CommunityAcquired Pneumonia Practicum December 8 th 2016 RACHEL

Community-Acquired Pneumonia Practicum December 8 th, 2016 RACHEL MARINI, PHARMD UNIT-BASED PHARMACIST UPMC PRESBYTERIAN MARINIRV 2@UPMC. EDU SLIDES ADOPTED FROM: BRIAN A. POTOSKI, PHARMD, BCPS

Learning Objectives �Determine the appropriate site of treatment for patients with Community-Acquired Pneumonia �Recognize the appropriate diagnostic criteria for CAP �Design a treatment and monitoring plan for an individual patient with CAP based on his/her clinical presentation and specific risk factors.

Quiz ~10 MINUTES PHOTO CREDIT: STYLISH STREAKING

Brief Review DEFINITION PATHOPHYSIOLOGY

Definition CAP �Acute infection of pulmonary parenchyma that is associated with signs/symptoms of infection, evidence of infiltrate on chest radiography, and presentation from the community setting �Community setting factors Do not live in long term care facility, skilled nursing facility, or nursing home No recent hospitalization or antimicrobial therapy No risk factors for multidrug resistant pathogens

Pathophysiology � Lung is constantly exposed to many different substances and microbes during inhalation � Body has a host defense system (both innate and acquired) that typically prevents these inhaled pathogens from causing an infection. � Infection occurs When there is a breakdown in the host defense mechanisms Exposure to a very virulent pathogen Overwhelming inoculum (or concentration of bacteria) � Routes of PNA infection: 1. 2. 3. Inhaled as aerosolized particles (most common) Enter the lung via bloodstream from extra pulmonary site of infection Aspiration of oropharyngeal contents � Adherence of these to the epithelial cell surface is the first step

Pathophysiology Organism inhalation Organisms pass upper airway defense mechanisms (mucus-producing cells, cilia, gag reflex, etc. ) Lower airway alveolar macrophages release cytokines Widespread inflammation and immune response causes damage and alveolar edema

IDSA Guidelines COMMUNITY ACQUIRED PNEUMONIA IN ADULTS

* * S S RE 7 1 G 0 O 2 r PR e N m I m E u T S A : n D o P i t U a * c * li b u P ed t c e j Pro

Areas of Focus �Site of care decisions �Diagnostic testing �Antibiotic treatment �Switch IV to PO �Duration of antibiotic therapy �Prevention

Site of Care Decisions � All major decisions regarding management start with initial assessment of severity � After diagnosis is made, options include: 1. 2. 3. Outpatient Hospitalization with admission to general medical ward Hospitalization with admission to intensive care unit (ICU) � Reasons to avoid unnecessary hospitalizations: Cost (25 x greater to treat inpatient) Resume normal activity sooner Patients prefer outpatient treatment Hospitalization increases risk of thromboembolic events and superinfection Mortality benefit

Site of Care Decisions �Physicians often overestimate severity of disease and hospitalize a significant # of patients who have a low risk for death �Scoring systems help to identify patients with CAP who may be candidates for outpatient treatment Strong recommendation; level I evidence �Severity of illness scoring system: CURB-65 PSI (Pneumonia Severity Index) is a prognostic model �Scoring system should supplement clinical judgment Strong recommendation; level II evidence

CURB-65 Table 1: Clinical Signs and Symptoms C Confusion U Uremia (BUN ≥ 20 mg/dl) R Respiratory rate ≥ 30 bpm B SBP < 90 mm. Hg or DBP ≤ 60 mm. Hg 65 Age ≥ 65 Table 2: Total Score 0 30 day mortality Risk Level (%) 0. 7% Low 1 2. 1% Low 2 9. 2% Moderate 3 14. 5% 4 or 5 40% or 57% Steps: 1. Assign one point for meeting each criteria in Table 1 (0 through 5) 2. Then apply to Table 2 to decide site-of-care Suggested Site-of. Care Outpatient Short inpatient / supervised outpatient Moderate to High Inpatient/ICU High ICU

Direct Admission to ICU �~10% hospitalized CAP patients require ICU admission � 1 major criteria Strong recommendation; level II evidence � 3 minor criteria Moderate recommendation; level II evidence

Areas of Focus �Site of care decisions �Diagnostic testing �Antibiotic treatment �Switch IV to PO �Duration of antibiotic therapy �Prevention

Diagnostic Testing �Diagnosis: clinical features + a demonstrable infiltrate on chest radiograph +/- microbiological data Moderate recommendation; level III evidence Clinical features maybe lacking/altered in elderly �Specific pathogens should be investigated if it would significantly alter standard empiric management Downside of extensive testing cost Less likely to change management in outpatients (optional) For inpatients, may be able to narrow antibiotics For inpatients who fail initial therapy, may indicate to broaden or direct coverage to specific pathogen, or may identify resistance

Diagnostic Testing

Diagnostic Testing � Outpatient point of care (POC) testing influenza � Respiratory tract specimen Gram-stain and culture Influenced by quality of specimen Usually low yield � Urinary antigen tests: Streptococcus pneumoniae Legionella pneumophila � Severe CAP diagnostic tests: Blood samples for culture Urinary antigen tests Expectorated sputum for culture (or endotracheal aspirate if intubated)

Respiratory Tract Specimen �Used to identify pathogens associated with CAP Also to broaden initial empiric coverage for less common pathogens (S. aureus or Gram-negative bacilli) �At least 40% of patients are unable to produce any sputum Higher yield with endotracheal aspirates or bronchoscopy sampling Best specimens are collected before antibiotics are given �Best indication for extensive respiratory tract cultures severe CAP

Blood Cultures �Pretreatment blood cultures yield probable pathogen 5 -14% of cases �Most common isolated pathogen: S. pneumoniae �Strongest indication for blood cultures severe CAP More likely to be infected with other pathogens including Staphylococcus aureus, Pseudomonas aeruginosa, other Gram-negative bacilli

Antigen Tests �Urinary antigen tests available: S. pneumoniae and L. pneumophila serogroup 1 Higher diagnostic yield in patients with more severe illness Questionable role empiric antibiotics will cover these pathogens �Rapid antigen test for influenza Consideration of antiviral therapy

Case #1

Case 1 � LI is a 70 y/o male who presents to the ED with SOB, productive cough, and altered mental status. His VS include T 38. 6 C, HR 106, RR 32, BP 85/45 after fluid resuscitation, O 2 sat 86% on 4 L nasal cannula. His Cr is 2. 1 and his BUN is 26. He is placed on a norepinephrine drip. 1. What is LI’s CURB-65 score? 2. Where is the best site-of-care for LI? 3. Which diagnostic tests are recommended?

Case 1 � LI is a 70 y/o male who presents to the ED with SOB, productive cough, and altered mental status. His VS include T 38. 6 C, HR 106, RR 32, BP 85/45 after fluid resuscitation, O 2 sat 86% on 4 L nasal cannula. His Cr is 2. 1 and his BUN is 26. He is placed on a norepinephrine drip. 1. What is LI’s CURB-65 score? Answer: 5 Table 1: Clinical Signs and Symptoms C Confusion 1 U Uremia (BUN ≥ 20 mg/dl) 1 R Respiratory rate ≥ 30 bpm 1 B SBP < 90 mm. Hg or DBP ≤ 60 mm. Hg 1 65 Age ≥ 65 1

Case 1 � LI is a 70 y/o male who presents to the ED with SOB, productive cough, and altered mental status. His VS include T 38. 6 C, HR 106, RR 32, BP 85/45 after fluid resuscitation, O 2 sat 86% on 4 L nasal cannula. His Cr is 2. 1 and his BUN is 26. He is placed on a norepinephrine drip. 2. Where is the best site-of-care for LI? Table 2: Total Score 0 30 day mortality Risk Level (%) 0. 7% Low 1 2. 1% Low 2 9. 2% Moderate 3 14. 5% 4 or 5 40% or 57% Answer: ICU Suggested Site-of. Care Outpatient Short inpatient / supervised outpatient Moderate to High Inpatient/ICU High ICU

Case 1 � JB is a 70 y/o male who presents to the ED with SOB, productive cough, and altered mental status. His VS include T 38. 6 C, HR 106, RR 32, BP 85/45 after fluid resuscitation, O 2 sat 86% on 4 L nasal cannula. His Cr is 2. 1 and his BUN is 26. He is placed on a norepinephrine drip. 3. Which diagnostic tests are recommended? Answer: • Blood culture • Sputum culture • Legionella and S. pneumoniae • UAT • Bronchoscopy if intubated

Areas of Focus �Site of care decisions �Diagnostic testing �Antibiotic treatment �Switch IV to PO �Duration of antibiotic therapy �Prevention

Goals of Antibiotic Therapy �Eradication of the infecting organism �Resolution of clinical disease �Avoid adverse events/ side effects from treatment regimens utilized

Antibiotic Treatment �Empiric antimicrobials are the mainstay of therapy until better diagnostic methods are available �Recommendations for empiric therapy based on: 1. 2. 3. Cover the most common pathogens Knowledge of local susceptibility patterns Patient specific factors

Thinking broadly, which of the following pathogens are most QUESTION 1 common etiologies of community-acquired pneumonia? a. b. c. d. e. f. g. h. i. j. k. Streptococcus pneumoniae Mycoplasma pneumoniae Chlamydophila pneumoniae Haemophilus influenzae Legionella spp. Oral anaerobes Gram-negative bacilli MRSA Respiratory viruses a, b, c, d, e, & i All of the above

CAP Pathogens � S. pneumonia is the most frequently isolated pathogen

Antibiotic Resistance Issues �Resistance patterns vary by geography �Hospital antibiograms should be considered in clinical practice when formulating empiric regimens 1. Drug-resistant S. pneumoniae (DRSP) 2. Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) UPMC Presbyterian Hospital Antibiotic Susceptibility Trend Data – 2014 Percent Susceptible Organism # Penicillin Tested S. pneumoniae 38 Vancomycin Erythromycin Ceftriaxone TMP/ SMX 88 (non 100 meningitis) 60 91 (non 70 meningitis) Moxifloxacin 100

Drug Resistant S. pneumoniae � Drug-resistant S. pneumoniae (DRSP) 1. Penicillin and cephalosporin resistance: decreased PBP affinity 2. Macrolide resistance Low-level: mef(A) – macrolide efflux pump – antibiotic gets pumped out � High-level: erm(B) - methylation of ribosomal target site – antibiotic cannot bind � � Risk factors for infection with β-lactam-resistant S. pneumo: Age <2 or >65 β-lactams within past 3 months Alcoholism Medical comorbidities Immunosuppressive illness/therapy Exposure to a child in a day care center

CA-MRSA � Strains are distinct from hospital-acquired MRSA Generally, remain susceptible to most antimicrobials � Contains gene for Panton-Valentine leukocidin (PVL) Toxin associated with necrotizing pneumonia, shock, and respiratory failure Can also cause abscesses or empyema � Should be considered if: Cavitary infiltrates without risks for anaerobic aspiration pneumonia Usually sputum and blood cultures are high-yield (Gram-positive cocci in clusters) � Rare but emerging problem Risk factors: end-stage renal disease, injection drug use, prior influenza pneumonia, prior antibiotic therapy

Context: Clinical Practice Community-acquired pneumonia Outpatient Inpatient Previously healthy and no use of antimicrobials in past 3 months Comorbid conditions* OR Use of antimicrobials in past 3 months OR DRSP risk Macrolide β-lactam plus macrolide Doxycycline Respiratory fluoroquinolone (Level I evidence) OR (Level III evidence) Which antimicrobials cover the organisms discussed? (Level I evidence) OR (Level I evidence) *Comorbid conditions: chronic heart, lung, liver or renal disease; diabetes mellitus; alcoholism; malignancy; asplenia; immunosuppressed Clin Infect Dis 2007; 44: S 27 -72

Empiric Outpatient Treatment � Divided into 2 groups: 1. Previously healthy PLUS no antibiotics within past 3 months: 1. 2. 1. A macrolide (azithromycin, clarithromycin) OR Strong recommendation; level I evidence Doxycycline Weak recommendation; level III evidence Presence of comorbidities OR use of antibiotics within past 3 months OR risks for DRSP: 1. 2. A respiratory fluoroquinolone (moxifloxacin, levofloxacin 750 mg) OR Strong recommendation; level I evidence A β-lactam plus a macrolide Strong recommendation; level I evidence 1. High-dose amoxicillin (1 gram TID) 2. Amoxicillin-clavulanate (2 grams BID) Alternatives: ceftriaxone, cefpodoxime, cefuroxime Alternative to macrolide: doxycycline If a patient has used antimicrobials within the past 3 months, an agent from a different class should be chosen

Outpatient therapy Comorbid Condition Considerations � Chronic heart disease � Chronic lung disease � Chronic liver disease � Chronic renal disease � Diabetes mellitus � Alcoholism � Malignancies � Asplenia � Immunosuppressing conditions � Use of immunosuppressing drugs

Outpatient Treatment �In regions with a high rate (>25%) of infection with high-level (MIC ≥ 16) macrolide-resistant S. pneumoniae: Consider the use of alternative agents to the macrolides for any patient including those without comorbidities

Case #2

Case 2 � DJ is a 34 year old female who presents to her PCP’s office complaining of a mild sore throat, a productive cough, and fevers for the past 3 days. She took her fever this morning and said it was 38. 9◦C and has noticed more purulent secretions over the past 24 hours. DJ’s daughter, age 4, is recovering from a “nagging” cough that lasted about 10 days. DJ states that a few other children in her daughters day care center have had the same type of “bug”. She has no known past medical history and no allergies. She has not needed medical care for a couple of years. � Her VS include T 39◦C, HR 100, RR 18, O 2 sat 93% on RA. CXR: LLL infiltrate c/w pneumonia. Her CURB-65 score is 0. She will be treated as an outpatient for CAP. Does DJ have any risk factors for DRSP? If so, which one(s)? 2. Which regimen(s) are acceptable choices for treatment of DJ’s CAP? 1.

Case 2 � DJ is a 34 year old female who presents to her PCP’s office complaining of a mild sore throat, a productive cough, and fevers for the past 3 days. She took her fever this morning and said it was 38. 9◦C and has noticed more purulent secretions over the past 24 hours. DJ’s daughter, age 4, is recovering from a “nagging” cough that lasted about 10 days. DJ states that a few other children in her daughters day care center have had the same type of “bug”. She has no known past medical history and no allergies. She has not needed medical care for a couple of years. Her VS include T 39◦C, HR 100, RR 18, O 2 sat 93% on RA. CXR: LLL infiltrate c/w pneumonia. Her CURB-65 score is 0. She will be treated as an outpatient for CAP. Age <2 or >65 1. Does DJ have any risk factors for DRSP? If so, which one(s)? β-lactams within past 3 months Alcoholism Medical comorbidities Answer: Yes, DJ has a daughter in a day care center Immunosuppressive illness/therapy Exposure to a child in a day care center

Case 2 � DJ is a 34 year old female who presents to her PCP’s office complaining of a mild sore throat, a productive cough, and fevers for the past 3 days. She took her fever this morning and said it was 38. 9◦C and has noticed more purulent secretions over the past 24 hours. DJ’s daughter, age 4, is recovering from a “nagging” cough that lasted about 10 days. DJ states that a few other children in her daughters day care center have had the same type of “bug”. She has no known past medical history and no allergies. She has not needed medical care for a couple of years. Her VS include T 39◦C, HR 100, RR 18, O 2 sat 93% on RA. CXR: LLL infiltrate c/w pneumonia. Her CURB-65 score is 0. She will be treated as an outpatient for CAP. 2. Which regimen(s) are acceptable choices for treatment of DJ’s CAP Outpatient Presence of comorbid conditions* OR use of antimicrobials in past 3 months OR DRSP risk β-lactam plus macrolide (Level I evidence) OR Respiratory fluoroquinolone (Level I evidence)

Case 2 � β- lactam + Amoxicillin 1 g PO TID Amox/clav 2 g PO BID Macrolide Azithromycin 500 mg PO q 24 h Doxycycline 100 mg PO q 12 h � Ceftriaxone 2 g IV daily � Cefpodoxime 400 mg PO BID � Cefuroxime 500 mg PO BID �Respiratory fluoroquinolone Levofloxacin 750 mg PO daily Moxifloxacin 400 mg PO daily Alternatives listed in black

Context: Clinical Practice Community-acquired pneumonia Outpatient Which antimicrobials cover the organisms discussed? Inpatient Non-ICU Intensive Care Unit (ICU) β-lactam plus macrolide β-lactam (Level I evidence) OR Respiratory fluoroquinolone (Level I evidence) PLUS (either) Macrolide (Level II evidence) OR Respiratory fluoroquinolone (Level I evidence) Clin Infect Dis 2007; 44: S 27 -72

Empiric Inpatient Treatment �Divided into 2 groups: 1. Inpatient, non-ICU treatment �A β-lactam plus a macrolide OR Strong recommendation; level I evidence Preferred B-lactams: ampicillin/sulbactam, cefotaxime, ceftriaxone Alternative to macrolide: doxycycline � A respiratory fluoroquinolone for penicillin-allergic patients Strong recommendation; level I evidence 2. Inpatient, ICU-treatment �A β-lactam + azithromycin OR � A β-lactam + a fluoroquinolone Preferred β -lactams: ampicillin/sulbactam, cefotaxime, ceftriaxone � For PCN-allergic patients: fluoroquinolone PLUS aztreonam Strong recommendation; level I evidence

Other Inpatient Considerations � For Pseudomonas aeruginosa infection: Anti-pseudomonal β-lactam � PLUS: � Piperacillin/tazobactam, cefepime, imipenem/cilastatin, or meropenem Either ciprofloxacin or levofloxacin OR an aminoglycoside + azithromycin OR an aminoglycoside + a respiratory fluoroquinolone For penicillin-allergic patients, use aztreonam in place of the β-lactam � Moderate recommendation; level III evidence Pseudomonas Risk Factors Recent ICU stay � For CA-MRSA: Multiple admission to healthcare facilities in past 3 months Add vancomycin or linezolid Multiple ABX courses in last 30 days Moderate recommendation; level III evidence Bronchiectasis � Structural lung disease with chronic corticosteroid use within last 3 months

Influenza �Early treatment (ie. within 48 h symptom onset) with oseltamivir or zanamivir is recommended for influenza type A Strong recommendation; level I evidence �Use of oseltamivir and zanamivir is not recommended for patients with uncomplicated influenza with symptoms >48 h However, these agents maybe used to reduce viral shedding in hospitalized patients Moderate recommendation; level III evidence

Time to First Antibiotic Dose �For impatient therapy, the first antibiotic dose should be administered in the emergency department Moderate recommendation; level III evidence

Areas of Focus �Site of care decisions �Diagnostic testing �Antibiotic treatment �Switch IV to PO �Duration of antibiotic therapy �Prevention

Switch From IV to Oral Therapy �Patients should be switched when they are hemodynamically stable AND improving clinically, can ingest medications, and have a normally functioning GI tract Strong recommendation; level II evidence �Patients should be discharged as soon as they are clinically stable, have no other active medical problems and have a safe environment for continued care Moderate recommendation; level II evidence �Inpatient care while receiving oral antibiotic therapy is not necessary

Areas of Focus �Site of care decisions �Diagnostic testing �Antibiotic treatment �Switch IV to PO �Duration of antibiotic therapy �Prevention

Duration of therapy � Before discontinuation of therapy: 1. 2. 3. CAP should be treated for a minimum of 5 days Patients should be afebrile for 48 -72 h Have no more than 1 CAP-associated sign of clinical instability 1. Moderate recommendation; level II evidence � A longer duration may be needed if initial therapy was not active against the identified pathogen or if it was complicated by an extrapulmonary infection (ie. meningitis or endocarditis) Weak recommendation; level III evidence � Most CAP patients have been treated for 7 -10 days � Longer durations may be necessary for S. aureus and Pseudomonas infections

Areas of Focus �Site of care decisions �Diagnostic testing �Antibiotic treatment �Switch IV to PO �Duration of antibiotic therapy �Prevention

Prevention � All patients ≥ 50 years of age, other risk factors for influenza complications, health care workers should receive inactivated influenza vaccine yearly Strong recommendation; level I evidence � Pneumococcal polysaccharide vaccine is recommended for patients ≥ 65 years of age and for those with selected high-risk diseases Strong recommendation; level II evidence � Smoking cessation should be a goal for persons hospitalized with CAP who smoke Moderate recommendation; level III evidence � Good respiratory and hygiene measures should be taken Strong recommendation; level III evidence

Case #3

Case 3 – Pre Class Case � JB is a 67 YO white male who presents to the ED complaining of SOB, coughing up yellow/green sputum for the past 2 or 3 days, fevers, and decreased appetite. For the past 3 days he called off sick to work and today he is feeling progressively weaker, so his wife brought him into the hospital. He states that he had similar symptoms a few weeks ago, so he took an antibiotic (could not remember the name) which he got from his wife who had leftover pills prescribed to her for a urinary tract infection. He took the medication for about a week and did notice a slight improvement in symptoms. He stopped taking the medication about a week ago and his symptoms have since worsened. � PMH: diabetes mellitus type II, hyperlipidemia, hypertension � Home Medications: metformin 1000 mg PO BID, lisinopril 10 mg PO q. AM, simvastatin 40 mg PO q. HS

Case 3 � Allergies: ciprofloxacin (reaction: rash) Social History: Retired but works part time as a vendor at a local stadium Smokes ½ pack of cigarettes/day Drinks alcohol socially � Physical Exam: General: Overweight gentleman in mild respiratory distress Ht/Wt: 6’ 1’’/223 lbs VS: Temp 38. 5 o. C, HR 115, RR 31, BP 132/85, O 2 saturation on RA 88% HEENT: NC/AT, PERRLA, EOMI. Normal/moist mucus membranes. Neck: supple, no JVD, no thyromegaly or lymphadenopathy. Lungs: slightly labored breathing with tachypnea. Diminished breath sounds and dullness to percussion in the left middle and lower lobe. Right lung CTA CV: RRR, no murmurs, rubs, or gallops Abd: Soft and non-tender, normo-active bowel sounds Neuro: A&O x 3, CN II-XII intact Extrem: No CCE Skin: warm, no rash � Pertinent Labs: WBC 18, 000 cells/mm 3, Cr 2. 1 mg/d. L, BUN 23 mg/d. L, glucose 200 mg/d. L � CXR: LLL infiltrate c/w pneumonia � Diagnosis: Community-acquired pneumonia � http: //www. glowm. com/resources/glowm/graphics/figures/atlases/Chest/LLLPNEUMONIAPOSTSEGPA_250. jpg

Case 3 �Treatment: JB is going to be admitted to the hospital (non-ICU). The primary team starts JB on azithromycin 250 mg daily for treatment of CAP. 1. 2. 3. 4. 5. 6. Do you think it was appropriate for JB to be admitted to the hospital for treatment of CAP? Why or why not? Do you agree or disagree with the physician’s antibiotic choice? If yes, why? If not, which antibiotic regimen would you have chosen (including dose) and why? Which pathogens are most likely the cause of JB’s CAP? What is the recommended duration of treatment for CAP? What parameters would you monitor for safety and efficacy of this treatment? What prevention strategies should be considered for this patient?

Case 3 1. Do you think it was appropriate for JB to be admitted to the hospital for treatment of CAP? Why or why not? Table 1: Clinical Signs and Symptoms C Confusion 0 U Uremia (BUN ≥ 20 mg/dl) 1 R Respiratory rate ≥ 30 bpm 1 B SBP < 90 mm. Hg or DBP ≤ 60 mm. Hg 0 65 Age ≥ 65 1 Table 2: Total Score 0 1 2 3 4 or 5 30 day mortality (%) Risk Level 0. 7% 2. 1% 9. 2% 14. 5% 40% or 57% Low Moderate to High Answer: Yes, admission is appropriate because JB’s CURB-65 score is 3. Suggested Site-of-Care Outpatient Short inpatient / supervised outpatient Inpatient/ICU

Case 3 � Treatment: JB is going to be admitted to the hospital (non -ICU). The primary team starts JB on azithromycin 250 mg daily for treatment of CAP. 2. Do you agree or disagree with the physician’s antibiotic choice? If yes, why? If not, which antibiotic regimen would you have chosen (including dose) and why? β-lactam plus macrolide Inpatient Non-ICU patients (Level I evidence) OR Respiratory fluoroquinolone Answer: Disagree. JB should be given a βlactam (i. e. ceftriaxone) with the macrolide. He cannot receive a FQ due to his allergy. The dose of azithromycin should also be 500 mg. (Level I evidence)

Case 3 � β- lactam + Ceftriaxone 2 g. IV q 24 h Amp/sulbactam 3 g IV q 6 h Cefotaxime 1 g IV q 8 h � Ertapenem Macrolide Azithromycin 500 mg IV q 24 h Doxycycline 100 mg IV q 12 h 1 g IV q 24 h �Respiratory fluoroquinolone Levofloxacin 750 mg IV daily Moxifloxacin 400 mg IV daily

Case 3 � 3. Which pathogens are most likely the cause of JB’s CAP?

Case 3 4. What is the recommended duration of treatment for CAP? Answer: Before discontinuation, he should be afebrile for 4872 h, have no more than 1 CAP-associated sign of instability, able to tolerate PO, and be treated for at least 5 days

Case 3 5. What should be monitored in JB to evaluate the safety and efficacy of his treatment? Drug Side Effects Ceftriaxone Anaphylaxis, rash Nausea/vomiting Diarrhea (C. diff) Liver function tests Interstitial nephritis Azithromycin Nausea/vomiting/diarrhea QTc prolongation Efficacy WBC trending down, temperature, improvement in dyspnea, cough, normalizing VS (e. g. , HR, BP, O 2 Sat%, temp. )

Case 3 6. What prevention strategies should be considered for this patient? �Influenza vaccine �Pneumococcal vaccine �Smoking cessation �Respiratory hygiene measures

Case 4

Case 4 �RT is a 68 year old female who presents to your retail pharmacy to fill her prescription. �RT presented to an urgent care facility this morning with a 2 -day history of productive cough, fever, malaise, and muscle aches. At the urgent care facility, she was diagnosed with community-acquired pneumonia and given the following prescriptions for an outpatient course of antibiotics: Azithromycin 500 mg PO daily x 7 days Amoxicillin/clavulanate 2 g PO BID x 7 days

Case 4 �PMH: hypertension and type 2 diabetes mellitus �Home medications: Hydrochlorothiazide 25 mg PO daily Ramipril 5 mg PO daily Metformin 500 mg PO daily �Social history: Does not smoke Social drinker Up to date on vaccines- including annual influenza �Allergies: penicillin

Case 4 �When you begin to process the patients prescription, you notice that she has an allergy listed on her profile to penicillins. You question the patient about the reaction that occurred when she took a penicillin in the past and she says “her throat swelled, but she was in the hospital last year for a cellulitis infection and was desensitized to penicillin during the admission” �Should you fill the prescription…

Case 4 �You should NOT fill the prescription and contact the physician to recommend an alternative agent to treat her CAP fluoroquinolone �Desensitization should be performed by an allergy specialist in a supervised outpatient setting or in the intensive care unit (ICU) of a hospital �Desensitization is temporary Once the antibiotic is stopped for ~24 hours the person is again at risk for sudden allergic reaction and desensitization should be repeated if the same medication is required

Questions? Email: marinirv 2@upmc. edu