Pneumonia Flashcards
What is pneumonia?
An acute infection of the pulmonary parenchyma
How soon do you want to begin antibiotics for pneumonia and what other care should be supplied?
Want to have PROMPT antibiotic initiation with appropriate spectrum of activity is an essential step in pneumonia management.
- supportive care with bronchodilators, symptomatic management and fluids
CAP definition
Microbiological therapy is usually successful, and knowledge of which pathogen does not usually change therapy
- empiric Abx therapy is usually successful and knowledge of which pathogen does not usually change therapy
Important bacteria to cover empirically for CAP
- S. pneumoniae and H. influenzae (typical)
- M catarrhalis, MSSA ( higher suspicioni in smokers, elderly, recent Abx use, those with comorbidities)
- Enterobacteriaceae such as K. pneumonie, E.coli (higher suspicioisn in structural lung diseases like COPD)
- Atypical bacteria- mycoplasma pneumoniae, legionella pneumophila, and chlamydia pneumoniae
Mainstay of therapy for CAP
beta- lactams are the mainstay of therapy
Which populations would likely have M. catarrhalis and MSSA
Higher suspicion in:
- smokers
- elderly
- recent Abx use
- those with comorbidities
Which populations would likely have enterobacteriaceae such as k.pneumoniae, e.coli
Higher suspicion in structural lung diseases such as COPD
CAP treatment for healthy individuals, under 65, with no recent antibiotic use
- Amoxicillin (GP, GN, Anaerobes, Atypical) - covers most strains of s. pneumoniae and h. influenzae
- +/- AZITHROMYCIN (PREFERRED) or doxycycline - targets the atypicals
- PCN allergy but tolerate cephalosporins - 3rd generation cephalosporin (cefdinir)
- Last- line : Levofloxacin (covers atypicals and normal pathogens)
CAP Treatment with comorbidities, 65+, recent antibiotics, smokers- expand coverage a bit
- amoxicillin/ clauvulanic acid (augmentin) + azithromycin or doxycycline
- alternative- 3rd generation - cefdinir + azithromycin OR doxycyline
- last line: Levofloxacin
Duration of therapy for CAP treatment
typically 5 days - afebrile > 48 hours and clinically stable (exception: high dose Azithromycin)
Pathogenic organisms in CAP typically a/w severe illness
Pseudomonas, Klebsiella, MRSA
Amoxicillin use
- first line treatment usually with azithromycin for healthy individuals and CAP treatment
- treating those with CAP and comorbidities. Usually combined with clavulanic acid (augmentin) then combined with azithromycin AND doxycyline
ADR of amoxicilliin
- allergic reaction- PCN allergies
- Cdiff and AAD (antibiotic associated diarrhea)
Augmentin is which drugs?
Amoxicillin and clavulanic acid
ADR of augmentin
More AAD than amoxicillin alone
Adjustment for augmentin
Renal adjusment is needed
Azithromycin indications
CAP and GP, GN, Atypicals
NO MRSA and Pseudomonas
Contraindications of azithromycin
Hx of cholestatic jaundice/ hepatic dysfunction a/w prior azithromycin use
Z pack
Aztithromycin
2 tabs 500mg day 1, then 250 mg qd x 4 days
ADR of azithromycin
- QT prolongation- increased risk of fatal heart rhythms
Doxycycline Contraindications
relative - children <8 years of age d/t discoloration of teeth - can use if no other alternative therapies
ADR of doxycyline
- GI disturbances
- AAD
- Photosensitivity
Levofloxacin Indications
Covers pseudomonas (no MRSA)
Levofloxacin US Box Warnings
- Tendinitis
- Exacerbation of myasthenia gravis
Levofloxacin is a fluoroquinolone that covers MSSA, GP, GN, Pseudomonas and atypicals
Adjustments of Levofloxacin
- Requires a renal adjustment
- Absorption is decreased by cations - Ca, Zn, Al, Mg, Fe- give 2 hours before and 6 hours after
What is HAP
A pneumoniae that occurs 48 hours or more AFTER admission and does NOT appear to be incubating at the time of admission
VAP
a type of HAP that develops more than 48 hour after ET intubations
Treatment for HAP and VAP
- Cefepime + Vanco, +/- Levofloxacin
- Zosyn + Vanco, +/- Levofloxacin
- If they have a PCN/ Cephalosporing allergy- Meropenem + Vanco, +/- Levofloxacin
- Can consider adding azithromycin or doxycycline if high suspicion of atypical but do NOT want to use levofloxacin
Cefepime inidications
- pneumonia (pseudomonal coverage)
Routes of cefepime
IV (only use this in the hospital)
ADR of Cefepime
- c.diff associated diarrhea
- antibiotic associated diarrhea
- neurotoxicity- encephalopathy, aphasia, myoclonus, seizures- rare!
Vancomycin indications
MRSA coverage
Routes of Vanco
- IV- all systemic infections
- Oral- C. Diff infections
ADR of Vanco
- Nephrotoxic- Renal Failure
- Red Man Syndrome- Rapid infusion can cause histamine release- flushing, rash, pruritis, tachycardia, hypotension
- thrombocytopenia- decreased platelets
Metabolism / excretion of Vanco
Dosed by nomogram- kidney function and weight based
Zosyn is which drugs
Piperaciillin and tazobactam
Indications of Zosyn
Pneumonia (pseudomonal coverage)
Route of zosyn
IV
ADR of Zosyn
AKI- particularly in combo with Vanco and other nephrotoxic drugs
HCAP comes from which places
- dialysis
- residing in nursing home
- previous hospitalization
- immunocompromised state
What is aspiration pneumonia
Type of pneumonia that results from the entry of gastric OP fluids which may contain bacteria
- leads to a pneumonia that may be aerobic, anaerobic or a mixture
Aspiration Pneumonia Outpatient Treatment
Augmentin (GP, GN and Anaerobes)
Aspiration Pneumonia- Inpatient therapy for those who are not severely ill
Unasyn (Ampicillin - sulbactam)
(GP, GN, Anaerobes, Atypicals)
Aspiration Pneumonia- Inpatient therapy for those who are severely ill
Zosyn (piperacillin and tazobactam)
- might use if someone is choking and can’t speak or has an unclear history. Could even add vanco to cover HAP, VAP or HCAP
3 treatments for aspiration pneumonia bring:
anaerobic coverage in addition to covering the normal suspected pathogens
What to do with a mixed etiology pneumonia
May have to cover a broader spectrum empirically and narrow
- unsure if it is aspiration or HCAP - lean toward Zosyn
