Pharm: CAP, HAP, VAP Flashcards
What does the prevnar vaccine offer protection from?
Who is recommended to get the vacceine?
Protection from 13 S. pneumonae strains
Recommended for:
All children < 2 yo
Immunocompromised adults
Adults 65+
What does Pneumovax offer protection from?
Who is recommended to get the vacceine?
Protects from 23 strains of S. pneumoniae
Recommended for:
All adults 65+
Immunocompromised people age 2-64
Adults 19-64 who smoke cigarettes
Readminister every 5 years once started
How do you treat viral pneumonia?
Get your flu shot!
Oseltamivir, sanamivir (only effective if started within 48 hrs of symptom onset)
No effective drugs for adenovirus, parainfluenza, RSV
What are patients with viral pneumonia at risk of developing?
Secondary bacterial “superinfections” caused by S. pneumoniae, S. aureus, or H. influenzae
What is first line treatment for patients without risk factors for severe cases of CAP without a penicillin allergy?
Amoxicilline plus a macrolide or doxycycline
What is the first line treatment for patients without risk factors for severe case of CAP with a penicillin allergy?
What if they can’t tolerate cephalosporins?
Third generation of cephalosporin plus a macrolide or doxycycline
If can’t tolerate cephalosportins, give respiratory fluoroquinolone or lefamulin
What is the first line treatment for patients with risk factors for a sever course of CAP with a penicillin allergy?
What if they can’t tolerate cephalosporins?
Third generation cephalosporin plus a macrolide or doxycycline
If unable to tolerate cephalosporins and no structural lung dz, give respiratory fluoroquinolone or lefamulin
If unable to tolerate cephalosporins and has structural lung dz, give respiratory fluoroquinolone only
What is the first line treatment for patients with risk factors for a severe course of CAP without a penicillin allergy?
Amoxicillin-clavulanate plus a macrolide (preferred) or doxycycline
What drug class can’t you combine with penicilins in same IV solution?
Aminoglycosides
What drugs do you use agains penicillinase-producing strains of S. aureus?
Penicillinase-resistant penicillins (ex. nafcillin)
What penicillins have the greatest activity agains gram negative bacteria?
Broad spectrum penicillins (ex. ampicillin, amoxicillin)
What penicillins are useful agains P. aeruginosa?
extended spectrum penicillins (ex. piperacillin)
What can you combine penicillins with to increase activity?
beta-lactamase inhibitors (ex. clavulanate, tazobactam, sulbactam)
When would you use amoxicillin + clavulanate?
CAP if no penicillin allergy
What are some toxicities associated with amoxicillin + clavulanate?
Hypersensitivity reactions
superinfections, fungal or bacterial, including c. diff
Don’t use in patient’s with mononucleosis –> rash
What is the MOA of piperacillin + tazobactam?
Piperacillin inhibits bacterial wall synthesis
Tazobactam inhibits many beta lactamases
What types of organisms does piperacillin + tazobactam protect against?
broad spectrum
most gram positive & gram negative aerobes & anaerobes
Active against pseudomonas
What can you use piperacillin + tazobactam for?
CAP, HAP & VAP
What are the third generation cephalosporins?
What group of bacteria are they active against?
ceftriaxone, cefpodoxime, cefditoren
Have improved penetration through gram negative outer membrane
What are the fourth generation cephalosporins?
What group of bacteria are they active against?
cefepime
Has improved penetration through gram negative outer membrane with improved activity against gram positive
Why is ceftriaxone noteworthy?
not eliminated by the kidney so dose adjustment not needed for renal impairment
What important cefalosporin has bleeding tendancies?
ceftriaxone
What are the parenteral cephalosporins?
ceftriaxone (3rd gen)
cefepime (4th gen)
What are the oral cephalosporins?
cefditoren (3rd gen)
cefpodoxime-proxetil (3rd gen)
What organisms can you use cefpodoxime and cefditoren agains?
wide spectrum of gram positive and gram negative
What do you have to be careful with when giving cefpodoxime and cefditoren to patients with decreased renal function?
Longer 1/2 life of medication
Potential nephrotoxic effects if mixed with other nephrotoxic drugs (ex. aminoglycosides, warfarin)
What are some toxicities associated with cefpodoxime and cefditoren?
Beta lactam allergy
Superinfection (c. diff)
Cefditoren increases INR
What is the MOA of tetracyclines?
Inhibits 30S subunit & interferes with tRNA delivery thereby slowing growth of bacterial peptide chains
Kills bacterial lacking cell walls!
What is the tetracycline drug of choice (in combination) for CAP?
Doxycycline
Can tetracyclines be used in kids?
They shouldn’t, lead to permanent teeth staining
What are some other adverse effects of tetracyclines?
Impaired absorption (esp if taking antacids, Ca or Mg supplements)
Esophageal irritation and ulceration
Photosensitivity
Not recommended in combo with bactericidal drugs (ex. penicillins)
What are some examples of macrolides?
Ezithromycin
Clarithromycin
Azithromycin
Clindamycin
What is the MOA of macrolides?
Bind 50S subunit and block peptide chain elongation
What are some indications for macrolide use?
What drugs are commonly used?
Drug of choice (in combo) for CAP (azithromycin or clarithromycin)
Coverage of aerobic and anaerobic gram-positive organisms (effective against most)
Generally not effective against gram negative bacteria EXCEPT pasteurella, haemophilus, & neisseria spp.
Effective against Legionella, mycoplasma, mycobacteria, some rickettsia, and chlamydia
Generally ot active against fungi or protozoa
What are some adverse effects of clarithromycin?
Less GI upset
CYP450 inhibitor
What are some advantages of azithromycin?
Does not disrupt CYP450 function
Has different ring structure tha other macrolides (better for allergies?)
Concentrates in phagocytes and slowly release bacteriostatic levels of drug from single dose with t1/2 of 2-4 days
What are some examples of respiratory fluoroquinolones?
levofloxacin (3rd gen)
gemifloxacin (4th gen)
moxifloxacin (4th gen)
What do respiratory fluoroquinolones cover?
How are they administered?
broad spectrum agains both gram positive and gram negative
Some adminstered orally
Should you use fluoroquinolones in CAP?
Use is discoraged unless:
- comorbid conditions
- recent antimicrobial use
- high prevalence of high-level macrolide resistant S. pneumonae in the local community
What are some adverse reactions of fluoroquinolones?
Achille’s tendon rupture (esp. in children, elderly, and those who stress tendon)
GI upset
photosensitivity
What are some indications for vancomycin?
Given IV for MRSA and MRSE
individuals with penicillin allergies
(anytime can’t give penicillins)
What happens if you infuse vancomycin too fast?
Red Man Syndrome
What is linezolid active against?
When do you use it?
Most gram positive bacteria
Use in CAP (S. pneumonae including concurrent infection with s. aureus) and HAP (S. aureus or S. pneumonae)
Can you give linezolid orally?
Yes
What organisms does aztreonam cover?
Wide spectrum of gram neg aerobes including pseudomonas
No activity agains gram pos or anaerobes
What is the MOA of imipenem?
Binds >1 PBPs
Inhibits bacterial wall synthesis
What organisims does imipenem cover?
Wide spectrum of activity agains gram neg and gram pos aerobic and anaerobic bacteria
Active against many MDR strains!
What are some adverse effects of gentamicin?
Nephrotoxicity (generally reversible)
Neurotoxicity
Ototoxicity
What are usually the drugs of choice for aspiration pneumonia?
Why did we switch to these drugs?
Ampicillin-sulbactam or amoxicillin-clavulanate
Used to use clindamycin but switched because of strong association with c. difficile colitis
What are some c. diff colitis causing antibiotics?
clindamycin
fluoroquinolones
broad spectrum cephalosporins
penicillin
macrolides (occasionally)
trimethoprim-sulfamethoxazole (occasionally)
What are your “nasty bugs”?
Why are these so bad?
ESKAPE
E. coli
Staphlococcus (S. aureus)
Klebsiella pneumoniae
Acinetobacter Baumannii
Pseudomonas aeruginosa
Enterococcus faecalis
All have post-translational modifications that give rise to abx resistance
What should you give a CAP pt at increased risk of both MRSA and Pseudomonas infection?
Anti-MRSA agent (Vancomycin or linezolid)
Levofloxacin
Aztreonam
An aminoglycoside (gentamycin)
What should you give a CAP pt with a severe beta lactam allergy with pseudomonas risk factors only?
levofloxacin
aztreonam
an aminoglycoside (gentamycin)
What should you give a CAP pt with a severe beta lactam allergy with MRSA risk factors only?
Anti-MRSA agent (vancomycin or linezolid)
A respiratory flurorquinolone (levofloxacin, moxifloxacin, gemifloxacin)
What should you give a CAP patient without a severe beta lactam allergy with an increased risk of MRSA and pseudomonas infection?
Anti-MRSA agent (vancomycin or linezolid)
Antipseudomonal/antipneumococcal beta lactam (piperacillin-tazobactam, cefepime, ceftazidime, imipenem or meropenem)
Antipseudomonal fluoroquinolone (ciprofloxacin or levofloxacin)
What is the prefered treatment for a CAP pt without a severe beta lactam allergy with an increased risk of MRSA infection only?
Combination beta lactam based regimen
If no macrolide contraindication: Anti-MRSA agent (vancomycin or linezolid) + antipneumococcal beta lactam (ceftriaxone, cefotaxime, ceftaroline, ertapenem, ampicillin-sulbactam) + a macrolide (azithromycin or clarythromycin)
If pt has macrolide contraindication: same regimen as above but swap macrolide for doxycycline
What is the alternative treatment for a CAP pt without a severe beta lactam allergy with an increased risk of MRSA infection only?
Fluoroquinolone based regimen
Respiratory fluoroquinolone (levofloxacin, moxifloxacin, or gemifloxacin)
Anti-MRSA agent (vancomycin or linezolid)
What should you give a CAP patient without a beta lactam allergy with a risk of pseudomonas infection only?
Antipseudomonal/antipneumococcal beta lactam (piperacillin-tazobactam, cefepime, ceftazidime, imipenem, meropenem)
Antipseudomonal fluoroquinolone (levofloxacin, ciprofloxacin)
What is the prefered treatment for a CAP patient with no beta lactam allergy and no MRSA or pseudomonas risk factors?
If no macrolide contraindication: An antipneumococcal beta lactam (ceftriaxone, cefotaxime, ceftaroline, ertapenem, ampicillin-sulbactam) + a macrolide (azithromycin or clarithromycin)
If macrolide contraindication: same as above but swap macrolide for doxycycline
What is an alternative treatment for a CAP patient with no beta lactam allergy and no MRSA or pseudomonas risk factors?
Respiratory fluoroquinolone monotherapy (levofloxacin, moxifloxacin or gemifloxacin)
What are risk factors for MDR pseudomonas and other gram negative bacilli in VAP?
Tx in ICU in which >10% of gram neg isolates are resistant to agent being considered for monotherapy
Tx in ICU in which local antimicrobial susceptibility rates are not known
Colonization with or prior isiolation of MDR pseudomonas or other gram neg bacilli
What are MRSA risk factors in VAP?
treatment in a unit in which >10 to 20 percent of Staphylococcus aureus isolates are methicillin resistant
treatment in a unit in which the prevalence of MRSA is not known
colonization with OR prior isolation of MRSA
What are general risk factors for MDR colonization in VAP?
- IV antibiotic use within the previous 90 days
- septic shock at the time of VAP
- ARDS preceding VAP
- ≥ 5 days of hospitalization prior to the occurrence of VAP
- acute renal replacement therapy prior to VAP onset
