Management of LRTI

Question 1

What are the expected pathogens in community-acquired pneumonia?

Answer 1

Outpatient
- Streptococcus pneumoniae
- Haemophilus influenzae
- Atypical organisms eg Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella pneumophila

Inpatient - add on
- Staphylococcus aureus
- Other Gram-negative bacilli, eg Klebsiella, Burkholderia pseudomallei

Possible MRSA and/or Pseudomonas aeruginosa, depending on risk

Question 2

What are the criteria for classifying how a pneumonia patient’s treatment should go?

Answer 2

Confusion (new onset)
Urea > 7 mmol/L
RR > 30 breaths/min
Blood pressure
(SBP < 90 mmHg or DBP ≤ 60 mmHg)
Age ≥ 65 years

Question 3

What are the regimens for CA-pneumonia handled in the outpatient setting, for a patient who has no comorbidities?

Answer 3

β-lactam (Amoxicillin 1g Q8H) OR
Respiratory fluoroquinolone
(levo or moxi)

Question 4

What are the regimens for CA-pneumonia handled in the outpatient setting, for a patient who has comorbidities?

Answer 4

β-lactam (augmentin/cefuroxime)
PLUS
Macrolide (azithro/clarithro) OR doxycycline

OR Respiratory fluoroquinolone
(levo or moxi)

Question 5

What are the regimens for CA-pneumonia handled in the inpatient setting that is non-severe?

Answer 5

β-lactam (augmentin/cefuroxime)
PLUS
Macrolide (azithro/clarithro) OR doxycycline

OR Respiratory fluoroquinolone
(levo or moxi)

Add on MRSA and/or Pseudomonas coverage prn

Question 6

What are the regimens for CA-pneumonia handled in the inpatient setting that is severe?

Answer 6

β-lactam (augmentin/cefuroxime)
PLUS
Ceftazidime
PLUS
Macrolide (azithro/clarithro) OR doxycycline

OR Respiratory fluoroquinolone
(levo or moxi)
PLUS
Ceftazidime

Add on MRSA and/or Pseudomonas coverage prn

Question 7

How long should CAP be treated for?

Answer 7

Minimum 5 days
7 days if suspected/confirmed MRSA/pseudomonas
Even longer for Burkholderia, Mycobacterium TB etc

Question 8

How can VAP be prevented?

Answer 8

Limit duration of mechanical ventilation, minimise duration and deep levels of sedation, elevate head of bed by 30 degrees

Question 9

What pathogens need to be empirically covered for HAP/VAP?

Answer 9

P.aeruginosa, Staphylococcus aureus and Enterobacterales

May need MRSA and/or gram negative coverage depending on hospital

Question 10

What are the possible empiric regimens for HAP/VAP?

Answer 10

Any 2 of the below:
Anti-pseudomonal β-lactam
(pip-tazo. Cefepime, ceftazidime, meropenem, imipenem)
OR
Anti-pseudomonal FQ
OR
Amikacin

Add on MRSA coverage prn