TOC | Pulm

REF:  CAP_Pneumonia 2007.pdf  

PNEUMONIA -Community acquired                                                                                                              

• Pneumococcus/Streptococcal pneumonia Rx
  Penicillin 1-2 mil U q4h or Cefazolin 1 g q8h IV
• Hemophilus influenzae Rx
  Cefuroxime 750 mg q8h IV
• Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella Rx
  Erythromycin 0.5-1 g q6h  IV or 500 mg qid PO 
  Azithromycin 500 mg PO, then 250 mg/d x 4 d
  Clarithromycin 500 mg bid PO
  Rifampin added if Legionella noted.
• REF: NEJM 1995;333:1618 Barlett JG, Mundy LM
  JCOM July 2002 Community-acquired Pneumonia  
• Management of Community-Acquired Pneumonia - Ethan A. Halm etc.
  NEJM Dec. 19, 2002;347:2039-2045
• 2003 Community Acquired Pneumonia Management   See Table  
• Clinical Infectious Diseases October 2003;37:1405-1433   ~  the Infectious Diseases Society of America.  IDSA GUIDELINES
  Update of Practice Guidelines for the Management of Community-Acquired Pneumonia in Immunocompetent Adults

Haemophilus influenzae Pneumonia

Antibiotic Rx:                                      REF: DynaMed March 2010

Medications: ampicillin (but 30% beta-lactamase) so consider Augmentin

IV treatment:

• ampicillin 1-1.5 g every 4 hours in known ampicillin-susceptible cases
• cefuroxime in suspected or known ampicillin-resistant
• alternatives - Bactrim or chloramphenicol

oral treatment :

• ampicillin 500 mg every 6 hours in ampicillin-susceptible cases
• Bactrim-DS 1 tab twice daily for 7-10 days
• Cefaclor 250 mg 3 times daily for 10 days
• Cefuroxime 250 mg twice daily for 10 days
• Clarithromycin (Biaxin) FDA approved (Monthly Prescribing Reference 2000 Dec;A-16)
• amoxicillin/clavulanate extended-release (Augmentin XR) 1,000 mg/62.5 mg as 2 tablets orally every 12 hours
  (PDR Monthly Prescribing Guide 2002 Dec:1(12):14)

Diagnosis and Treatment of Community-acquired Pneumonia

Patients with pneumonia usually present with cough (more than 90 percent), dyspnea (66 percent), sputum production (66 percent), and pleuritic chest pain (50 percent), although nonrespiratory symptoms can also predominate.  Elderly patients may report fewer symptoms.  Unfortunately, information obtained from the history or physical examination cannot rule in or rule out the diagnosis of pneumonia with adequate accuracy.   All rigorous definitions of pneumonia require the finding of a pulmonary infiltrate on a chest radiograph.

The initial antibiotic regimen should be chosen empirically to cover common typical and atypical pathogens (Table 1). Pneumonia due to atypical organisms (Mycoplasma pneumoniae, legionella species, and Chlamydia pneumoniae) accounts for 20 to 40 percent of cases and cannot be differentiated from cases due to typical bacteria on the basis of the patient's history, the results of the physical examination, or findings on chest radiographs.   Two large observational cohort studies found that antibiotic regimens that cover both typical and atypical organisms are associated with a lower risk of death than regimens that cover just typical bacteria.     Although rigorous data regarding the duration of therapy are limited, most experts recommend a total of 10 to 14 days. Intravenous therapy with antibiotics that have a high level of oral bioavailability (e.g., fluoroquinolones) may be no better than oral therapy with such antibiotics in patients with uncomplicated infections who have a functioning gastrointestinal tract.

Differential Diagnosis of Community Acquired Pneumonia: Especially in the elderly patient, the signs and symptoms of pneumonia may be mimicked by many disorders, including

• pulmonary embolism (PE),
• CHF,
• lung cancer,
• hypersensitivity pneumonitis,
• tuberculosis,
• chronic obstructive pulmonary disease (COPD),
• granulomatosis disease, and
• fungal infections.
• A variety of drugs also can induce pulmonary disease. Cytotoxic agents; non-steroidal anti-inflammatory drugs (NSAIDs); and some antibiotics, including sulfonamides and certain antiarrhythmics (e.g., amiodarone or tocainide), can mimic pulmonary infection. In addition, common analgesics, including salicylates, propoxyphene, and methadone, also may precipitate acute respiratory symptoms.
• Such collagen vascular diseases as systemic lupus erythematosus, polymyositis, and polyarteritis nodosa may cause fever, cough, dyspnea, and pulmonary infiltrates, thereby mimicking symptoms of pneumonia. Rheumatoid arthritis can cause an interstitial lung disease, although it usually does not cause fever or alveolar infiltrates.

REF: 2003 ASCAP (Antibiotic Selection for Community-Acquired Pneumonia) Panel* Consensus Report®

The Pneumonia Severity Index is used to determine a patient's risk of death. The total score is obtained by adding to the patient's age (in years for men or in years – 10 for women) the points assigned for each additional applicable characteristic.

The Pneumonia Severity Index is based on data that are commonly available at presentation and stratifies patients into five risk classes in which 30-day mortality rates range from 0.1 percent to 27.0 percent. The higher the score, the higher the risk of death, admission to the intensive care unit, and readmission and the longer the length of stay. Easy-to-use versions of the index are now available on the Internet (http://ursa.kcom.edu/CAPcalc/default.htm, http://ncemi.org, and http://www.emedhome.com/dbase.cfm )30,31,32 and handheld computers.

Pneumonia - Hospital acquired

• Gentamicin + Piperacillin
• Gentamicin + Ceftazidime, or
• Imipenem
• Ciprofloxacin
• Aztreonam 1 gm q8h (Max 2 g q6h)

05162003