Antibiotic Guidelines Flashcards
What are two very common etiologies of Community acquired pneumonaie
Streptococcus pneumoniae
Mycoplasm pneumonaie
(H. influenza, Clymydophila pneumonaie usually vaccinated against)
What are my three most common Hospital acquired etiologies of pneumonia?
S. pneumoniae
M. pneumoniae
C. Pneumonaie
Joan comes to the hospital and is diagnosed with pneumoniae. Pt was previously healthy and has not had a hospital stay in the past year. What do you tx with?
Macrolide (Azithromycine or Clarithromycin)
or
Doxycycline
*for outpatient that was previously healthy
Guy names Bill comes to hospital with uncontrolled HTN, not been in hospital recently and your attending diagnose him with CA-pneumoniae
What do you recommend for tx and why?
Bill has CA-aquired pneumoniae, has co-morbidity (uncontrolled HTN) and hasn’t been in hospital
Tx with Anti-pneumococcal FQ or B-lactam plus a Macrolide (azithromycin or clarithromycin)
You are doing rounds with your attending. Larry, your patient, has been in the hospital for several weeks and has been showing signs and symptoms of pneumoniae. He has no known allergies. What would you Rx and why?
Larry; inpatient = Hospital acquired
No allergies, thus penicillin is safe
RX: B-lactam + macrolide
7 yo female has been in the hospital for the past three days for a severe penicillin reaction as she being treated for bacterial infection. Her doctor found during rounds she was showing signs of pneumoniae. What do you tx her with and why?
In patient, non ICU, penicillin allergy, Hospital acquired pneumoniae
RX: anti-pneumococcal FQ
How do you tx an ICU pt with no med allergies for pneumoniae
tx for hospital aquired== B-lactam + macrolide or anti-pneumococcal FQ
How do you tx IC pt with PNC allergy for pneumoniae?
anti-pneumoccocal FQ plus Azteronam
Community acquired pneumonia
• Pneumonia is not present in up to ____of patients treated
• Do not treat abnormal x-rays with antibiotics if
• Discontinue antibiotics initially started for pneumonia if
30%
the patient does not have systemic
evidence of inflammation (fever, wbc, sputum
production, etc)
alternative diagnosis revealed
What would we prescribed to INpatient that has pneumoniae if Pseudomonas is a consideration
an Anti-pneumococcal, anti-pseudomonal B-lactam (pipercillin-taza, cefepime or meropenem) PLUS anti-psuedomonal FQ
What B-lactams have anti-pseudomonal activity?
Pipercillin-taxobactam
Cefepime
Meropenum
If you suspect MRSA in INpatient with pneumoniae, what would you add to tx in addition to the B-lactam plus macrolide regimen?
Add vancomycin or linezolid
If you suspect ASPIRATION in INpatient with pneumoniae, what would you add to tx in addition to the B-lactam plus macrolide regimen?
Add clindamycin to cover oral anaerobes
What are the 5 subdivisions of B-lactams?
Penicillins Cephalosporins (have ceph or cef in name) Carbapenems (end in 'penem') Monobactams (aztreonam) Beta-lactamase inhibitors
Clavulanic acid and sulbactam are what type of drug?
Beta lactamase inhibitors
Mech of B-lactams
inhibit cell wall synthesis
What B-lactam should I use for MSSA
Nafcillin and Cefazolin are drugs of choice
All beta lactams except PCN, Ampicillin
What B-lactam do I prescribe for in pneumococcus
Cefotaxime (for peds) Ceftriaxone (for adults)
Pt has Pseudomonas aeruginosa infection… what B-lactam is recommended for tx?
Piperacillin/Tazobactam, Ceftazadime, Cefepime,
Meropenem / Imipenem
Aztreonam (mono bactam)
Erythromycin, Clarithromycin, Azithromycin are all:
Macrolides
What is my spectrum of coverage for macrolides (azithro/clarithro/erythromycin)?
(think in 3s, 3 macrolides, three coverage)
Gram +
Gram -
Intracellular Atypicals
What two flouroquinoloes offer Anti-pneumococcal coverage?
- Moxifloxacin
* Levofloxacin (preferred)
What two FQs offer anti-pseudomonal coverage?
Ciprofloxacin (mother)
Levofloxacin (mother-in-law)
These drugs are second line coverage for some mycobacterial species, intracellular atypical pathogens and have anti-pneumococcal and anti-pseudomonal activity
FQs
-all end in floxacin
What do Tetracyclines cover?
Wide range of G+ and G- bacteria found in respiratory tract.
Atypicals as well
Most and least effective tetracyclines
tetracycline is least effective
minocycline and doxycline more effective
This drug is good for resistant Gram positive bacteria and needs to be given IV
Vancomycin
What three drugs offer coverage in G+ resistant bugs?
Vanco
Linezolid
Daptomycin
What is daptomycin used for? What is a limitation of Daptomycin?
Used to tx G+ resistant bugs
can’t be used in pneumonia bc it gets bound by surfactant
What is a negative side of Linezolid if used for long time?
bone marrow suppresion and neuropathy
When tx CAP, how long must you tx a patient for?
When is it safe to discontinue ts?
minimum of 5 days
patient should be afebrile for 48 - 72 hours, breathing without
supplemental oxygen (unless required for preexisting
disease), and have no more than one clinical instability factor (defined as HR >100, RR >24 and SBP≤90)
What infections causing pneumonia would require longer tx then other CAPs?
if pt has culture + for coagulase positive staphylococcus or pseudomonas they will need tx longer
Many patients with HCAP are at risk for colonization or infection with
multidrug resistant organisms (MDROs)
Laundry list of risk factors for MDROs
• Current hospitalization of > 5 days
• Hospitalization in an acute care hospital for > 2 days within the past 90 days
• Residents of a nursing home or long-term care facility
• Recipients of recent intravenous antibiotic therapy,
chemotherapy, or wound care within the past 30 days
• Chronic dialysis within 30 days
• Family member with multidrug-resistant pathogen
You are waiting on cultures for patient with pneumonia that has increased risk of exposure with MDROs, what type of drug therapy do we do?
Broad spectrum antibiotic therapy:
Anti-pseudomonal beta-lactam + anti-pseudomonal FQ OR
Aminoglycoside + Vanco or Linezolid if MRSA is suspected
You are waiting go get cultures back on patient that most likely has hospital aquired pneumonia. It is unlikely this patient has MDROs. Tx recommended?
Ceftriaxone OR
Amp/Sublactam OR
Ertapenem OR
FQs
Likely pathogen responsible for pneumoniae in pt with EARLY stage HIV infection?
Streptococcus pneumoniae
Likely pathogen responsible for pneumoniae in pt with LATE stage HIV infection?
- Pneumocystis jirovecii
- Non-tuberculous mycobacteria
- Histoplasma
What bugs cause pneumonaie in transplantation (bone marrow or solid organ)?
- Cytomegalovirus
- Respiratory syncitial virus
- Aspergillus
- Mucormycosis
Other random exposures that lead to respiratory infection I really hope we don’t need to know
- Exposure to birds
- Chlaymdophila psittaci (parrot family)
- Avian influenza (poultry)
- Exposure to rabbits
* Francisella tularensis - Exposure to farm or parturient animals
* Coxiella burnetti (Q fever) - Travel to SW United States
- Coccicioides
- Hantavirus
Pts with structural lung disease (cystic fibrosis, chronic
obstructive pulmonary disease, bronchiectasis) have different exposures to pathogens. what are they?
- Pseudomonas aeruginosa for CF
- Staphylococcus aureua in COPD
- Non-tuberculous mycobacteria
- Aspergillus
What do we use when deciding to tx patient as inpatient or outpatient?
CURB-65 scale
In the CURB-65 scale, you can have a total of up to 5 points… what do you get points for, what do they mean?
- Confusion
- Blood urea nitorgen > 19mg/dL
- RR > 30
- Systolic <60mmHg
- over 65 yo
point system to decide if you tx pt as inpatient or outpatient
A score of 0-1 on CURB scale results in what kind of tx
low risk, consider home Rx
A score of 2 on CURB results in what tx?
short inpatient rx or closely observed OP rx
A score of 3-5 on CURB results in what tx?
severe pneumoniae, admit and consider ICU
49 year old white male with a history of
hypertension and hyperlipidemia presents with 3
days of cough, chills, malaise, body aches, and a
fever to 102.5. He has no known medical
allergies.
Exam: B/P 110/70, T 101.0 , RR 26.
Crackles at the left lung base, and a chest x-ray
reveals a corresponding pneumonia.
The patient reports that he is unable to sleep
because of the cough, and he has never felt as bad
as he presently feels.
What’s his CURB scale and what tx is recommended?
CURB = 0
low risk, consider home rx with azithromycin (for community aquired pneumoniae)
A 77 year old female presents to the emergency
department with dyspnea, fever, hypotension, and
mental status changes. She lives at home and had
been in relatively good health until this presentation.
Exam: T 103, B/P 88/60, P 110, R 34 Pulse Ox 88% on
RA - improves to 99% on 4L NC
Lungs: Crackles in left lung base
CXR: Left lower lobe infiltrate.
Labs: WBC of 2.3 BUN of 33, creatinine of 1.3.
Based upon the above presentation, which of the
following is the most appropriate course of action?
Whats this womans CURB scale and recommended tx?
CURB = 5
treat as severe pneumoniae, admit and most likley ICU
Begin fluid resuscitation and IV Ceftriaxone and Moxifloxacin
–if pt had MDRO risk, you would tx with piperacillin-tazo
• F/74, DM on oral hypoglycemic drugs
• Presented with fever and malaise, cough with
sputum, tachypnea; chest X-ray revealed bilateral
infiltrates
• Travel history, occupation, contact and clustering
non-remarkable
• Received a course of amoxicillin for urinary tract
infection 10 weeks ago
• Diagnosis: Community-acquired pneumonia
What is our empirical tx for CAP?
B lactams to cover typicals (S. pneumoniae, H.influenzae, M. Catarrhalis)
Doxyclicine/macrolides to cover atyipcals (C. pneumonaie, M. pneumoniae, L.pneumophilia)
Respiratory FQs for B-lactam allergy
Risk factors for Penicillin resistant Streptococcus pneumonaie
- Age > 65 years
- Beta-lactam therapy in past 3 months
- Alcoholism
- Multiple medical comorbidities (e.g. immunosuppressive illness or medications)
- Exposure to a child in a day care center
Penicillin resistant Streptococcus pneumonaie
• If susceptible,_______ group is the drug of choice for Streptococcus pneumoniae
• Check _____ and_____ if resistant to penicillin
penicillin
susceptibility and MIC
• Penicillin susceptible if the MIC is:
</= 0.1 mcg/ml
When looking at the MIC for pts pneumoccal infection, you see it is 0.08 mcg/ml. What drugs would you prescribe?
Penicillin susceptible if MIC is less then/equal to 0.1
Use Penicillin G or amoxicillin
Penicillin resistant (0.1< MIC </= 1.0 mcg/ml) what do you prescribe?
• High dose penicillin G or ampicillin, cefotaxime / ceftriaxone
Penicillin resistant with MIC>2.0mcg/ml, what can you prescribe?
• Vancomycin +/- rifampin
• High dose cefotaxime tried in meningitis
• Non-meningeal infection: cefotaxime /
ceftriaxone, high dose ampicillin, carbapenems,
or fluoroquinolone (levofloxacin, moxifloxacin)
Multidrug resistant (MDRSP, resistant to any 2 of the following: penicillins, erythromycin, tetracycline, macrolides, cotrimoxazole) What do you recommend for tx?
- Vancomycin +/- rifampin
- Clindamycin, levofloxacin, moxifloxacin could be tried
- Linezolid
