Respiratory Antibiotics Flashcards
What antibiotics are cidal?
Cell wall inhibitiors
Aminoglycocides
Quinolones
What antibiotics are static?
Protein synthesis inhibitors
What are the categories of the beta-lactams?
Penicillins
Cephalosporins
Carbapenems
Monobactams
What do you use to treat atypical pneumonia (legionella)?
Azithromycin
What do you use to treat anaerobes?
Treat with Metronidazole/Clindamycin
Only second generations cephalosporins (so not ceftriaxone)
What do you do use if the patient is penicillin-allergic?
Aztreonam – Monobactam are safe
What are the big bugs for Community Acquired Pneumonia (CAP)?
Outpatient: S. pneumoniae, Mycoplasma pneumoniae, Haemophilus influenzae, Clamydophilia pneumoniae,, Respiratory viruses
Inpatient also are susceptible to Legionella (non-ICU) or S. aureus and gram-neg (ICU)
What do we use for healthy outpatient CAP?
How about if they have co-morbidities?
Previously healthy: Macrolide (not azithromycin ideally), Doxycycline
Co-morbidities: Alpha-pneumococcal fluoroquinolone (FQ), beta-lactam plus macrolide
What drugs for inpatient pneumonia(non-ICU)?
If they are PCN allergic?
No PCN allergy: Beta-lactam plus macrolide
PCN Allergy: FQ
What drugs for inpatient ICU pneumonia?
With allergy?
No PCN allergy: Beta-lactam plus macrolide or FQ
PCN allergy: FQ plus aztreonam
What do we use if we are afraid of pseudomonas pneumonia?
MRSA pneumonia?
Aspirated?
Pseudomonas concern: Piperacillin-tazobactam, cefepime, meropenem (alpha-pneumococcal, alpha-pseudomonal beta-lactam) plus an FQ
MRSA: Vancomycin or linezolid
Aspiration suspected: Add clindamycin to cover oral anaerobes
What is the indication for MSSA?
All beta lactams except PCN, Ampicillin
Nafcillin and Cefazolin are drugs of choice
What antibiotics are used for pneumococcus? (Beta lactams)
Ceftiraxone (adults)
Cefotaxime (children)
Which beta-lactams for pseudomonas?
Piperacilin/Tazobactam, Ceftazadime, Cefepime, Meropenem/Impipenem, Aztreonam
What do macrolides treat?
Respiratory gram positive and gram negative bacteria; intracellular atypical pathogens (mycoplasma, chlamydia, legionella)
What is moxifloxacin indicated for?
Levo?
Cipro?
How about other general FQ indications?
Anti-pnuemococcal
Anti-pneumococcal, anti-pseudomonal
Anti-pseudomonal
Intracellular atypical pathogens (mycoplasma, chlamydia, legionella), secondary mycobacterial species
What are the teracyclines indicated for?
How do their efficacies stack up?
Wide range of gram-positive and gram-negative bacteria in RT
Atypicals such as chlamydia, mycoplasma, legionella
Tet least eff., Dox and Mino most eff.
What is vancomycin indicated for?
Resistant Gram Positives
Not VRE
IV formulation for resistants
What is linezolid indicated for?
What is a risk with use?
Resistant Gram Positives
Bone marrow suppression and neuropathy with prolonged use
What is daptomycin indicated for?
Resistant Gram Positives
Not for use in pneumonia – bound by surfactant
What is the treatment protocol for CAP?
Treat for a minimum of five days
Before stopping therapy patient should be afebrile for 48 to 72 hours, breathing without supplemental oxygen and have no more than one clinical instability factor (HR > 100, RR > 24, SBP < 90)
Longer duration if culture positive for coagulase positive Staphyloccus or Pseudomnoas
What are the risk factors for multidrug resistant organisms?
Current hospitalization of > 5 days
Hospitalization in an acute care hospital for > 2 days within the past 90 days
Residents of a nursing home or long-term care facility
Recipients of recent IV antibiotics, chemotherapy or wound care within the past 30 days
Chronic dialysis within 30 days
Family member with multidrug-resistant pathogen
What is the empiric antibiotic thearpy for HCAP?
No risk factors for MDROs: Ceftriaxones OR Amp/Sulbactam OR Ertapenem OR Fluoroquinolone
Yes risk factors for MDROs: Anti-psuedomonal beta-lactam PLUS (FQ or Aminoglycoside) PLUS (Vancomycin or Linezolid if MRSA suspected)
What immunocompromised pneumonias are associated with:
Early HIV
Late HIV
Transplantation
HIV Infection Early: S. pneumonia
HIV Infection (late): Pneumocystis jiroveci
Non-TB mycobacteria
Histoplasma
Transplantation: CMV
RSV
Aspergillus
Mucormycosis
Pneumonia due to:
Bird exposure?
Rabbit exposure?
Farm exposure?
SW US exposure?
Structural lung disease?
Bird exposure: Chlamydophila psittaci (parrots) Avian influenza (poultry)
Rabbit exposure: Francisella tularensis
Exposure to farm or parturient animals: Coxiella burnetti (Q fever)
Travel to SW United States: Coccicioides
Hantavirus
Structural Lung Disease: Pseudomonas
S. aureus
Non-TB mycobacteria
Aspergillus
What is CURB-65?
What does it stand for?
Criteria for teratment and admission
Confusion – 1
Blood Urea Nitrogen > 19 mg per dL – 1
RR > 30 – 1
Systolic blood pressure < 90 mm Hg or Diastolic blood pressure < 60 mm Hg – 1
Age > 65 – 1
What do CURB-65 scores indicate doing?
0 – Low risk, consider home Rx
1 –Low risk, consider home Rx
2 – Short inpt Rx or closely observed OP Rx
3 – Severe pneumonia, admit/consider ICU
4 or 5 – Severe pneumonia, admit/consider ICU
What are risk factors for PCN Resistant S. pneumonia?
Age > 65 years
Beta-lactam
Alcoholism
Multiple medical comorbidities (e.g. immunosuppressive illness or medications)
Exposure to a child in a day care center
What are the stages of PCN resistance for S. pneumonia and what drugs are used to treat them?
Penicillin susceptible (MIC < 0.1 mcg/ml): Penicillin G, amoxicillin
Penicillin resistant (0.1 < MIC < 1.0 mcg/ml): High dose pencillin G or ampicillin, cefotaxime/ceftriaxone
Penicillin resistant (MIC \> 2.0 mcg/ml):Vancomycin w/w/o rifampin High dose cefotaxime tried in meningitis Non-meningeal infection: cefotaxime/ceftriaxone, high dose ampicillin, carbapenems, or fluoroquinolone (levofloxacin, moxifloxacin)
Multidrug resistant (MDRSP, resistant to any 2 of the following: penicillins, erythromycin, tetracycline, macrolides, cotrimoxazole)
Vancomycin w/w/o rifampin
Clindamycin, levofloxacin, moxifloxacin could be tried
Linezolid
