CAP Therapy Babak Sayad Associate Professor of Infectious
CAP Therapy Babak Sayad Associate Professor of Infectious Diseases Department of Infectious Diseases Kermanshah University of Medical Science (KUMS)
Introduction n n In 1901, Sir William Osler' noted in the fourth edition of his book, The Principles and Practice of Medicine, that "the most widespread and fatal of all acute diseases, pneumonia, is now Captain of the Men of Death“ Over a century later, the prominence of pneumonia a same clinical entity remains
Introduction n n It remains among the top 10 most common causes of death among all age groups in the United States It is the single most common cause of infection-related mortality
Management n n The first decision confronting the clinician is whether the patient presenting with respiratory symptoms in fact has pneumonia. The next decision is whether the patient is to be hospitalized or out patient treatment The next problem is determining the most likely cause of pneumonia. The final step in the management of CAP is Empirical Antibiotic Therapy
Management n The patient in fact has pneumonia: n Clinical evaluation History n Physical Examination n
Management n The patient is to be hospitalized or out patient treatment: n PORT score (Patient Outcome Research. Team) or Pneumonia Severity Index (PSI) n CURB, CURB-65, CRB-65 n n n C: Confusion U: Urea> 7 mmol/L R: RR>30/min B: BPs<90 mm Hg or BPd<60 mm Hg 65: Age>65 Y
Management n The most likely cause of pneumonia: n Diagnostic Testing Radiologic Examination n Sputum Examination n Blood Culture n Examination of Pleural Effusions n Serologic Studies n Urine Studies, Including Antigen Detection n Fiberoptic Bronchoscopy n Lung Biopsy n
Management n Empirical Antibiotic Therapy For most patients, a specific diagnosis cannot be established with certainty before the onset of therapy n Recent controversies and questions have included when antibiotics should be started, how to determine the most appropriate antibiotics to use, and how long therapy should continue n
Management n Empirical Antibiotic Therapy n When antibiotics should be started? n In 2007, the Joint Commission suggested that antibiotics be started within 6 hours, even though no other data had been presented. The joint IDSA & ATS guidelines have suggested a more common sense approach that antibiotic treatment for pneumonia be started “as soon as possible” after the diagnosis is considered likely
Management n Empirical Antibiotic Therapy n How to determine the most appropriate antibiotics to use? n Outpatient Therapy n n n Previously Healthy Comorbidities Inpatient Therapy n n n Medical Ward Intensive Care Unit (ICU) Health Care–Associated Pneumonia
Management n Comorbidities COPD n Diabetes n Renal Failure n Congestive Heart Failure n Malignancy n
Management n Empirical Antibiotic Therapy n Outpatient Therapy n Previously Healthy n n No recent antibiotic therapy Recent antibiotic therapy
Management n Recent antibiotic therapy n n n That is, the patient was given a course of antibiotic(s) for treatment of any infection within the past 3 months, excluding the current episode of infection Such treatment is a risk factor for drug-resistant Streptococcus pneumoniae and possibly for infection with gram-negative bacilli Depending on the class of antibiotics recently given, one or another of the suggested options may be selected
Management n Empirical Antibiotic Therapy n Outpatient Therapy n Previously Healthy n No recent antibiotic therapy n n Macrolide or doxycycline Recent antibiotic therapy n A respiratory fluoroquinolone alone, an advanced macrolide plus oral β-lactam
Management n Empirical Antibiotic Therapy n Outpatient Therapy n Comorbidities n n No recent antibiotic therapy n An advanced macrolide plus oral β-lactam or a respiratory fluoroquinolone Recent antibiotic therapy n A respiratory fluoroquinolone alone or an advanced macrolide plus a β -lactam Suspected aspiration with infection n Amoxicillin-clavulanate or clindamycin Influenza with bacterial superinfection n Vancomycin, linezolid, or other coverage for MRSA or CA-MRSA
Management n Empirical Antibiotic Regimens for Out. Patient CAP therapy: Macrolide n Doxycycline n A respiratory fluoroquinolone alone n An advanced macrolide plus oral β-lactam n Amoxicillin-clavulanate n Clindamycin n Linezolid n
Management n Empirical Macrolide Azithromycin (500 mg once daily) n Clarithromycin (250 -500 mg twice daily) n Erythromycin (250 -500 mg four times a day) n
Management n Empirical Doxycycline n Doxycycline (100 mg 2 times/day)
Management n Empirical respiratory fluoroquinolone Moxifloxacin (400 mg once daily) n Gemifloxacin (320 mg once daily) n Levofloxacin (750 mg once daily) n
Management n Empirical advanced macrolide plus oral βlactam n Advanced macrolide Azithromycin (500 mg once daily) n Clarithromycin (250 -500 mg twice daily) n n Oral β-lactam High-dose amoxicillin (1 g three times a day) n High-dose amoxicillin-clavulanate (2 g twice daily) n Cefpodoxime (200 mg twice daily) n Cefuroxime (500 mg twice daily) n
Management n Empirical Amoxicillin-clavulanate n High-dose amoxicillin-clavulanate (2 g twice daily)
Management n Empirical Clindamycin n Clindamycin (300 mg PO q 6 h)
Management n Empirical Linezolid n Linezolid (600 mg twice daily)
Management n Empirical Antibiotic Therapy n Inpatient Therapy n Medical Ward n n No recent antibiotic therapy n A respiratory fluoroquinolone alone or an advanced macrolide plus an IV β -lactam Recent antibiotic therapy n An advanced macrolide plus an IV β -lactam, or a respiratory fluoroquinolone alone (regimen selected will depend on nature of recent antibiotic therapy)
Management n Empirical Antibiotic Therapy n Inpatient Therapy n Intensive Care Unit (ICU) n n Pseudomonas infection is not a concern n A β -lactam plus either an advanced macrolide or a respiratory fluoroquinolone Pseudomonas infection is not a concern but patient has a β-lactam allergy n A respiratory fluoroquinolone, with or without clindamycin
Management n Pseudomonas infection is a concern in: Severe structural lung disease (e. g. , bronchiectasis, cystic fibrosis) n Recent antibiotic therapy n Health care–associated exposures n Stay in hospital (especially in the ICU) n
Management n Empirical Antibiotic Therapy n Inpatient Therapy n Intensive Care Unit (ICU) n n n … Pseudomonas infection is a concern n Either (1) an antipseudomonal β -lactam plus ciprolloxacin, or (2) an antipseudomonal agent plus an aminoglycoside plus a respiratory fluoroquinolone or a macrolide Pseudomonas infection is a concern but the patient has a β -lactam allergy n Aztreonam plus aminoglycoside plus a respiratory fluoroquinolone
Management n Health care-associated pneumonia n n Pneumonia developing in patients who have been hospitalized for 2 or more days within 90 days of developing infection Patients attending hospital or hemodialysis clinics Patients receiving intravenous antibiotic therapy, wound care, or chemotherapy at home within 30 days of developing infection Residents of long-term care facilities or nursing homes
Management n Empirical Antibiotic Therapy n Inpatient Therapy n Health care-associated pneumonia n Either (1) an antipseudomonal β-lactam plus ciprofloxacin or levofloxacin or (2) an antipseudomonal agent plus an aminoglycoside plus a respiratory fluoroquinolone or a macrolide plus vancomycin or linezolid (for MRSA coverage)
n Empirical Antibiotic Regimens for In. Patient CAP therapy: n n n n A respiratory fluoroquinolone alone An advanced macrolide plus an IV β -lactam A β-lactamg plus a respiratory fluoroquinolone A respiratory fluoroquinolone with clindamycin An antipseudomonal β-lactam plus ciprofloxacin An antipseudomonal agent plus an aminoglycoside plus a respiratory fluoroquinolone or a macrolide Aztreonam plus aminoglycoside plus a respiratory fluoroquinolone An antipseudomonal agent plus an aminoglycoside plus a respiratory fluoroquinolone or a macrolide plus vancomycin or linezolid
Management n Empirical Antibiotic Therapy n How long therapy should continue? The classic 10 to 14 days of care is unsupported by evidence n Recent data suggest that clinical stability occurs more quickly, and therefore antibiotic therapy may be safely discontinued earlier n Less than 7 days and as short as 3 days are just as effective as any longer durations of therapy for mild to moderate pneumonia. n Oral antibiotic therapy is safe after clinical stability has been reached n
Management n Empirical Antibiotic Therapy n Adjunctive Therapy Critical illness-related corticosteroid insufficiency (CIRCI) has been associated with communityacquired pneumonia n Statins also possess anti-inflammatory properties n
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