Pharmacotherapy of



Pharmacological Treatment Options for Community Acquired Pneumonia (CAP)

Elizabeth Nolte, PharmD Candidate 2007

| |Doxycycline |Macrolides |Fluoroquinolones |PCN & PCN Combo |

|Product Availability |Adoxa™; Doryx®; Doxy-100®; Monodox®; |Azithromycin (Zithromax®; Zmax) |Levofloxacin (Levaquin®) |Amoxicillin (Amoxil, Trimox) |

|Generic (Brand) |Oracea™; Periostat®; Vibra-Tabs®; |Clarithromycin (Biaxin® XL; Biaxin®) |Sparfloxacin (Zagam®) |Amoxicillin/Clavulanate (Augmentin) |

| |Vibramycin® |Erythromycin (A/T/S®; Akne-Mycin®; E.E.S.®; Ery-Tab®; |Trovafloxacin (Trovan®) | |

| |**injection available |Eryc®; Eryderm®; Erygel®; EryPed®; Erythrocin®; PCE®; |Moxifloxacin (Avelox®; Vigamox™) | |

| | |Romycin®; Staticin® [DSC]; T-Stat® [DSC]; Theramycin Z®) |Gatifloxacin (Tequin®; Zymar™) | |

| | |**eye drops, ointment, & gel available. |Ciprofloxacin (Cipro) | |

|Mechanism |Inhibits protein synthesis by binding |Inhibits RNA-dependent protein synthesis at the chain |Inhibits DNA-gyrase in susceptible organisms |Amoxicillin- Inhibits bacterial cell wall |

|of Action |with the 30S and possibly the 50S |elongation step; binds to the 50S ribosomal subunit |thereby inhibits relaxation of supercoiled DNA |synthesis by binding to one or more of the |

| |ribosomal subunit(s) of susceptible |resulting in blockage of transpeptidation |and promotes breakage of DNA strands. |penicillin-binding proteins (PBPs) |

| |bacteria; may also cause alterations | | | |

| |in the cytoplasmic membrane | | |Clavulanic acid- Binds and inhibits |

| | | | |beta-lactamases that inactivate amoxicillin |

|EFFICACY |IDSA 1st Line therapy recommendation |IDSA 1st Line therapy recommendation for all antibiotic |IDSA 1st Line therapy recommendation for |IDSA 2nd Line therapy when used in combination |

| |for “healthy,” antibiotic naïve |naïve patients, and as 2nd Line therapy in combination |“healthy,” all patients. |with Macrolides for patients with recent |

|(Indication/Use, |patients with no co-morbidities. |with Amoxicillin, Augmentin, or Cephalosporins in |*Per CDC- Avoid use as first line therapy due |antibiotic use. |

|Clinical Data Support) | |patients with recent antibiotic use. |to increased resistance. | |

| |Effective in eradicating CAP | | |Due to overuse, 50% of all S. pneumoniae is now|

| |etiologies that are still susceptible |Azithromycin- effective in eradicating S. pneumoniae and |Effective in eradicating S. pneumoniae and |resistant to PCN. Only use in combination with|

| | |H. influenzae. |other etiologies of CAP, including multidrug |other antibiotics in areas with possible |

| | | |resistant strains of S. pneumoniae (MDRSP) |resistance. |

| | |Clarithromycin- effective against H. influenzae, H. | | |

| | |parainfluenzae, Mycoplasma pneumoniae, S. pneumoniae, or |Sparfloxacin- effective against C. pneumoniae, | |

| | |Chlamydia pneumoniae (TWAR). **A drug of choice in |H. influenzae, H. parainfluenzae, M. | |

| | |elderly with CAP. |catarrhalis, M. pneumoniae or S. pneumoniae | |

| | | | | |

| | |Erythromycin- effective in eradicating some S. |Ciprofloxacin- recommended in combination with | |

| | |pneumoniae, some S. aureus, M. pneumoniae, Legionella |ICU patients | |

| | |pneumophila, Chlamydia, erythrasma, and N. gonorrhoeae. | | |

| | | | | |

| | |Clarithromycin and Erythromycin – preferred in H. | | |

| | |influenza patients | | |

|SAFETY |Preg Cat D! – Do not use in pregnant |Preg Cat B: Azithromycin & Erythromycin |Preg Cat C: All |Preg Cat B |

| |women. Substantial teratorgenic risk |Preg Cat C: Clarithromycin |Passed to breast milk- Avoid use |Usable in pregnancy/lactation, but caution (esp|

|(Major Drug |and tooth discoloration. | | |if premature rupture of fetal membranes) |

|Interactions, | |Peds: |Peds: NO | |

|Pre-cautions, |Peds: |Azithromycin & Clarithromycin = | |Peds: All ages |

|Contra-indications, |> 8 years old (can cause tooth |> 6 months old |Levofloxacin- | |

|Adverse Effects, |discoloration) |Erythromycin = > 1 month old (has benzyl alcohol, avoid |Increased risk of seizure when combined with |Serious caution with PCN hypersensitivity. |

|Pregnancy Risk Category)| |in neonates) |NSAID use | |

| |Avoid use: Hepatic dysfunction | | |Drug Interactions: |

| | |Azithromycin- may mask s/s gonorrhea/clamydia, avoid with|Trovafloxacin- |Allopurinol |

| |S/e: |increased risk of STD transmission. |For use in life-threatening infections only. |Aminoglycosides |

| |Photosensitivity | |Must be administered in an inpatient healthcare|Methotrexate |

| | |Clarithromycin- dose adjusting needed in patients with |facility with constant monitoring! |Oral Contraceptives!!! |

| |Drug Interactions: |renal impairment |Hepatotoxicity resulting in death. |Probenecid |

| |Major interaction with 3A4. | | |Warfarin |

| |Antacids |All: |Gatifloxacin- | |

| |Anti-epileptics |Pseudomembranous colitis |Serious contraindication in patients with | |

| |Oral Contraceptives!!! |Caution with renal dysfunction |diabetes mellitus recently discovered. Causes |**Note- if diabetic may get false positive with|

| |Iron-containing products |QTc prolongation, Ventricular arrhythmia, and other |glucose dysregulation. Although current stocks|Clinistix® urine glucose monitor. |

| | |cardiac complications |are not being recalled, Bristol-Myers Squibb | |

| | |Avoid with hepatic disease |Co. with be ending shipment of Tequin on June |**Note- Two 250mg Augmentin tablets DO NOT |

| |**Note- if diabetic may get false | |2, 2006. |equal one 500mg Augmentin tablet. The |

| |positive with Clinistix® urine glucose|Drug Interactions: | |Amoxicillin values are the same, but the |

| |monitor. |Azithromycin- |All: |Clavulanic will double when giving two tablets.|

| | |Cardiac Glycosides |QTc prolongation (esp with Moxifloxacin) | |

| | |Cholchicine |Photosensitivity | |

| | |Nelfinavir |Pseudomembranous colitis | |

| | |Warfarin |Tendon inflammation (elderly) | |

| | | |Peripheral neuropathies | |

| | |Clindamycin- | | |

| | |MANY Drug Interactions- too many to list. Major |Drug Interactions: | |

| | |interaction with 3A4. |Corticosteroids | |

| | | |Glyburide | |

| | |Erythromycin- |QTc-prolonging agents | |

| | |MANY Drug Interactions- too many to list. Major |Probenicid | |

| | |interaction with 3A4. |Warfarin | |

| | |Interaction with EtOH. *per Lexi-Comp: Other macrolides |Metal cations | |

| | |and FQ are better tolerated. Use only if needed. | | |

| | | | | |

| |Doxycycline |Macrolides |Fluoroquinolones |PCN & PCN Combo |

|Dosage & Administration |Children ≥8 years ( 6 months old: |500 mg every 24 hours for 7-14 days or 750 mg |divided every 8 hours |

|hepatic adjustments) |mg/day |10 mg/kg on day 1 (maximum: 500 mg/day) followed by 5 |every 24 hours for 5 days |-Children5-15 years: |

| | |mg/kg/day once daily on days 2-5 (maximum: 250 mg/day) |With renal impairment: |100 mg/kg/day divided every 8 hours with |

| |Adults: |-Adolescents > 16 years old: |Clcr 20-49 mL/minute: 250 mg every 24 hours |clarithromycin, azithromycin, or doxycycline |

| |100 mg twice daily |Zmax 2gm po once |Clcr 10-19 mL/minute: 250 mg every 48 hours |-Adults: |

| | |-Adults: |Hemodialysis/CAPD: 250 mg every 48 hours |875 mg every 12 hours or 500 mg every 8 hours, |

| | |500mg po once daily for 2 days | |in combination |

| | | |Sparfloxacin- |-Adults [high dose]: |

| | |Clarithromycin- |Loading dose: 400 mg on day 1 |1000 mg every 8 hours |

| | |XR form should be taken with food. |Maintenance: 200 mg/day for 10 days total | |

| | |Dose must be cut in half if CrCl is 6 months old: |With renal impairment: |-Infants < 3 months: |

| | |7.5 mg/kg q12hours for 10 days |Clcr 16 years old and Adults: |

| | |g/day | |Extended release tablet: Two 1000 mg tablets |

| | |-Adults: | |every 12 hours for 7-10 days |

| | |500-1000 mg 4 times/day for 10-14 days | | |

| | |If Legionella is suspected, 750-1000 mg 4 times/day for | |Both- with renal impairment: |

| | |21 days or more may be recommended | |The 875 mg tablets should not be used in |

| | | | |patients with Clcr ................
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