LRTI Flashcards
Outpatient empiric therapy options for CAP patient without comorbidities or risk factors for antibiotic resistance
Amoxicillin 1gm PO Q8H
or
Doxycycline 100mg PO BID - good atypical coverage (walking pneumonia
Comobidities
Chronic heart, lung, or renal disease, Diabetes mellitus, alcoholism, malignancy, asplenia or immunosuppression
Outpatient empiric therapy options for CAP patient WITH comorbidities
COMBO is recomended over monotherapy
B-lactam + Macrolide OR doxy if patient is contraindicated to macrolide
B-lactam options include
- Augmentin PO 500/125mg Q8H or 875/125mg Q12H
- Cefpodoxime PO Q12H
- Cefuroxime PO Q12H
Monotherapy
- Levofloxacin 750mg PO daily
- Moxifloxacin 400mg PO daily
Empiric therapy for non-severe CAP patient INPATIENT w/ NO MRSA or pseudomonas risk factors
Combo B-lactam + Macrolide (can use doxy IV or PO if contraindicated to Macrolide) Preferred over monotherapy
B-lactam options include
- Ampicillin/sulbactam 1.5-3 gm IV Q6H
- Ceftriaxone 1-2 gm IV Q24H
Monotherapy
- Levofloxacin 750mg PO daily
- Moxifloxacin 400mg PO daily
Empiric therapy for severe CAP patient INPATIENT w/ NO MRSA or pseudomonas risk factors
Combo B-lactam + Macrolide OR Fluoroquinolone + B-Lactam (can use doxy IV or PO if contraindicated to Macrolide)
B-lactam options include
- Ampicillin/sulbactam 1.5-3 gm IV Q6H
- Ceftriaxone 1-2 gm IV Q24H
MRSA coverage drugs
- Vancomycin target AUC 400-600
- Linezolid 600mg IV/PO Q12H
Pseudomonas coverage
- Piperacillin/tazobactam 4.5gm IV Q6H
- Cefepime 2gm IV Q8H
- Meropenem 1gm IV Q8H
Pathogen Directed therapy
Streptococcus Pneumoniae
Preferred therapy
- Penicillin G; Amoxicillin
- Ceftriaxone; Moxi or Levo
Alternative therapy
- Ceftriaxone; Moxi or Levo; Doxycycline; Vancomycin; Linezolid
Pathogen Directed therapy
Staphylococcus Aureus
MSSA
MRSA
MSSA: Cefazolin; nafcillin
MRSA: Vancomycin; Linezolid
Alternative therapy
- Vancomycin; Clindamycin; Ceftaroline; TMP/SMX
Duration of CAP therapy
Ensure clinical stability prior to D/C
Temp < 38
HR < or equal 100bpm
RR < or equal 20
SBP < or equal to 90
O2 > or equal to 90
Continue antibiotic until clinical stability for a minimum of 5 days
Hospital acquired pneumonia definition
Pneumonia occuring > or equal to 48 hours after hospital admissions
Ventilator associated pneumonia definition
pneumonia occuring > or equal to 48 hours after endotracheal intubation
HAP and VAP pathogenesis
Micro-aspiration usually colonized with aerobic gram positive bacteria
after 3-5 days of hospitalization converts to gram negative organism
Risk factors for HAP/VAP
Advanced age
severity of comorbid disease
duration of hospitalization
Endotracheal intubation
Nasogastric tube
Altered mental status
Surgery
Previous antimicrobial therapy
Common pathogens of HAP and VAP
Aerobi gram negative
- Pseudomonas aeruginosa
- CEEK
- Acinetobacter baumannii
Staphylococcus aureus
- MRSA greater concern in this population
Risk factors for Multi-Drug resistant HAP
- Prior antibiotic use within 90 days
Risk factors for Multi-Drug resistant VAP
- Prior antibiotic use within 90 days
- Septic shock at time of diagnosis
- Acute respiratory distress syndrome prior to diagnosis
- Acute renal replacement therapy prior to diagnosis
- > or equal to 5 day hospitalization prior to diagnosis
Risk factors for Multi-Drug resistant Pseudomonas aeruginosa
Prior IV antibiotic use within 90 days
specifically - Carbapenems, broad spectrum B-lactams, FQ
Empiric therapy - MRSA coverage for HAP/VAP
Risk factors
- typical risk factors for MRSA
- ICU where > 10-20% MRSA isolates
- treatment where prevalence is unknown
Treatment options
- Vancomycin - AUC 400-600
- Linezolid 600mg PO/IV Q12H
HAP/VAP Empiric therapy - Pseudomonas aeruginosa Coverage
Risk factors
- ICU where >10% of isolates resistant
- treatment where resistance rates are unknown
Treatment options
- Piperacillin-Tazobactam 4.5gm IV Q6H
- Cefepime 2mg IV Q8H
- Imipenem 500mg IV Q6H
- Meropenem 1gm IV Q8H
- Levofloxacin 750mg IV Q24H
HAP Empiric therapy for patient not at high risk for mortality (not on ventilatory or septic shock) NO MRSA risk
- Piperacillin-Tazobactam 4.5gm IV Q6H
- Cefepime 2mg IV Q8H
- Imipenem 500mg IV Q6H
- Meropenem 1gm IV Q8H
- Levofloxacin 750mg IV Q24H
HAP Empiric therapy for patient not at high risk for mortality (not on ventilatory or septic shock) + MRSA risk
pseudomonas coverage
- Piperacillin-Tazobactam 4.5gm IV Q6H
- Cefepime 2mg IV Q8H
- Imipenem 500mg IV Q6H
- Meropenem 1gm IV Q8H
- Levofloxacin 750mg IV Q24H
+
MRSA coverage
Vancomycin IV - AUC 400-600
Linezolid 600mg IV Q12H
HAP Empiric therapy for patient at high risk for mortality (on ventilatory OR septic shock) + MRSA risk
Want to do a B-lactam drug and non B lactam drug (goal is to provide MDR pseudomonas aeruginosa and MRSA coverage)
- Piperacillin-Tazobactam 4.5gm IV Q6H
- Cefepime 2mg IV Q8H
- Imipenem 500mg IV Q6H
- Meropenem 1gm IV Q8H
+
- Levofloxacin 750mg IV Q24H
- Tobramycin/ amikacin IV
+
MRSA coverage
Vancomycin IV - AUC 400-600
Linezolid 600mg IV Q12H
VAP empiric therapy
Goal is to provide MRSA + pseudomonas aeruginosa
Choose 2 anti- pseudomonals when risk factors for resistance are present (wanna do BL and non BL drug
- Piperacillin-Tazobactam 4.5gm IV Q6H
- Cefepime 2mg IV Q8H
- Imipenem 500mg IV Q6H
- Meropenem 1gm IV Q8H
- Levofloxacin 750mg IV Q24H
-Tobramycin/amikacin IV
+
Vancomycin IV - AUC 400-600
Linezolid 600mg IV Q12H
Duration for HAP/VAP
Recommend 7 day duration if clinically stable
VAP - no difference in mortality with longer duration of therapy (keep it at 7)
