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Antibiotics Aminoglycosides Action: bactericidal. Bind to 30S and 50S subunits of the ribosome, blocking the reading of mRNA in the initial phases of protein synthesis. Spectrum: active against several Grampositive and many Gramnegative microorganisms. Amikacin, Gentamicin, and Tobramycin are also active against Pseudomonas aeruginosa while Streptomycin is active against Mycobacterium tuberculosis. Side effects: hypersensitivity reactions are rare. In exceptional cases, these drugs can cause neuromuscular blocking. Cochlear toxicity (Neomycin +++), vestibular toxicity (Streptomy cin+++), reversible nephrotoxicity (Neomycin +++). Contraindications: myasthenia gravis. Adjust dosage in cases of CRF. Generic name Neomycin Streptomycin Tobramycin Gentamicin Amikacin Brand name® Dose NIVEMYCIN 500 mg tablets STREPTOMYCIN sulphate 1 g TOBRAMYCIN HOSPIRA GENTAMICIN HOSPIRA AMIKACIN HOSPIRA 1 g/6 h oa 15 mg/kg/d im (maximum 1 g) 3‐5 mg/Kg/d 3‐5 mg/kg/d im or iv 1‐3 doses per day 15‐20 mg/kg/d im 2‐3 doses per day βLactams Cephalosporins Action: inhibit bacterial cell wall synthesis by blocking the transpeptidase activity of PBP (Penicillin Binding Protein) Antibiotic spectrum Antibiotics Grampositive Enterobacteriaceae Gramnegative P. aeruginosa B. fragilis Cephalotin Cefazolin Cephalexin Cefadroxil Cefaclor Cefpodoxime Cefuroxime Cefonicid Cefditoren Cefixime Ceftibuten Cefotixin Ceftriaxone Ceftazidime Cefepime Cefotaxime Cefminox Side effects: nausea, vomiting, abdominal pain, diarrhea (nonspecific or caused by C. difficile), thrombophlebitis, hypersensitivity reactions, interstitial nephritis, neutropenia, eosin ophilia, transient increase in AST, ALT, ALP. Convulsions and encephalopathy with high doses in cases of CRF. Contraindications: history of anaphylaxis to Penicillin. 10% of patients with an allergy to Penicillin have an allergy to Cephalosporins. 1st Generation Generic name Cephalexin Cephalotin Cefadroxil Brand name® Dose CEFALEXIN APS CEPHALOTIN SODIUM 1 g CEFADROXIL 500 mg 20‐500 mg/6‐8 h oa 1‐2 g/4‐6 h iv or im 500 mg‐1 gr/8‐12 h oa 2nd Generation Generic name Cefoxitin Cefuroxime Cefaclor Cefonicid Brand name® Dose MEFOXIN 1 g CEFTIN 250‐500 mg CEFUROXIME SODIUM 750‐1500 mg CECLOR caps 250‐500 and 750 mg MONOCID 0.5 and 1 g 1‐2 g/4‐6 h iv or im 250‐500 mg/12 h oa 750‐1500 g/8 h iv or im 0,5‐1 g/6‐8 h oa 1‐2 g/24 h iv or im 3th Generation Generic name Cefotaxime Ceftazidime Ceftriaxone Cefixime Cefpodoxime Ceftibuten Cefditoren Brand name® Dose CLAFORAN 1 and 2 g TACIZEF 500 mg‐1‐2 g ROCEPHIN 250‐500 mg and 1‐2 g SUPRAX 200 mg tablets VANTIN 100‐200 mg CEDAX 400 mg tablets SPECTRACEF 200‐400 mg 1‐2 g/6‐8 h iv or im 1‐2 g/8‐12 h iv or im 1‐2 g/12‐24 h iv or im 200‐400 mg/12‐24 h oa 100‐200 mg/12‐24 h oa 400 mg/24 h oa 200‐400 mg/12 h oa 4thgeneratiom Generic name Brand name® Dose Cefepime MAXIPIME 1‐2 g 1‐2 g/8‐12 h im or iv Carbapenem Action: bactericidal; resistant to βlactamases that inhibit bacterial cell wall synthesis after binding to the PBP (Penicillin Binding Protein). Spectrum: broad spectrum against numerous anaerobic, Grampositive, and Gramnegative microorganisms. Side effects: Imipenem in high doses can cause neurotoxicity, especially in patients with neurological diseases. Changes in intestinal flora that promotes superinfection. Convulsions. Rarely causes nausea, vomiting, thrombocytosis, increased transaminases or alkaline phos phatase, increased creatinine. Contraindications: hypersensitivity to ßlactams or Carbapenem. Generic name Brand name® Dose Ertapenem Imipenem + Cilastatin Doripenem Meropenem INVANZ 1 g TIENAM 500/500 mg DORIBAX 500 mg MERONEM 0.5‐1 g 1 g/12‐24 h iv 0.5‐1 g/6‐8 h iv 500 mg/8 h iv 0.5‐1 g/6‐8 h iv Monobactam Action: Inhibits bacterial cell wall synthesis. Bactericidal; resistant to βlactamases. Spectrum: Gramnegative aerobic bacteria including Neisseria meningitidis, Haemophilus influenza, and Pseudomonas aeruginosa. Side effects: hypersensitivity reactions, rash, nausea, vomiting, diarrhea, dysgeusia, buccal ulcers, jaundice and hepatitis, flushing, thrombocytopenia, and neutropenia. Contraindications: hypersensitivity. Generic name Brand name® Dose AZACTAM 0.5‐1 g 1‐2 g/8‐12 h iv or im Aztreonam Sulfonamides + trimethoprim Cotrimoxazole Action: a combination of Trimethoprim plus Sulfametoxazole (1:5 ratio). Trimethoprim is a bacteriostatic antibiotic whereas Sulfametoxazole is an intermediate‐acting sulfonamide. The combination produces sequential blockage of folic acid synthesis. The effect is synergistic and bactericidal. Spectrum: S. aureus and S. epidermidis methicillin‐resistant, Grampositive and negative aerobes. Side effects: hyperkalemia, hyponatremia, nausea, diarrhea, headache, vomiting, rash, photo sensitivity, glossitis, stomatitis, hepatitis, hypoglucemia. Hematological disorders (leukopenia, thrombocytopenia, megaloblastic anemia, eosinophilia). Contraindications: hypersensitivity, porphyria, severe blood disorders, advanced CRF and HF. Generic name Brand name® Sulfametoxazol + Trimethoprim SEPTRIN 400+80 mg SEPTRIN FORTE 800+160 mg Dose 1‐2 tab/12 h oral* 1 tab/12 h oral *1/2 tablet per night for 6‐12 months as UTI prevention Phosphonic acid (derivatives) Fosfomycin Action: exerts rapid bactericidal effect in bacterial growth phase. Blocks the synthesis of peptidoglycan precursors. Synergistic action with Erythromycin, Trimethoprim, ßlactams, Aminoglycosides, Vancomycin, Colistin, Chloramphenicol, Tetracycline. Spectrum: S. epidermidis, S. aureus, Proteus, Gramnegative aerobes, and anaerobes. Side effects: hypersensitivity reactions, bronchospasms, rash, urticaria, angioedema, disturb ances in vision, loss of appetite, dyspnea, increased transaminases and alkaline phosphatase, headache, nausea, heartburn, diarrhea, superinfection. Contraindications: hemodialysis, hypersensitivity, severe CRF with Cc < 10 mL/min. Generic name Brand name® Dose FosfomycinTrometamol MONUROL 2‐3 g sachets 2‐3 g/24 h 1‐2 d Glucopeptides Action: inhibit peptidoglycan synthesis. They also alter cytoplasmic membrane permeability and inhibit RNA synthesis. Slow bactericidal effect (time‐dependent). Spectrum: Grampositive aerobes including methicillin‐resistant Staphylococcus. Gram negative resistant. Side effects: phlebitis, hypersensitivity: fever, chills, skin rash, and eosinophilia. If Vancomycin perfusion is too fast, an itchy rash may appear on the neck and upper trunk (redneck or red man syndrome), sometimes accompanied by hypotension and cardiac arrest. This condition occurs due to release of histamine from mast cells and can be avoided through slow infusion of the drug (1 h). Contraindications: hypersensitivity. Generic name Brand name® Dose Teicoplanin TARGOCID 200‐400 mg Vancomycin VANCOCIN 0.5 ‐1 g Initial: 400 mg/12 h iv or im 3 doses and continue with 400 mg/24 h iv 0.5 g/6 h or 1 g/12 h iv Lincosamides Action: inhibit bacterial protein synthesis at the level of the ribosomal 50S subunit; prevent the formation of peptide bonds. Bacteriostatic. Spectrum: similar to that of macrolides (Grampositive and anaerobic microorganisms). Side effects: pseudomembranous colitis. Hepatotoxicity. Neutropenia, agranulocytosis, and thrombocytopenia. Hypersensitivity reactions. Diarrhea, nausea, vomiting, abdominal pain. Contraindications: meningitis, hypersensitivity to Clindamycin or Lincomycin. Generic names Brand names® Dose DALACIN 150‐300 mg CLEOCIN 300 ‐900 mg Clindamycin 150‐450 mg/6‐8 h oral 300‐900 mg/6‐8 h im o iv Macrolides Action: can behave either bacteriostatically or as bactericides, acting through inhibition of protein synthesis. Spectrum: Mycoplasma, Chlamydia, Campylobacter, Legionella, Grampositive cocci, toxo plasma. Side effects: gastrointestinal effects due to their prokinetic activity; abdominal pain, nausea, and vomiting. Vertigo, tinnitus, and deafness at high doses. Cholestatic hepatitis. Contraindications: because they prolong QT intervals, these drugs should be used with caution in patients with a history of arrhythmias. Generic names Erythromycin Spiramycin Brand names® Dose ERYTRHOMYCIN 125‐250‐500 mg ERYTHROMYCEN LACTOBIONATE 1 g ROVAMYCINE 1.5 M IU tablets 500‐1000 mg/6‐8 h 0.5‐1 g/6‐8 h iv or im 1‐3 tablets/8‐12 h oral 150 mg/12 h or 300 mg/24 h oral 0.5‐1 g/8‐12 h oral 0.5 g/d for 3 d or 1 g single dose 500 mg/d iv 2‐3 d; then oral continuation 250‐500 mg/12 h oral 500 mg/12 h iv 600 mg/12 h oral Roxithromycin Josamycin Azithromycin Clarithromycin Midecamycin RULIDE 150 and 300 mg tab JOSAMYCIN granules 250‐500 mg ZITHROMAX powder 0.5‐1 g ZITHROMAX 500 mg KLACID granules 250‐500 mg KLACID 500 mg MIOCACIN 600 mg Nitroimidazoles Action: antibacterial and antiparasitic when interacting with DNA. Rapid bactericidal effect. Spectrum: in strictly anaerobic conditions, these drugs are active against some strains of E. coli, Proteus, and Klebsiella. Active against anaerobic protozoa (Trichomonas vaginalis, Entamoeba histolytica, Giardia lamblia, and Balantidium coli); anaerobic bacteria; Bacteroides (including B. fragilis), Fusobacterium, Clostridium, and Grampositive cocci. Other sensitive bacteria include Gardnerella vaginalis, Helicobacter pylori, and to a lesser extent, T. pallidum. Side effects: pancreatitis, leukopenia. Dark pigmentation of the urine due to the presence of photosensitive metabolites. Nausea, vomiting, abdominal pain, and metallic taste in the mouth. Prolonged treatments may lead to sensory polyneuropathy. Contraindications: Disulfiram effect if taken with alcohol. Hypersensitivity to Imidazoles. Generic names Metronidazole Brand name® Dose FLAGYL 250 mg capsules FLAGYL 500 mg solution 250‐750 mg/8‐12 h oral 250‐750 mg/8‐12 h iv Nitrofurans (derivatives) Nitrofurantoin Action: bactericidal. Interferes with bacterial wall synthesis, cellular respiration, and glucose metabolism. Spectrum: Grampositive and enterobacteriaceae. Side effects: pyrosis, nausea, vomiting. Prolonged treatment can cause allergic disorders and polyneuritis. Contraindications: severe CRFHF, hypersensitivity. Risk of hemolytic anemia in infants with Glucose6phosphate dehydrogenase deficiency. Generic names Nitrofurantoin Brand names® Dose FURADANTIN 50 mg tablets 50‐100 mg/oral/6 h* *Nocturnal prophylaxis in recurrent UTI 50 mg/night Penicillins Group Natural Penicillin Penicillinresistant penicillinase Classification Spectrum Cocci Grampositive S. aureus β‐lactamase production Aminopenicillin Cocci Grampositive, Gram negative community acquired Carboxy and ureidopenicillin P. aeruginosa, nosocomial Gramnegative Generic name Benzylpenicillin (Penicillin G) Procaine Benzylpenicillin Benzathine Benzylpenicillin Phenoxymethylpenicillin(PenicillinV) Benzathine Phenoxymethylpenicillin Cloxacillin Ampicillin Amoxicillin Amoxicillin + clavulanic acid Sulbactam Ticarcillin Piperacillin Action: bactericidal. These drugs block the transpeptidase activity of penicillinbinding protein (PBP). Side effects: gastrointestinal alterations; non‐specific or C. difficile diarrhea, abdominal pain, nausea, vomiting. Thrombophlebitis, pain at the injection site. The major side effect of Penicil lin is hypersensitivity, which manifests with a rash and anaphylaxis and can be fatal. Patients with a history of immediate anaphylaxis, urticaria, or rash upon administration of Penicillin are at risk of developing immediate hypersensitivity to these drugs and should not receive penicillins, cephalosporins, or other βlactam antibiotics. Encephalopathy due to cerebral irritation at high doses or in patients with severe RF. Intestinal or vaginal colonization by Candida. Neutropenia, thrombocytopenia, and reversible eosinophilia. JarischHerxheimer reaction within the first 24 h manifested by headache, myalgia, and fever. Contraindication: hypersensitivity. Natural Penicillin Generic name Benzylpenicillin Procaine Benzylpenicillin Benzathine Benzylpenicillin Phenoxymethylpenicillin Benzathine Phenoxymethylpenicillin Brand name® Dose BENZYLPENICILLIN 1‐2‐5‐ IU BICILLIN C‐R BICILLIN L‐A PEN‐V BENORAL oral suspension 1,500,000 IU/4‐6 h im or iv 600,000‐1,200,000 IU/d im 1,200,000 IU/im single dose 0.5‐1 g/6‐8 h oral 400,000‐800,000 IU/6 h oral Penicillin resistant Generic name Cloxacilin Brand name® Dose ORBENIN 0.5 g caps ORBENIN powder 0.5‐1 g 0.5‐1 g/4‐6 h oral 1‐2 g/4‐6 h iv Aminopenicillin Generic name Ampicillin Amoxicillin Amoxicillin + clavulanic acid Brand name® Dose AMPICILLIN 0.5‐1 g tablets BRITAPEN powder 0.5‐1 g CLAMOXYL 250‐500‐1000 mg tablets CLAMOXYL powder 1000 mg AUGMENTIN (tablets and powder) 500+125‐875+125 mg AUGMENTINE powder 1000+200 and 2000+200 mg 0.5‐1 g/6‐8 h oral 1‐2g/4‐6 h oral 250 mg‐1 g/8 h oral 1‐2 g/iv/4‐6 h 1 comp/8‐12 h oral 1000‐2000 mg/6‐8 h iv Carboxy and ureidopenicillin Generic name Azlocillin PiperacillinTazobactam Brand name® Dose SECUROPEN powder 1 ‐5 g PIPERACILLIN‐TAZOBACTAM 2‐0.25 and 4‐0.5 g 1‐3 g/4‐6 h iv or im 2‐4 g/6‐8 h iv Quinolones Generation 1st (pipemidic acid, norfloxacin) 2nd (Ciprofloxacin, Ofloxacin) 3rd (Levofloxacin) 4th (Moxifloxacin) Spectrum Enterobacteriaceae Active against aerobic Gram – bacilli Ciprofloxacin: active for Pseudomonas Active against aerobic Gram – bacilli and aerobic Gram + cocci Active against aerobic Gram – bacilli, aerobic Gram + and anaerobes, but with a low urinary excretion (20%) Action: bactericidal. These drugs block DNA gyrase activity as well as that of bacterial topoisomerase IV. Side effects: abdominal pain, diarrhea (rarely: colitis associated with antibiotics), nausea, vomiting, dyspepsia, sleep disorders, rash, pruritus, headache, and dizziness. Hypersensitivity reactions manifested as fever, urticaria, angioedema, arthralgia, myalgia, and anaphylaxis. Other less common side effects include anorexia, increased urea and creatinine, dizziness, agitation, fatigue, depression, confusion, hallucinations, convulsions, tremor, paresthesia and hypoesthesia, photosensitivity, blood disorders (eosinophilia, leukopenia, thrombocytopenia), and alterations in vision, taste, hearing, and smell. Tendon injuries (more frequent in elderly patients or with concomitant use of corticoids). Other side effects may include hemolytic anemia, CRF, interstitial nephritis, and hepatic dysfunction. Precautions: patients should avoid exposure to excessive sunlight (discontinue treatment if photosensitivity occurs). Patients with a history of epilepsy or conditions that predispose them to seizures; patients with glucose 6phosphatodehydrogenase deficiency, miasthenia gravis (risk of exacerbation), or CRF; children and adolescents. Generic name Brand name® Dose Pipemidic acid Norfloxacin Ciprofloxacin Ofloxacin Levofloxacin Moxifloxacin* *Respiratory infections PIPEMIDIC ACID 400 mg tablets NOROXIN 400 mg tablets CIPRO 250‐500‐750 mg tablets CIPRO 200‐400 mg solution FLOXIN 200 mg tablets and solution TAVANIC 500 mg tablets and solution ACTIRA 400 mg tablets and solution 400 mg/12 h oral 400 mg/12 h oral 250‐750 mg/12 h oral 200‐400 mg/12 h iv 200‐400 mg/12 h oral or iv 500 mg/24 h oral or iv 400 mg/24 h oral or iv Tetracyclines Action: bacteriostatic. These drugs interfere with protein synthesis by binding to the 30S ribosomal subunit. Spectrum: Rickettsiae (Q fever), Chlamydia (trachoma, psittacosis, salpingitis, urethritis, and lymphogranuloma venereum), Brucella and the spirochete Borrelia burgdorferi (Lyme). The‐ se drugs are also used against respiratory and genital infections caused by mycoplasms, acne, periodontal diseases, chronic bronchitis flare‐ups (due to their activity against Haemophilus influenzae). Side effects: photosensitivity. Cutaneous hypersensitivity (urticaria, fixed rash, periorbital edema, anaphylaxis). Gastrointestinal disorders: nausea, vomiting, diarrhea, esophageal ul cers, and pancreatitis. Accumulation in areas of bone and tooth growth can produce a charac‐ teristic pigmentation. Weak neuromuscular blockade. Hepatotoxicity (fatty degeneration). Candida vaginitis. Benign and reversible craneal hypertension. Hemolytic anemia, eosinophil‐ ia, neutropenia, thrombocytopenia, hypoprothrombinemia. Transient myopia due to hydra‐ tion of the lens. Contraindications: hypersensitivity to tetracyclines. Pregnancy, breastfeeding, children < 8 years. Generic name Tetracycline Oxitetracycline Doxycicline Minocycline Brand name® Dose ACHROMYCIN 250 mg tablets TERRAMYCIN ointment VIBRAMYCIN 100 mg capsules VIBRAMYCIN 100 mg solution MINOCIN 100 mg capsules 1‐2 g/d oral* 1 application/8‐12 h 1 caps/12 h oral** 100m/12‐24 h iv 100 mg/12 h oral *** *1 h before or 2 h after meals ** Concomitant food intake does not alter its absorption ***Initially 200 mg/12 h. Antimycobacterial drugs for Tuberculosis Isoniazid Spectrum: 1st line of combined treatment and prophylaxis. The most effective anti‐TB bactericidal drug. Side effects: hepatitis (more frequent the older the patient), nausea, vomiting, peripheral neuritis (reduced with 10 mg/day of Pyridoxine). Administration: take on an empty stomach. Used in pregnant women with TB. Concomitant administration of Pyridoxine is necessary. Contraindications: liver disease and hypersensitivity. Generic name Isoniazid Brand name® Dose ISONIAZID 300 mg solution LANIAZID 50‐100‐300 mg 300 mg/d im or iv 5 mg/kg/d oral (max 300 mg/d) Rifampicin Spectrum: 1st line combination therapy. Bactericidal. Side effects: thrombocytopenia, hepatitis, red staining of secretions, gastrointestinal upset, rash. May alter the function of oral contraceptives. Administration: take on an empty stomach. Contraindications: jaundice, allergy to Rifampicin. Generic name Rifampicin Brand name® RIFADIN 600 mg‐300 mg tablets RIFADIN 600 mg solution Dose 10 mg/kg/d oral (max 600 mg/d) 600 mg/d iv Pyrazinamide Spectrum: bactericidal. 1st line combination therapy. Side effects: dose dependent hepatotoxicity, nausea, vomiting, photodermatitis, arthralgia. Administration: take after meals. Contraindications: liver disease, hypersensitivity, pregnancy. Generic name Brand name® Dose Pyrazinamide PYRAZINAMIDE 250 mg tablets 3 tabs/d oral Ethambutol Spectrum: 2nd line drug. Alternative to 1st line therapies. Bacteriostatic. Side effects: retrobulbar optic neuritis. Cholestasis. Red/green colorblindness. Administration: take with meals. Contraindications: CRF. Optic neuritis, drug allergy. Generic name Brand name® Dose Ethambutol MYAMBUTOL 400 mg tablets 2‐3 tabs (>70 kg)/d oral Rifabutin Spectrum: reserved for infections caused by drug‐resistant strains of bacteria or in HIV patients treated with protease inhibitors. More active in vitro than Rifampicin. Side effects: alteration of liver enzymes. Jaundice. Rash. Turns urine red. Contraindications: drug allergy. Dosage should be decreased if used concomitantly with Indinavir. Generic name Rifabutin Brand name® Dose MYCOBUTIN 150 mg capsules 1‐3 caps/d oral Ethionamide Spectrum: 2nd line treatment in combination with other drugs. Bacteriostatic. Side effects: peripheral neuropathy, jaundice, nausea, depression, gait disturbance. Administration: take with meals. Contraindications: liver disease, depression, pregnancy, drug allergy. Generic name Brand name® Dose Ethionamide TRECATOR‐SC 250 mg tablets 1 tab/6 h oral Cycloserine Spectrum: 2nd line treatment (in resistant TB strains). Bacteriostatic. Side effects: headache, dizziness, vertigo, depression, anxiety, rash. Administration: take with meals. Take in combination with Pyridoxine. Contraindications: liver disease, depression, pregnancy, drug allergy. Generic name Brand name® Dose Cycloserine SEROMYCIN 250 mg tablets 3‐4 tabs/d oral Streptomycin Spectrum: 2nd line treatment in combination with other drugs. Side effects: requires frequent audiometric testing. Nephrotoxicity. Contraindications: adjust dosage in cases of CRF. Generic name Brand name® Estreptomycin ESTREPTOMYCIN sulfat powder 1 g Dose 1 g/24 h im Capreomycin Spectrum: 2nd line treatment in combination with other drugs. Used in resistant TB strains. Side effects: hepatotoxicity nephrotoxicity, ototoxicity, rash, tinnitus. Contraindications: pregnancy. Breastfeeding. Children. Drug allergy. Generic name Capreomycin Brand name® Dose CAPASTAT powder 1 g 1 g/24 h im Antimycobacterial dosage recommendations in adults Drug 1 dose/d (mg/kg) 2 dose/week (mg/kg) 3 dose/week(mg/kg) 5 (max 300 mg) 10 (max 600 mg) 15‐30 (max 2 g) 15‐25 15 (max 1 g) 5 (max 450 mg) 15 (max 900 mg) 10 (max 600 mg) 50‐70 (max 4 g) 50 25‐30 (max 1,5 g) 15 (max 900 mg) 10 (max 600 mg) 50‐70 (max 3 g) 25‐30 25‐30 (max 1.5 g) Isoniazid (INH) Rifampicin (RIF) Pyrazinamide (PRZ)* Ethambutol (ETM) Streptomycin Rifabutin Combination drugs Generic names Rifampicin 120 mg Isoniazid 50 mg Pyrazinamide 300 mg Rifampicin 300 mg Isoniazid 150 mg Rifampicin 120 mg Isoniazid 50 mg Pyrazinamide 300 mg Ethambutol 275 mg Dose RIFATER caps 1 caps/10 kg/d (max 6 caps) 2 months* RIFINAH caps 2 caps/24 h or 3 caps/48 h 2‐4 months RIMSTAR tabs 38‐54 kg: 3 tablets/d 2 months 55‐70 kg: 4 tablets /d 2 months >71 kg: 5 tablets /d 2 months Before breakfast or two hours later. Take in combination with PRZ if patient weighs over 90 Kg. * Brand name®