Pharmacotherapy of



Pharmacological Treatment Options for Community Acquired Pneumonia (CAP) #2

Elizabeth Nolte, PharmD Candidate 2007

| |2nd/3rd Generation Cephalosporins |Combinations |Severe Antibiotic Resistance |Other |

|Product Availability |Cefpodoxime (Vantin®) |TMP/SMX (Bactrim) |Imipenem |Clindamycin (Cleocin HCl®; Cleocin |

|Generic (Brand) |Cefprozil (Cefzil®) |Trimethoprim / Sulfamethoxazole |Vancomycin |Pediatric®; Cleocin Phosphate®; |

| |Cefuroxime (Ceftin®; Zinacef®) | |Oxazolidinone |Cleocin T®; Cleocin®; Clindagel®; |

| |Cefotaxime- inj/infuse only | |Aminoglycosides |ClindaMax™; Clindesse™; Clindets®; |

| |Ceftriaxone- inj/infuse only | | |Evoclin™) |

|Mechanism |Inhibits bacterial cell wall synthesis by binding to one or more of|SMX interferes with bacterial folic acid |Various |Reversibly binds to 50S ribosomal |

|of Action |the penicillin-binding proteins (PBPs) |synthesis and growth via inhibition of | |subunits preventing peptide bond |

| | |dihydrofolic acid formation; TMP inhibits | |formation thus inhibiting bacterial|

| | |dihydrofolic acid reduction resulting in | |protein synthesis |

| | |inhibition of enzymes of the folic acid | | |

| | |pathway | | |

|EFFICACY |IDSA 2nd Line therapy in patient with underlying co-morbidities and|Effective for acute exacerbations of chronic |Useful in resistant strains of CAP. |Effective in eradicating aerobic |

| |recent antibiotic use. |bronchitis in adults due to susceptible | |and anaerobic streptococci (except |

|(Indication/Use, | |strains of H. influenzae or S. pneumoniae |These are more commonly used in |enterococci) and most |

|Clinical Data Support) |Due to overuse, 50% of all S. pneumoniae is now resistant to PCN. | |Institutional Acquired Pneumonia. In |staphylococci. |

| |Cephalosporins are structurally similar to PCN and often share this| |these cases, bacterial etiology can be | |

| |resistance. Use only 2nd and 3rd generation cephalosporins and use| |resistant to the more commonly used |Recommended in patients at risk for|

| |only in combination in areas where PCN-resistance exists. | |antibiotics. Patients usually contract |aspiration. |

| | | |the infection in a hospital (ICU | |

| |Cefpodoxime, Cefprozil, Cefuroxime are the recommended agents for | |particularly) or nursing home. |Ideal for patients with beta-lactam|

| |more common CAP infections, since they can be administered orally. | | |allergy, where Pseudomonas is not |

| | | |Use only recommended for most severe cases|an etiology. |

| |The other two cephalosporins are used in more severe, in-patient | |of resistant pneumonia. Use in less | |

| |settings since they require IV administration | |severe CAP patients increases the risk of | |

| | | |developing resistance. | |

| | | | | |

|SAFETY |**Use caution in patients with PCN allergy!! |**Use caution in patients with sulfa allergy | |Black Box Warning: Severe/fatal |

| | | | |pseudomembranous colitis |

|(Major Drug |Preg Cat B |Preg Cat C/D!! | |Higher risk of hypersensitivity and|

|Interactions, |Usable in pregnancy/lactation, but caution | | |secondary fungal infections |

|Pre-cautions, | |Contains benzyl alcohol- avoid use in infants| | |

|Contra-indications, |Peds: All ages- common treatment of infections in infants | | |Use cautiously |

|Adverse Effects, | |Caution: | | |

|Pregnancy Risk Category)|All: |G6PD deficiency, impaired renal or hepatic | | |

| |Colitis or colitis secondary to C. difficile. |function, potential folate deficiency, or | | |

| |Increased INR |thyroid dysfunction | | |

| | | | | |

| |Drug Interactions: |Much larger range of Adverse Reactions than | | |

| |Probenecid |other antibiotic options- most are rare. | | |

| |Aminoglycosides & Furosemide- increase risk of nephrotoxicity | | | |

| |Antacids/H2-antagonists (cefpodoxime) |S/e: | | |

| | |Photosensitivity | | |

| |**Note- if diabetic may get false positive with Clinistix® urine | | | |

| |glucose monitor. |Drug Interactions: | | |

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

|Dosage & Administration |If intravenous therapy is needed, switch to oral dosage form 2 days|Children >2 months: |See Lexi-Comp for more information |Infants and Children: |

| |after initiation of therapy. |Mild-to-moderate infections- | |Oral: 8-20 mg/kg/day as |

|(Include renal and/or | |Oral: 8-12 mg TMP/kg/day in divided doses | |hydrochloride; 8-25 mg/kg/day as |

|hepatic adjustments) |Cefprozil- |every 12 hours | |palmitate in 3-4 divided doses |

| |-Infants and Children >6 months to 12 years: |Serious infection- | |(minimum dose of palmitate: 37.5 mg|

| |7.5-15 mg/kg/day divided every 12 hours |Oral: 20 mg TMP/kg/day in divided doses every| |3 times/day) |

| |-Children >12 years and Adults: |6 hours | |I.M., I.V.: |

| |250-500 mg every 12 hours or 500 mg every 24 hours |I.V.: 8-12 mg TMP/kg/day in divided doses | |1 month: 20-40 mg/kg/day in 3-4 |

| |500 mg every 12 hours for 10 days | | |divided doses |

| | |Adults: | | |

| |Cefpodoxime- |One double-strength tablet every 12 hours for| |Adults: |

| |-Children 2 months to 12 years: |10-14 days | |Oral: 150-450 mg/dose every 6-8 |

| |10 mg/kg/day divided every 12 hours (maximum dose: 800 mg/day) | | |hours; maximum dose: 1.8 g/day |

| |-Children ≥12 years and Adults: |With renal impairment- | |I.M., I.V.: 1.2-1.8 g/day in 2-4 |

| |200 mg every 12 hours for 14 days and 10 days |Clcr 15-30 mL/minute: Administer 50% of | |divided doses; maximum dose: 4.8 |

| | |recommended dose | |g/day |

| | |Clcr ................
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