---|---|---|---|
| Chloroquine | Nausea/vomiting, pruritus, postural hypotension, rash, headache, dizziness | Retinopathy (prolonged use), hypotension/shock (IV) | Avoid in psoriasis, porphyria |
| Quinine/Quinidine | Cinchonism (nausea, tinnitus, headache, dizziness, visual disturbance) | Hypotension, cardiac dysrhythmias, hypoglycemia, Coombs+ hemolysis, NM paralysis | Avoid in cardiac disease |
| Primaquine | Nausea/vomiting, methemoglobinemia | Massive hemolysis (G6PD deficiency) | Contraindicated in G6PD deficiency, pregnancy |
| Mefloquine | Nausea, dizziness, nightmares, bradycardia | Dysrhythmias (cardiac disease), acute toxic confusional states, seizures | Avoid with quinidine; neuropsychiatric disorders |
| Doxycycline | GI disturbance, phototoxicity, vaginal candidiasis | Esophageal ulceration | Avoid <8 yrs, pregnancy |
| Artemether-lumefantrine | Headache, dizziness, anorexia | QT prolongation (rare) | CYP3A4 and CYP2D6 interactions |
| Atovaquone-proguanil | Nausea, vomiting, oral ulcers, headache | Severe allergic reactions, alopecia | Contraindicated if CrCl <30 |
Mnemonics:
Chloroquine - "CHLOR-EYE": Cornea deposits + EYE retinopathy (Bull's eye maculopathy - classic exam finding)
Primaquine - "PRIME target: G6PD": G6PD deficiency → hemolysis + methemoglobinemia
Quinine - "QUININE = CINchonism": Cinchonism: ringing ears (tinnitus), headache, nausea/vomiting (reversible at low dose)
All anti-malarials - "QT Killers in malaria": Quinine, Quinidine, Mefloquine, Halofantrine, Artemether-lumefantrine can all prolong QT interval
8. ANTI-HELMINTHIC DRUGS
| Drug | Target Worm(s) | Key Adverse Effects |
|---|---|---|
| Mebendazole / Albendazole | Broad spectrum (roundworm, hookworm, whipworm, tapeworm) | Generally well tolerated; abdominal pain, diarrhea; Albendazole: hepatotoxicity, bone marrow suppression (leukopenia), alopecia with prolonged use; teratogenic (avoid pregnancy) |
| Praziquantel | Trematodes, cestodes (tapeworm, schistosoma) | Headache, dizziness, drowsiness, nausea/vomiting, abdominal pain; worsens neurocysticercosis seizures (inflammatory reaction) - use with corticosteroids + albendazole |
| Ivermectin | Filaria, strongyloides, onchocerca | Mazzotti reaction (in onchocerciasis: fever, urticaria, edema, pruritus = Jarisch-Herxheimer-like), dizziness, hypotension; CNS toxicity if P-glycoprotein deficient (MDR1 mutation) |
| Diethylcarbamazine (DEC) | Filaria (W. bancrofti, lymphatic filariasis) | Mazzotti-like reaction, fever, lymphangitis, encephalopathy (loiasis - avoid in high Loa loa microfilaria load) |
| Pyrantel pamoate | Roundworm, pinworm, hookworm | Mild GI side effects; NM blockade (depolarizing), headache |
| Niclosamide | Tapeworm (intestinal only) | Mild GI effects; vomiting may allow systemic absorption → cysticercosis risk |
| Thiabendazole | Strongyloides | Dizziness, nausea, hepatotoxicity, leucopenia |
Mnemonics:
Albendazole - "ALBA-toxins": Alopecia, Leucopenia (bone marrow), Big liver (hepatotoxicity), Abortion risk (teratogenic)
Praziquantel - "PRAZ-Drown the worm, wake the brain": Drowsiness + dizziness + GI; brain cysticercosis → seizures (treat with dexamethasone)
Ivermectin - "IVER-Mazz": Mazzotti reaction in onchocerciasis (massive inflammatory kill-off response)
9. ANTI-PROTOZOAL DRUGS
| Drug | Target Organism | Key Adverse Effects |
|---|---|---|
| Metronidazole | Giardia, Entamoeba, Trichomonas, anaerobes | Metallic taste, disulfiram-like reaction (absolute alcohol avoidance), peripheral neuropathy (prolonged use), seizures (high dose), nausea, headache, dark urine |
| Tinidazole | Same as metronidazole | Similar to metronidazole; better GI tolerability |
| Chloroquine | Malaria, amoebiasis | (See antimalarials above) |
| Pentamidine | Pneumocystis jiroveci, Leishmaniasis, Trypanosomiasis | Hypoglycemia (then hyperglycemia - toxic to beta cells), nephrotoxicity, hypotension (IV), pancreatitis, electrolyte disturbances (hypokalemia, hypomagnesemia), cardiac dysrhythmias |
| Amphotericin B | Leishmaniasis, fungi | (See cell membrane inhibitors above) |
| Sodium stibogluconate (antimonials) | Leishmaniasis | Cardiotoxicity (QT prolongation, ventricular arrhythmia), hepatotoxicity, pancreatitis, nephrotoxicity |
| Suramin | African trypanosomiasis (T. brucei) | Neuropathy, nephrotoxicity, adrenal insufficiency, blood dyscrasias |
| Melarsoprol | African trypanosomiasis (CNS stage) | Reactive encephalopathy (5-10%, fatal), peripheral neuropathy, fever, hepatotoxicity, thrombophlebitis |
| Nifurtimox/Benznidazole | T. cruzi (Chagas) | Peripheral neuropathy, GI (nausea, vomiting, anorexia), skin rash (benznidazole), neurological (nifurtimox) |
| Pyrimethamine + sulfadiazine | Toxoplasmosis | Megaloblastic anemia (folate antagonist - add leucovorin), rash, thrombocytopenia, SJS |
Mnemonics:
Metronidazole - "METRO = Metallic, disulfiRAm, neuropaTHY, seIZURE": M - Metallic taste E - Ethanol = disulfiram reaction (vomiting) T - Tingling (peripheral neuropathy) R - Reacts with alcohol O - pOlyuria/dark urine + CNS (seizures in high dose)
Pentamidine - "PENTA-SUGAR chaos": Hypoglycemia (initial insulin release) → then Hyperglycemia (beta cell necrosis = diabetes), Nephrotoxicity, Pancreatitis, Hypotension
Melarsoprol - "Mela = Arsenic = Encephalopathy": Contains arsenic derivative → Reactive encephalopathy (most feared side effect)
MASTER COMPARISON SUMMARY TABLE
| Drug Class | Drug Examples | Most Feared ADR | Classic Mnemonic |
|---|---|---|---|
| Cell Wall (Beta-lactams) | Penicillin, Cephalosporins | Anaphylaxis | PACH-SIN |
| Cell Wall (Glycopeptide) | Vancomycin | Red man syndrome, nephrotoxicity | RED MAN VAN |
| Cell Membrane | Amphotericin B | Nephrotoxicity, shake-and-bake | Ampho-terrible |
| Cell Membrane | Daptomycin | Myopathy (CPK), no lungs! | DUMP not in lungs |
| DNA Inhibitors | Fluoroquinolones | Tendinitis, QT prolongation | FQTPCA |
| DNA Inhibitors | Metronidazole | Disulfiram + metallic taste | METRO |
| 30S Inhibitors | Aminoglycosides | Ototoxicity + nephrotoxicity | MEAN / OTAN |
| 30S Inhibitors | Tetracyclines | Teeth staining, phototoxicity | TEETH |
| 50S Inhibitors | Chloramphenicol | Gray baby, aplastic anemia | GRAY CAP |
| 50S Inhibitors | Clindamycin | C. diff colitis | CLINDA |
| 50S Inhibitors | Linezolid | Serotonin syndrome, thrombocytopenia | STALL |
| Folate Inhibitors | Sulfonamides | SJS, crystalluria, kernicterus | SHCK-M |
| Folate Inhibitors | Trimethoprim | Megaloblastic anemia, hyperkalemia | TMP |
| Anti-TB | INH | Peripheral neuropathy (B6!) | INH PLANS |
| Anti-TB | Rifampicin | Orange urine, CYP inducer | RED CYP |
| Anti-TB | PZA | Hyperuricemia, hepatotoxicity | PZA HURTS |
| Anti-TB | Ethambutol | Optic neuritis (eye!) | EMB = Eyes |
| Anti-malarial | Chloroquine | Retinopathy (bull's eye) | CHLOR-EYE |
| Anti-malarial | Primaquine | Hemolysis (G6PD!) | G6PD alert |
| Anti-malarial | Quinine | Cinchonism, QT | QUININE = CIN |
| Anti-helminthic | Albendazole | Hepatotoxicity, leucopenia | ALBA-toxins |
| Anti-helminthic | Ivermectin | Mazzotti reaction | IVER-Mazz |
| Anti-helminthic | Praziquantel | Seizures (neurocysticercosis) | PRAZ-Wake brain |
| Anti-protozoal | Pentamidine | Hypoglycemia→Hyperglycemia | PENTA-SUGAR |
| Anti-protozoal | Melarsoprol | Reactive encephalopathy | Arsenic-Encephalo |
BONUS: "WHICH DRUG CAUSES WHICH NEPHROTOXICITY?" Quick Chart
| Drug | Type of Renal Injury |
|---|---|
| Aminoglycosides | Acute tubular necrosis (proximal tubule) |
| Amphotericin B | Tubular damage + RTA type I |
| Polymyxins | Proximal tubule toxicity |
| Sulfonamides | Crystalluria/obstructive |
| Vancomycin | Interstitial nephritis + tubular necrosis |
| Penicillin/Nafcillin | Interstitial nephritis |
BONUS: G6PD DEFICIENCY TRIGGER DRUGS (High-Yield Exam!)
"MIND THE GAPS": M - Metronidazole (mild) I - Isoniazid N - Nitrofurantoin D - Dapsone T - Trimethoprim (mild) H - Hydroxychloroquine/Chloroquine (mild) E - --- G - G6PD trigger A - ASA (high dose) P - Primaquine (most classic!) S - Sulfonamides
Sources: Katzung's Basic and Clinical Pharmacology 16e | Fishman's Pulmonary Diseases and Disorders | Tintinalli's Emergency Medicine (Table 159-4) | Harrison's Principles of Internal Medicine 22e | Goodman & Gilman's Pharmacological Basis of Therapeutics | Murray & Nadel's Textbook of Respiratory Medicine | Lippincott Illustrated Reviews Pharmacology
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