Lower Respiratory Tract Infections Flashcards
Community Acquired Pneumonia (CAP)
Onset outside of the hospital or < 48 hours from hospital admission
CAP Outpatient Empiric Therapy if No Comorbidities and No Antimicrobial Use Within 90 Days
High-dose amoxicillin (preferred)
Doxycycline
Azithromycin (if pneumococcal resistance < 25%)
CAP Outpatient Empiric Therapy if Comorbidities or Antimicrobial Use Within 90 Days
Combination Therapy:
Augmentin or 2nd Gen PO CEPH (cefpodoxime or cefuroxime) PLUS EITHER
Macrolide or Doxycycline
Monotherapy: respiratory FQ (levofloxacin or moxifloxacin)
CAP Inpatient, Non-ICU Empiric Therapy No PCN Allergy
Ampicillin/sulbactam, cefotaxime, ceftriaxone, or ceftaroline PLUS EITHER
Macrolide or doxycycline
CAP Inpatient, Non-ICU Empiric Therapy if PCN Allergy
Levofloxacin or moxifloxacin
CAP Inpatient, ICU Empiric Therapy No PCN Allergy
Ampicillin/sulbactam, cefotaxime, ceftriaxone, or ceftaroline PLUS EITHER
Macrolide or fluoroquinolone
CAP Inpatient, ICU Empiric Therapy if PCN Allergy
Aztreonam PLUS
Levofloxacin or moxifloxacin
Risk Factors for MRSA
Antibiotic use within 90 days ESRD Prior influenza infection Radiographic finding of cavitary/necrotizing lesions Structural lung disease
CAP MRSA Therapy
Add vancomycin or linezolid to regimen
Risk Factors for Pseudomonas
Antibiotic use within 90 days
Alcoholism
COPD
Structural Lung Disease
CAP Pseudomonas Therapy
Anti-pneumococcal, anti-pseudomonal beta-lactam (Zosyn, Cefepime, Meropenem) PLUS EITHER
Fluoroquinolone or Aminoglycoside PLUS
Azithromycin
CAP Directed Therapy - S. pneumoniae (PCN-susceptible)
Amoxicillin or PCN G
CAP Directed Therapy - S. pneumoniae (PCN-resistant)
Cefotaxime, ceftriaxone, levofloxacin, moxifloxacin
CAP Directed Therapy - H. influenzae (non-beta-lactamase)
Amoxicillin
CAP Directed Therapy - H. influenzae (beta-lactamase)
Cefotaxime or ceftriaxone
CAP Directed Therapy - MSSA
Dicloxacillin, Oxacillin, Nafcillin
CAP Directed Therapy - MRSA
Vanco or linezolid
CAP Directed Therapy - Legionella
Fluoroquinolone or macrolide
CAP Duration of Therapy
5 days
Hospital-Acquired Pneumonia (HAP)
Occurring at least 48 hours from admission, with no prior sxs
HAP High Mortality Risk
Need for ventilator support due to pneumonia
Septic shock
HAP MRSA Coverage Needed
IV antibiotic use within 90 days
Unit where prevalence of MRSA > 20%
HAP Double Pseudomonas Coverage Needed
IV antibiotic use within 90 days
Structural lung disease
HAP Empiric Therapy if Low Risk for Mortality and MDR GNR and Local MRSA < 20%
Beta-lactam (Zosyn, Cefepime, Meropenem, Imipenem) OR
Levofloxacin
HAP Empiric Therapy if Low Risk for Mortality and MDR GNR and Local MRSA > 20%
Beta-lactam (Zosyn, Cefepime, Meropenem, Imipenem, Aztreonam) OR
Levofloxacin or ciprofloxacin PLUS
Vanco or linezolid
HAP Empiric Therapy if High Risk for Mortality or MDR GNR
Double Pseudomonas coverage from 2 separate classes: beta-lactams (Zosyn, Cefepime, Meropenem, Imipenem, Aztreonam), fluoroquinolones (Ciprofloxacin, Levofloxacin), aminoglycosides (amikacin, gentamycin, tobramycin) PLUS
Vanco or linezolid
HAP Duration of Therapy
7 days
VAP MDR Risk Factors
IV antibiotics within 90 days
Septic shock
ARDS and renal replacement therapy prior to VAP
Hospitalization at least 5 days prior to VAP
VAP MRSA Coverage Needed
MDR VAP Risk Factors
Unit where prevalence of MRSA > 10%
VAP Double Pseudomonas Coverage Needed
MDR VAP Risk Factors
Units where resistance to anti-pseudomonal agent > 10%
VAP Empiric Therapy if No MDR VAP Risk Factors and Local MRSA and GNR Resistance < 10%
Beta-lactam (Zosyn, Cefepime, Meropenem, Imipenem) OR
Levofloxacin
VAP Empiric Therapy if No MDR VAP Risk Factors, Local MRSA > 10%, and GNR Resistance < 10%
Beta-lactam (Zosyn, Cefepime, Meropenem, Imipenem, Aztreonam) OR
Levofloxacin or ciprofloxacin PLUS
Vanco or linezolid
VAP Empiric Therapy if No MDR VAP Risk Factors, Local MRSA < 10%, and GNR Resistance > 10%
Double Pseudomonas coverage from 2 separate classes: beta-lactams (Zosyn, Cefepime, Meropenem, Imipenem, Aztreonam), fluoroquinolones (Ciprofloxacin, Levofloxacin), aminoglycosides (amikacin, gentamycin, tobramycin), polymyxins (colistin or polymyxin B)
At least one agent active against S. aureus
VAP Empiric Therapy if No MDR VAP Risk Factors and Local MRSA and GNR Resistance > 10%
Double Pseudomonas coverage from 2 separate classes: beta-lactams (Zosyn, Cefepime, Meropenem, Imipenem, Aztreonam), fluoroquinolones (Ciprofloxacin, Levofloxacin), aminoglycosides (amikacin, gentamycin, tobramycin), polymyxins (colistin or polymyxin B) PLUS
Vanco or linezolid
VAP Empiric Therapy if MDR VAP Risk Factors
Double Pseudomonas coverage from 2 separate classes: beta-lactams (Zosyn, Cefepime, Meropenem, Imipenem, Aztreonam), fluoroquinolones (Ciprofloxacin, Levofloxacin), aminoglycosides (amikacin, gentamycin, tobramycin), polymyxins (colistin or polymyxin B) PLUS
Vanco or linezolid
Duration of VAP Therapy
7 days
HAP/VAP Directed Therapy - MRSA
Vancomycin or linezolid
HAP/VAP Directed Therapy - Pseudomonas
Per antibiotic susceptibility results
Continue combination therapy for septic shock/high mortality risk
Monotherapy if septic shock resolves
HAP/VAP Directed Therapy - Acinetobacter
Per antibiotic susceptibility results
Carbapenem
Ampicillin/sulbactam
Polymyxin + inhaled colistin
HAP/VAP Directed Therapy - ESBL GNR
Carbapenem treatment of choice
HAP/VAP Directed Therapy - CRE
IV polymyxin + inhaled colistin Ceftolozane/tazobactam Ceftazidime/avibactam Imipenem/relebactam Cefidercol
