13 - CAP Flashcards
DOSING + ADR
B-Lactams
(+Macrolides or Doxycycline or Respiratory Fluoroquinolone)
for
INPATIENT CAP Non-ICU
- *CEFTRIAXONE**
- *1g IVPB qd**
- *Cefuroxime**
- *0.75-1.5gm IVPB q8**
- *Ertapenem**
- *1gm IVPB qd**
- *Ampicillin/sulbactam**
- 3gm IVPB q6h (**QID too often)*
- *RENAL ADJUSTMENT - except cefTRIAXone**
- Rash + Diarrhea*
- *ERTAPENEM = RARE SEIZURE**
DOSING + ADR
Aztreonam
(+respiratory fluroquinolone)
for
INPATIENT CAP ICU** w/ **PCN ALLERGY
- *Aztreonam**
- *1-2gm IVPB q8**
- *RENAL ADJUSTMENT**
- Rash*
Special Populations for CAP
Cystic Fibrosis
need to cover for pseudomonas
Bronchiectasis
LONGER duration
HIV
Legionella –> 7-10 day treatment
Signs & Symptoms
CAP
Cough / Fatigue / Fever
Tachypnea (Rapid Breathing) / TachyCardia
Lung Sounds
Rales & Rhonchi // Dullness to percussion
Infiltrates on CXR
Chest Xray
Chest Discomfort
Chills / Rigors / Nightsweats
Comorbid Conditions
that warrant for step-up therapy for outpatient CAP
Recent AB use or comorbid Conditions:
Respiratory Fluoroquinolones OR Macrolide+B-Lactam
Chronic: Liver / Heart / Renal / Lung Disease
Diabetes / Malignancy
Diabetes / Asplenia / IMS disease-drugs
When to SWITCH from
IV -> ORAL
for CAP
AFEBRILE for 24-48 hours
&
GI tract is Intact
DOSING + ADR
Clindamycin
for
Outpatient CAP - ASPIRATION (mouth)
- *Clindamycin**
- *300mg q6** or 450mg q8
- *7-14 days**
- no renal adjustment*
- Rash*
- *COLITIS -** pseudomembraneous
Outpatient CAP Treatment
ASPIRATION
mouth
CLINDAMYCIN
300mg q6 or 450mg q8
or
AUGMENTIN
500mg q8 or 875mg q12
- *7-14 days**
- *legionella = 7-10 days**
INPATIENT CAP Treatment
ICU + PCN ALLERGY
RESPIRATORY FLUOROQUINOLONE
Levofloxacin + Moxifloxacin
+
AZTREONAM
1-2gm IVPB q8
INPATIENT CAP Treatment
NON-ICU
B-LACTAM
cefuroxime / ceftriaxone / ertepenem / amp-sulbactam
+
MACROLIDE** or **DOXYCYLINE** or **RESPIRATORY FLUOROQUINOLONE
levofloxacin / moxifloxacin
Outpatient CAP Treatment
No recent AB therapy
<90 days
MACROLIDE** or **DOXYCYCLINE
-
ZPAK (500mg x1day -> 250mg x4days)
- 5 days, stays INSIDE cellls
-
Azithromycin XR Suspension 2gm
- one dose
-
Clarithromycin 250-500mg BID or XR 1gm daily
- no renal adjustment
- GI upset / Ototoxicity / 3A4 inhibitor
-
DOXYCYCLINE 100mg q12h
- 7-14 days
- no renal adjustment
- Teeth discoloration / GI Upset
- antacids / magnesium / iron / calcium
Body’s Defenses to CAP
Anatomy:
Nose / Throat / Nasal Hair
MuscoCiliary System:
Mucous / Cilia / pH
COUGH + GAG reflex + Stomach Acid
Humoral Mechanisms:
IG’s / TNF / IL’s / Complement
Cellular Mechanisms:
Alveolar Macrophages / PML’s
Diagnosis of CAP
Determines if hospital or not:
CURB-65 or PSI (port Severity Index)
Sputum Culture
technique & timeliness is important
>25 WBC & <10 Epi’s
CHEST X-RAY
Blood Cultures / CBC +diff / Chemistry
Thoracentesis / Pathogen specific test
Why do Pneumonias Occur?
Impaired Body Defenses
Virulent organisms or excess inoculum
overwhelms body defenses
Colonization of URI
HEMAtogenous spread = Staph Aureus
Microorganisms gain access as follows:
- *Aerosolized particles** = TB
- *Hematogenous / Aspiration**
CAP Definition
Clinical Symptoms
or
Infiltrate Presence = CXR
does NOT rule out pneumonia
or
Ausculatory Findings
DOSING + ADR
B-Lactams
(+Macrolides or Respiratory Fluoroquinolone)
for
INPATIENT CAP ICU
Same Doses as NON-ICU,
except for: Ceftriaxone can be q12
CEFTRIAXONE
1g IVPB qd or 1g IVPB Q12
- *Cefuroxime**
- *0.75-1.5gm IVPB q8**
- *Ertapenem**
- *1gm IVPB qd**
- *Ampicillin/sulbactam**
- 3gm IVPB q6h (**QID too often)*
- *RENAL ADJUSTMENT - except cefTRIAXone**
- Rash + Diarrhea*
- *ERTAPENEM = RARE SEIZURE**
DOSING + ADR
B-Lactams (+Macrolides)
for
Outpatient CAP w/ comorbid conditions
or recent abx use <90days
- *AUGMENTIN**
- *500mg q8** or 875mg q12
- *Amoxicillin**
- *1gm q8**
- *Cefuroxime**
- *500mg q12**
Cefpodoxime
200mg q12
- *RENAL ADJUSTMENT**
- Rash + Diarrhea*
Which CAP drugs require RENAL ADJUSTMENT?
LEVOFLOXACIN + Gemifloxacin
Respiratory fluoroquinolones, except MOXI
-BETA LACTAMS
Augmentin / Amoxicillin / Cefuroxime / Cefpodoxime
IV:
ERTAPENEM + Cefuroxime + Ampicillin/sulbactam
except cefTRIAXone
AZTREONAM
for PCN allergy with respiratory fluoroquinolone
Pathogenesis of CAP
Factors that can
Impair Lung Defenses
- *Neuromuscular Disorders**
- *GB / MS** / Seizures
Cystic Fibrosis
CV Disorders
MI / Stroke
Altered Sensorium
Narcotics + Alcohol
Viruses that Impair Alveolar Macrophage Function
HIV
Depressing Mucociliary Transport
Narcotics + Alcohol + Smoking
Colonization
INPATIENT CAP Treatment
ICU
B-LACTAM
cefuroxime / ceftriaxone / ertepenem / amp-sulbactam
ceftriaxone could be dosed 1gm IVPB q12
+
MACROLIDE** or **RESPIRATORY FLUOROQUINOLONE
levofloxacin / moxifloxacin, same doses
Common Organisms (6)
CAP
“SMH - MILC”
SMH = Same as AOM
STREPtococcus PNEUMoniae
M. Catarrhalis
H. Influenzae
Legionella + Influenza
Mycoplasma + Chlamydophilia
Which CAP drugs require you to avoid
ANTACIDS / MAG / IRON / CALCIUM?
RESPIRATORY FLUOROQUINOLONES
Levofloxacin / Moxifloxacin / Gemifloxacin
RENAL ADJUSTMENT - except MOXI
Kids / tendon rupture / QTC prolongation / hypoglycemia
DOXYCYCLINE
100mg q12h f7-14 days
Teeth Discoloration / GI upset
DOSING + ADR
Respiratory Fluoroquinolones
for
Outpatient CAP w/ cmorbid conditions or Recent ABx
- *LEVOFLOXACIN**
- *750mg QD x5d** or 500mg QD x7-14d
- *Moxifloxacin**
- *400mg QD**
- *Gemifloxacin**
- *320mg QD**
- *RENAL ADJUSTMENT** - EXCEPT MOXI
- *KIDS / tendon rupture / QTc prolongation / hypoglycemia**
- ANTACIDS / MAG / IRON / CALCIUM*
Outpatient CAP Treatment
Recent AB therapy (90days) or Comorbid Conditions
Chronic: Liver / Heart / Renal / Lung Disease
Diabetes / Malignancy
Diabetes / Asplenia / IMS disease-drugs
RESPIRATORY FLUOROQUINOLONE
Levofloxacin / Moxifloxacin / Gemifloxacin
or
MACROLIDE + B-LACTAM
Zpak or Clarithromycin
Augmentin / Amoxicillin / Cefuroxime / Cefpodoxime
DOSING + ADR
Respiratory Fluoroquinolones
(+ Beta Lactam)
for
INPATIENT CAP ICU
SAME AS *NON-ICU*
- *LEVOFLOXACIN**
- *500-750mg IVPB QD**
- same as PO*
- *Moxifloxacin**
- *400mg IVPB qd**
- same as PO*
- *RENAL ADJUSTMENT** - EXCEPT MOXI
- *KIDS / tendon rupture / QTc prolongation / hypoglycemia**
- ANTACIDS / MAG / IRON / CALCIUM*
Risk Factors
CAP
AGE
Alcoholism / Smoking
COPD / CVD / Diabetes
Immunocompromised:
HIV / Hematologic Malignancy
CURB-65
Score:
0-1 = Outpatient
2 = Inpatient
> 3 = ICU
20 - 30/60/90
Confusion
Uremia = BUN > 20mg/dl
Respiratory Rate > 30
Blood Pressure < 90/60 mmHg
Age > 65
CAP Treatment
Length of Therapy
7-14 Days total
except for zpak (5days) / levofloxacin (750mg 5days)
Legionella = 7-10 days
DOSING + ADR
Macrolides
(+B-lactam)
for
INPATIENT CAP Non-ICU
or
INPATIENT CAP ICU
ICU and NON-ICU same dose
Azithromycin
500mg IVPB qd
or same dose of outpatient if ORAL
- no renal adjustment*
- *GI upset / Ototoxicity / 3A4 inhibitor**
DOSING + ADR
Respiratory Fluoroquinolones
(+ Beta Lactam)
for
INPATIENT CAP Non-ICU
- *LEVOFLOXACIN**
- *500-750mg IVPB QD**
- same as PO*
- *Moxifloxacin**
- *400mg IVPB qd**
- same as PO*
- *RENAL ADJUSTMENT** - EXCEPT MOXI
- *KIDS / tendon rupture / QTc prolongation / hypoglycemia**
- ANTACIDS / MAG / IRON / CALCIUM*
DOSING + ADR
Macrolides
for
Outpatient CAP w/o recent ABx
or
Outpatient CAP w/ comorbid conditions
(+ B-Lactam)
- *Z-PAK**
- *500mg x1d -> 250mg QD f4d**
- *Azithromycin XR suspension**
- *2gm 1 dose**
- *Clarithromycin**
- *250-500mg q12** or XR @1gm QD
- no renal adjustment*
- *GI upset / Ototoxicity / 3A4 inhibitor**
DOSING + ADR
DOXYCYCLINE (+B-lactam)
for
INPATIENT CAP NON-ICU
- *Doxycycline**
- *100mg IVPB q12**
- same as PO*
- no renal adjustment*
- *Teeth discoloration / GI UPSET**
- antacids / mag / iron / calcium*
DOSING + ADR
DOXYCYCLINE
for
Outpatient CAP w/o recent ABx
- *Doxycycline**
- *100mg qd f7-12days**
- same as IV*
- no renal adjustment*
- *Teeth discoloration / GI UPSET**
- antacids / mag / iron / calcium*
