Pneumonia Therapeutics Flashcards
What drugs have “grey” activity to Strep pneumo
- All penicillins (overcome with high doses)
- All BL-BLIs (amoxi-clav, pip-taz)
- 1st and 2 gen cephalosporin
- Cefixime
- Macrolide
- Septra
What drugs have good activity against strep. pneumo
- 3rd gen cephalosporin
- Vancomycin
- FQ (levo, moxi)
- Clindamycin
(linezolid, dapto, carbapenems)
What drugs do high-level BL resistance require?
Levo/moxi
Vanco
Linezolid
Daptomycin
What is the relative potency of different B-lactams
Amoxi > Cefuroxime/Cefprozil (2nd gens)»_space; Cefixime (3rd gen) > Cephalexin (1st gen)
What are good alternate options for strep pneumo if Beta lactams cannot be used (3)
Doxycycline
- work as well as ML and FQ in mild - moderate disease (outpatient/inpatient)
FQ
- Good evidence to support use
- Concerns RE: resistance, collateral damage, C. diff, QTc prolongation
Macrolide
- good evidence for use
- 15-20% resistance in canada
- QTc prolongation
What does CAP-START trial tell us about mild-moderate CAP disease with routine atypical coverage
BL + ML/FQ vs BL alone is not needed for outpatients
Meta-analysis showed combo therapy to decrease death for severe CAP
Which drugs would be effective for treating legionella?
ML (azith> clarith)
FQ (levo> moxi, cipro)
Doxy
- use if patient has QT prolongation
Duration for legionalla
Not studied
7 days minimum preferred
When would you want to use cipro for pneumonia since it does not cover Strep. pneumo?
Admitted to ICU
- need to cover s. pneumo, H. influ, Legionella
You have a urinary test shows + for legionella
- cipro would be good
What is the preferred and alternate treatment with doses for outpatient with strep pneumo
Preferred:
Amoxicillin
- 500mg po TID
- 1000mg po BID to TID if at risk of PRSP
(65+, daycare, diabetes, recent hosp, abx use in past 3 months)
Alternates
Doxycycline
- 200mg x 1 then 100mg po BID
- 100mg BID x 1 day then 100mg po daily
Cefuroxime, cefprozil (2nd gen)
- 500mg po q12h
Levofloxacin: 750mg daily
Moxifloxacin: 400mg daily
What are the options for Inpatients when want to cover S. pneumo and H. influ with doses
Amoxi-clav
875/125mg po BID
500/125mg po TID +/- amoxi 500mg po TID
*Give higher dose if patient is at risk of PRSP
3rd gen cephalosporin
- Cefotaxime: 1g IV q24h
- Ceftriaxone: 1g IV q8h
*Give 2g dose if patient is obese
FQ
Levofloxacin: 750mg daily
Moxifloxacin: 500mg daily
What are the options with doses if you want to cover for legionella in inpatient? (3)
What to note here in terms of combo therapy vs FQ?
For legionella coverage, add ML to BL:
Clarithromycin 500mg x 1 then q12h
Azithromycin 500mg x1 then 250mg po x4
Azithromycin 500mg po x 3 days
Note:
- Levo, Moxi already cover for legionella = no need to add an agent here
- BUT we prefer using combo (3rd gen ceph + ML over FQ alone)
For ICU patients, what is the preferred drugs with dosing with NO risk factors for pseudomonas and staph aureus?
IV: Cefotaxime or Ceftriaxone (3rd gens) + Azithromycin (IV)
OR
IV/ORAL: Levofloxacin/Moxifloxacin (can be given orally)
Prefer oral if functioning gut (FQs are 100% bioavailable)
- But remember, FQs carry higher more ADRs + not preferred in pregnancy
What to give empirically in ICU if patient has risk factors for pseudomonas
Give levofloxacin and replace BL with pip-taz 4.5g IV q8h
What to give empirically in ICU if patient has risk factors for MRSA
For MRSA coverage:
Add to BL, doxycycline or ML:
- Vancomycin 15 to 20 mg/kg IV q12h
- Linezolid 600mg po q12h
Need to use in combo as they do not cover h. influ
What is the best agent to use if you pseudomonas is confirmed?
Ceftazidime
When can you drop psuedomonas coverage?
No pseudomonas growth on culture
AND
improving at 48-72 hours
When can you drop MRSA coverage?
No MRSA growth on culture
AND
nasal swab negative
AND
improving at 48-72 hours
When can antibacterial be dropped entirely
PCR evidence of viral infection
AND
no suspicion of concurrent bacterial infection
When should you convert IV to PO (4)
- Clinically improving
- Afebrile for 24 hours
- Hemodynamically stable for 24 hours (not requiring BP-maintaining meds like Vasopressors) Otherwise, we risk poor gut perfusion
- Tolerating oral meds/diet for 24 hours
No other contraindication to oral administration
What would you convert ceftriaxone/cefotaxime IV to for oral option
Amoxi-clav
OR
Cefuroxime
When should overall symptoms improve?
Fever
Fatigue
CXR
Generally: in 48-72 hours
Fever: 3 days
Fatigue: 14 days
CXR: several weeks, do not use to assess efficacy
1/3 patients will have at least 1 symptom at 28 days
Duration of therapy for
Outpatient
Inpatient
ICU
Outpatient: 5 days
Inpatient:
- 5 days min (can d/c when afebrile 28hrs + no more than one of HR, RR, SBP, O2)
- 7 days if bacteria
ICU
- 7 days reasonable
- count 7 days from start of new therapy
What does failure to improve in before 72 hours mean?
Wait at least 72 hours
What does no improvement in 72+hrs (4)
- Resistant pathogen
- Empyema/effusion (pus in pleura)
- Superinfection (double infection)
- Non-infectious cause (CHF, MI)
What does worsening sx in under 72 hours mean (3)
- Severe illness/resistant pathogen (need O2, ICU transfer)
- Metastatic infection
- Misdiagnosis
What does worsening sx after 72 hours mean? (3)
- Superinfection (second pathogen that is resistant to first treatment causes infection)
- Worsening comorbidities
- Intercurrent, non-infectious disease (CHF, MI)
What are risk factors for invasive pneumococcal disease?
- Smoking
- Diabetes
- homelessness
- LTC residence
- Alcohol misuse
- Chronic - heart, lung, liver, kidney disease
- chronic neurological condition that impairs swallowing
- asthma requiring medical care for the past 12 months
How to prevent CAP
- swallowing assessment
- optimize COPD management
- Address alcohol and smoking
- Anuual flu shot
- RSV for 60+
What are possible pathogens that can cause pneumonia from COPD (3)
Strep. pneumo
H. influ
Psuedomonas
Does sputum purulence differentiate between viral and bacterial infections
No
- (pus is a sign of dead neutrophils – which are activated with any infection)
Does presence of bacteria = infection
No
What are GOLD indications for antibiotics in COPD
Increase sputum purulence
AND
increased sputum volume OR dyspnea
Anyone with AECOPD who requires mechanical ventilation (Brett does not agree with this)
Which type of patients have clear evidence of benefit from ABX in AECOPD patients
in ICU patients
When would you do a sputum culture in AECOPD patients (3)
- Requiring mechanical ventilation
- Severe airflow obstruction (FEV <30%)
- Frequent exacerbations (i.e frequent abx use)
What are options to give for AECOPD if clinician insists on giving abx
- Amoxi-clav, ceftriaxone/cefotaxime
- FQ (levo, moxi)
- Outpatient
- Cefuroxime (2nd gen), doxy, macrolide, Septra
- Brett does not believe outpatient should get
When would you add pseudomonas in AECOPD patient (5)
- Previous pseudomonas culture
- Chronic bronchiectasis
- Chronic steroids
- FEV <30%
- broad spectrum in past 3 months or 3 uses in 1 year
What is bronchiectasis
Bronchiectasis is the result of lung insults or complications.
Inflammation -> destruction -> thicker airways -> more mucus -> more bacteria colonization -> if infected, more damage (and cycle continues)
When are CXR ordered in children CAP
If required hospitalization
No need if wheezing or typical presentation of bronchiolitis or asthma in outpatient
What common bacteria are with CAP in children (5)
Gram positives:
- s. pneumo
- staph.aureus
- GAS
Atypicals:
- c.pneumo
- m.pneumo
When would we be worried about M. pneumo in children with CAP
When to start empiric therapy (4)?
- common if 3 to 7 years
- Subacute onset with prominent cough
- Can resolve without therapy
Start empiric therapy if:
- admitted to ICU
- worsening symptoms at 72 hours after BL therapy
- persisent sx for >1-2 weeks + household member has m.pneumonia,
- high clinical suspicion (Subacute onset with prominent cough)
Which viruses in children should you give antivirals for?
Which should you not? (3)
if nasal swab positive for influenza virus
if RSV, human MPV, parainfluenza
- do not give
What is the first line for CAP in children for
Outpatient
Inpatient, ward
ICU
Outpatient
- Amoxicillin
Inpatient, ward
- Ampicillin IV
ICU
- Ceftriaxone/cefotaxime (3rd gen) + macrolide
- cover for m. pneumo
When would you see improvement in CAP in children?
What to do if no improvement? (2)
Improvement in: 48 hours
- decrease fever, O2 needs, normal RR
If no improvement
- CXR
- consider m. pneumo
What is the duration of therapy in children in CAP in:
outpatient
inpatient
outpatient: 5 days
inpatient: 7-10 days
- can give 5 if mild inpatient
