Nhatsakorzian.weebly.com



Nayri Hatsakorzian Pharm.D/MPH candidate 2014Touro University- CAWho should be admitted to ICU? Direct admission to ICU is required for patients with: 1- 2 major criteriaSeptic shock requiring vasopressorsAcute respiratory failure requiring intubation and mechanical ventilation2- at least 3 of the minor criteriaPaO2/FiO2 ratio 250 (arterial oxygen pressure/fraction of inspired oxygen)Multilobar infiltrates Leukopenia (WBC <4000)Thrombocytopenia (PLT <100,000)Hypothermia (core temp <36C)Hyponatremia Hypoglycemia (in non-diabetic patients) Acute alcoholism/alcoholic withdrawalUnexplained metabolic acidosisElevated lactate levelsCirrhosis Asplenia CURB-65 Confusion/disorientation Uremia (BUN ≥ 20)RR ≥ 30 Blood PressureHypotension requiring aggressive fluid resuscitation Etiologies of CAP:Outpatient: Streptococcus pneumoniaeMycoplasma pneumoniaeHaemophilus influenzaeChlamydophila pneumoniae Respiratory virusesInpatient (non-ICU)Streptococcus pneumoniaeMycoplasma pneumoniaeHaemophilus influenzaeChlamydophila pneumoniae Legionella speciesAspirationRespiratory virusesInpatient (ICU)Streptococcus pneumoniaeStaphylococcus aureusLegionella speciesGram negative bacilliHaemophilus influenzaeDiagnostic testingObtain blood culture, sputum culture, legionella UAT, Pneumococcal UATICUPleural effusion Active alcohol abuse patients Obtain blood and sputum cultureCavity infiltratesObtain blood cultures and Pneumococcal UAT Leukopenia Chronic severe liver diseases Asplenia CA-PNA Empiric treatment OUTPATIENT Previously healthy with no ABX tx for the past 3 monthPO: 1st line: Macrolides Azithromycin (Zithromax) 500 mg PO day1 then 250mg day 2-5- Adjust azithromycin when CrCl <10 Clarithromycin (Biaxin) 250mg PO every 12 hours for 7-10 days- Decrease clarithromycin by 50% when CrCl < 30 Alternative to macrolides is Doxycycline - (Vibramycin, Doryx) 100 mg PO twice daily - No renal adjustment is needed- Macrolides active against most common pathogens including atypicals- Erythromycin is not used d/t major GI side effects and losing efficacy against H. influenzae PathophysiologyPNA is an acute infection that inflames the pulmonary parenchyma. PNA is associated with a constellation of features such as cough, sputum production, fever, chills, difficulty breathing, and acute infiltrates that is demonstrable on chest x-ray. Some terminology from CXR impressions. Pulmonary edema: build up of fluid in the alveoli leading to SOB. Pulmonary edema is mainly caused by CHF. When blood is not pumped efficiently from heart, the returning blood can back up into the veins and lungs. The pressure and the fluid build up the normal oxygen/carbon dioxide exchange leading to SOB and the feeling of drowning. Pneumothorax: is a collapsed lung due to collection of air in the space around the lungs. The air build up exerts pressure on the lungs causing it not to expand as much during breathingPericardial effusion: pericardium is a double layered, sac like structure that surrounds the heart and maintains its normal function. This double layered sac usually has fluid within, but when the fluid exceeds the limits due to blood build up, inflammation or infection, it exerts pressure on the heart causing SOB, heart failure and, if left untreated, death. Duration- 5 days - Afebrile for 48-72h and - No more than 1 CAP signs of clinical instability - Longer duration of therapy may be needed if initial therapy was not active against the identified pathogen or was complicated with extrapulmonary infections such as meningitis or endocarditis. Switching from IV to PO and dischargeHemodynamically stable and clinically improvingAble to ingest medicationsNormally functioning GIDischarge patients as soon as:They are clinically stable with no other active medical problemsTemperature 37.8CHR 100 beats/minRR 24 breath/minSBP ≥ 90Arterial O2 saturation ≥ 90% or pO2 ≥60 on room airAble to maintain oral intakeNormal mental statusHave safe environment for continuous carePrevention: Influenza vaccinePPSVSmoking cessation Cases of public health concern should be reported to state or local health departmentHygiene and patient educationFollow up evaluationOUTPATIENT Presence of comorbidities (COPD, CHD, liver, renal diseases, DM, alcoholism, malignancies, asplenia, immunosuppressing conditions or use of immunosuppressing drugs). Or ABX tx the past 3 months (use different ABX: If patient received FQ then use macrolide and V.V) Respiratory FQLevofloxacin (Levaquin) 750mg PO daily for 5 daysAdjust frequency when CrCl < 50 Moxifloxacin (Avelox) 400 mg PO daily for 7-10 daysNo renal or hepatic dose adjustment is necessary Gemifloaxacin PO 320mg daily for 7 days Or: B-lactam + macrolidesAmoxicillin 1g three times daily Adjust dose renally when CrCl < 30 Augmentin (Amoxicillin-Clavulanate) 2g twice daily for 7-10 daysAdjust dose renally when CrCl < 30Hepatic adjustment is necessary Ceftriaxone (Rocephin) 1g daily for 7-10 daysNo adjustments necessary Cefpodoxime (Vantin) 200mg PO twice daily for 14 days Decrease frequency to every 24 hours when CrCl < 30 Cefuroxime (Ceftin) 750 mg every 8 hours Decrease frequency to every 24 hours when CrCl < 10NON-ICU PATIENTS:Respiratory FQLevaquin 750 mg IV daily Moxifloxacin IV Gemifloaxacin (Available PO only)Or: B-lactams + macrolidesCeftriaxone 1-2g IV (IM) dailyCefotaxime (Claforan) 1-2g IV (IM) every 8 or 12 hours depending on severity of infectionDecrease dose by 50% when CrCl < 20 Ertapenem (Invanz) 1g IV (IM) daily for 10-14 daysDecrease Ertapenem by 50% when CrCl < 30Ertapenem has activity against S. pneumoniae and similar coverage to CTX and cefotaxime, but is inactive against atypicals and Pseudomonas aeruginosa.ICU PATIENTS: B-lactams + macrolides or FQCefotaximeCeftriaxoneAmpicillin/sulbactam (Unasyn) 1500-3000 mg every 6 hoursDecrease frequency to every 12 hours when CrCl <30 PLUS azithromycin or respiratory FQIf PCN allergy then FQ + aztreonam recommendedAztreonam (Azactam) 1-2 g IV (IM) every 6,8 or 12 hours depending on the severity of infectionDecrease dose by 50% when CrCl < 30 but keep same interval If pseudomonas DOUBLE coverage Antipneumococcal, antipseudomonal b-lactams: Zosyn (piperacillin/tazobactam) 3.375g - 4.5 g IV every 6 hours for 7-14 days Cefepime (Maxipime) 1-2g IV every 12 hours for 10 daysDecrease frequency to every 24 hours when CrCl <60 rather than change doseAntipseudomonal carbapenems: Imipenem (Primaxin) 500mg IV every 6 hours or 1 g every 8 hours See Lexicomp for dosing adjustment based on weight and CrClMeropenem (Merrem) > 50kg 1g IV every 8 hours (< 50kg: 20-40 mg/kg q8hrs) CrCl <26 decrease frequency to every 12 hoursCrCl < 10 decrease dose by 50% every 12 hoursPLUS Ciprofloxacin (Cipro) 400mg every 8 hoursAdjust Cipro when CrCl < 30Levofloxacin 750mg In Case of AllergiesIf FQ allergy then b-lactams + aminoglycoside and azithromycin If b-lactam allergy then aztreonam should be substituted Aztreonam + FQ + aminoglycosideIf CA- MRSA then add vanco or LinezolidReference: Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases 2007; 44: S27-72Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia Definitions:HAP: Defined as pneumonia that occurs 48 hours or more after admission, which was not incubating at the time of admission. If patients require intubation in case of severe HAP, then they should be manage similar to patients with VAP.VAP: pneumonia that arises more than 48-72 hours after endotracheal intubation. HCAP: Cover MDR pathogensAny patient who was hospitalized in an acute care hospital for two or more days within 90 days of the infectionResides in a nursing home or long term care facilityReceived recent IV ABX tx, chemotherapy, or wound care within the past 30 days of the current infectionAttended a hospital or hemodialysis clinic Family member with MDR pathogensImmunocompramised patients Consider MDR pathogens when:Antimicrobial therapy in the preceding 90 daysCurrent hospitalization of 5 days or moreHigh frequency of antibiotic resistance in the community or in the specific hospital unitPresence of risk factors for HCAP 44577001143000 Empiric Antibiotic Therapy for HAP 11430036830HAP, VAP or HCAP Suspected0HAP, VAP or HCAP Suspected114300368300 -160020066675011430027305Late onset (>5days) or risk factors for MDR pathogens 0Late onset (>5days) or risk factors for MDR pathogens -153606595885-233616595885160020036830No- See table 10No- See table 1036830Yes-See table 20Yes-See table 2Table 1: Initial empiric therapy for HAP/VAP/HCAP in patients with no known risk factors for MDR pathogens, early onset, and any disease severity Potential PathogensTreatments (one of the following options only)Streptococcus pneumoniaeHaemophilus influenzaeMethicillin-sensitive Staphylococcus aureusAntibiotic-sensitive enteric gram negative bacilli Escherichia coli Klebsiella pneumoniae Enterobacter species Proteus species Serratia marcescensCeftriaxoneLevofloxacinMoxifloxacinCiprofloxacinUnasyn ErtapenemTable 2: Initial empiric therapy for HAP/VAP/HCAP in patients with late onset disease or risk factors for MDR pathogens and all disease severityPotential PathogensTreatments Streptococcus pneumoniaeHaemophilus influenzaeMethicillin-sensitive Staphylococcus aureusAntibiotic-sensitive enteric gram negative bacilli Escherichia coli Klebsiella pneumoniae Enterobacter species Proteus species Serratia marcescensMDR pathogens include:Pseudomonas aeruginosaKlebsiella pneumoniae (ESBL)Acinetobacter species Legionella pneumohila Antipseudomonal cephalosporin (OR)Cefepime 1-2g q8-12hCeftazidime 2g q8hAntipseudomonal carbapenem (OR)Imipenem 500mg q6h or 1g q8hMeropenem 1g q8hB-lactam/B-lactamase inhibitor Zosyn 4.5g q 6hPLUS Antipseudomonal FQ (OR)Ciprofloxacin 400mg q8hLevofloxacin 750mg dailyAminoglycosideAmikacin 20mg/kg daily (Tr goal < 4-5 mcg/ml)Gentamycin 7mg/kg daily (Tr goal < 1 mcg/ml)Tobramycin 7mg/kg daily (Tr goal <1 mcg/ml)Methicillin Resistant Staphylococcus aureus ADD Linezolid 600mg q12h or Vancomycin 15mg/kg q12h (Tr goal should be 15-20 mcg/ml)Common & Possible Side Effects for Common Antibiotics PenicillinUnasyn, amoxicillinRash, urticaria, diarrhea, ALT/AST elevation, pseudomembraneous colitis, bronchospasm, and hypotension. CephalosporinsCeftriaxoneRash, diarrhea, BUN elevation (~1%), alk phos elevation, hemolytic anemia, aplastic anemia, allergic dermatitis, edema, angioedema, and creatinine elevations. CefepimeFever, HA, rash, pruritis, N/V/D, elevation of alk phos, BUN, creatinine, and bilirubin. Hyperkalemia, hyperphosphotemia, and hypercalcemiaFluoroquinoloneLevaquinHA, insomnia, dizziness, rash, pruritis, abdominal pain, dyspepsia, diarrhea-can be C.diff associated, constipation, arrhythmias, QT prolongation, TdP, and psychosis. AveloxAbove mentioned plus AST/ALT, alk phos, BUN, and creatinine elevation, hypokalemia, hyperglycemia, hyperlipidemia, triglycerides and uric acid increaseCiproPT/INR prolongation- All FQ have category C interactions with WarfarinMacrolidesAzithromycinQTc prolongation- have category C interaction with WarfarinCombination with Amiodarone should be avoided ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download