pneumonia
DESCRIPTION
Pharmacotherapeutics of pneumoniaTRANSCRIPT
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Pneumonia
Anas Bahnassi PhD
Pharmacotherapy of Infectious Diseases
Anas Bahnassi 2014
A Case-Based Approach
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• Community Acquired Pneumonia (CAP)
– Common and serious disease.
– 80% of cases can be treated at home.
– Mortality rate for patients requiring hospitalization is 8-10%, and can increase to 40% to those requiring ICU.
– Clinical presentation of CAP does not allow for and etiological diagnosis.
– Many organisms can be
Anas Bahnassi 2014
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Pneumonia treated on ambulatory basis
Streptococcus pneumoniae
Mycoplasm pneumoniae
Haemphilus Influenzae
Chlamydophila pneumoniae
Respiratory viruses
Moraxelia catarrhalis
Anas Bahnassi 2014
Pneumonia requiring hospital admission
Streptococcus pneumoniae
Chlamydophila pneumoniae
Haemphilus Influenzae
Lagionella supp.
Aspiration
G –ve. Bacilli
Mixed etiology
Respiratory viruses
Mycoplasm pneumoniae
Pneumonia requiring ICU admission
Streptococcus pneumoniae
Staphylococcus aureus
Lagionella supp.
G –ve. Bacilli
Haemphilus Influenzae
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h Goals of Therapy
• Assess severity of pneumonia. • Eradicate infecting pathogen. • Relieve symptoms.
– Fever, cough, pleuritic chest pain, sputum, dyspnea.
• Promptly recognize and minimize complications. – Metastatic infection, empyema, cavitation,
pneumothorax, septic shock, respiratory failure, worsening of comorbid condition (IHD, DM).
• Provide end-of-life care if emerges.
Anas Bahnassi 2014
Empyema is a collection of pus in the space between the lung and the inner surface of the chest wall (pleural space). Pneumothorax: collapsed lung.
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• History and PI with particular attention to: – Symptoms:
• Cough, SOB, pleuritic chest pain, hemoptysis, sputum, fever, chills, headache, confusion, ….
– History of recent travel and other risk factors like: • Smoking, alcohol, comorbid illnesses.
– Physical findings:
• Objective measurements: – Vital signs: RR≥30 is the most sensitive and specific sign. – Oxygenation status: If O2 saturation is ≤ 92% then perform
arterial blood gas. – Chest radiograph: consider a CT scan if radiograph is
negative.
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• Laboratory testing:
– Electorlytes, Glu, BUN, Cr, CBC, differential WBC.
– Blood cultures.
– Sputum culture from the lower respiratory tract.
– Urine for Legionella antigens.
– Rapid test for flu.
– Serological studies.
– Nucleic acid amplification.
Anas Bahnassi 2014
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Anas Bahnassi 2014
Ph
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Anas Bahnassi 2014
Ph
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Anas Bahnassi 2014
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h Initial Management of CAP
Anas Bahnassi 2014
CAP diagnosed based on
History, PE, Findings,
chest X-ray
PSI is for guidance
not to replace clinical
judgment
< 90 and not hypo-oxynated
> 90 treat in hospital
Otherwise healthy, no use of antibiotics for 3 months, and no other risk factor use
macrolide or doxycycline po
Co-morbidities , lung or kidney disease, risk factors then respiratory
fluroquinolone *po, or Amox HD or Amox/Clav + Macrolide No Erythromycin alone
Treat at home
*moxifloxacin, levofloxacin. Gemifloxacin is not approved for CAP
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h Initial Management of CAP
Anas Bahnassi 2014
CAP diagnosed based on
History, PE, Findings,
chest X-ray
PSI is for guidance
not to replace clinical
judgment
> 90 treat in hospital
(Respiratory Fluroquinolone po/iv or B-lactam po/iv )+ Macrolide po/iv
Antipnumococcal, antipsudomonal B-lactam*+ one of the followings:
•Ciprofloxacin •Aminoglycoside + Macrolide •Aminoglycoside + Ciprofloxaxin
Ward
B-lactam iv + (Macrolide iv or respiratory fluroquinolone iv)
ICU
ICU S.aregunesa
* Cefepime or imipenem or meropenem or piperacillin/tazopactam
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Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class Drug Dose ADR Comments Cost
Amino-glycosides
Gentamicin Conventional: 1.5mg/kg DBW Q8H iv Extended: 4-6mg/kg DBW Once iv
Nephro/ Ototoxicity
Do not permeate pulmonary tissue very well. Exhibit conc.
dependent bacterial killing and postantibiotic effect Co-administration
with vancomycin or loop diuretics may increase the risk of nephro/ototoxicity
$
Tobramycin Conventional: 1.5mg/kg DBW Q8H iv Extended: 4-6mg/kg DBW Once iv
$
In obese patients >30 of ideal body weight (IBW) use dosing body weight (DBW) instead of total body weight (TBW) to prevent overdosing. DBW=0.4 (TBW-IBW)
Ideal body weight in (kg) Males: IBW = 50 kg + 2.3 kg for each inch over 5 feet. Females: IBW = 45.5 kg + 2.3 kg for each inch over 5 feet.
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Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class Drug Dose ADR Comments Cost
Fluro-quinolones
Cipro-floxacin
PO: 500-750mg BID IV: 400mg Q12H
GI upset, HA, dizziness, photo-sensitivity, hepatitis. Avoid in children: Cartridge toxicity.
Cipro is not a 1st line agent for CAP. Cipro available in suspension. Decreased absorption with
antacids, metals, and sucrafate. Cipro may decrease
theophylline or cyclosporin elimination. Levo 750 BID X5d is
equivalent to 500 BID X10d. May increase warfarin effect. Avoid in class Ia and III
arrhythmia patients or prolonged QT intervals Can switch from iv to po
$
Levo-floxacin
PO: 500mg Q24H X10 days. or 750mg Q12H X5 days. IV: 500mg Q24H
$
Moxi-floxacin
400mg Q24H po/iv`
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Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class Drug Dose ADR Comments Cost
Glyco-peptides
Vanco-mycin
1g Q12H iv
Nephro/ ototoxicity Infusion related ADRs may increase with shorter infusion times
For MRSA pneumonia. Increase risk of
nephrotoxicity when co-administered with aminoglycosides.
$$$$
Ketolides Telithro-mycin
800mg daily X7-10 days
Diarrhea, nausea, vomiting, elevated liver enzymes, hepatotoxicity.
Can not be considered as a first line. Hepatotoxicity can be fatal. Telithromycin: Atorvastatin, Lovastatin, Simvastatin, Itraconazole, Ketoconazole. Digoxin levels. Contraindicated with ergot, pimozide and disopyramide.
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Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class Drug Dose ADR Comments Cost
Linco-semides
Clindamycin 300-450mg Q6H po 600mg Q8H iv
Diarrhea C.Difficile
For suspected aspiration provide anareobic coverage
$
Macro-lides
Azithromycin Adults 500mg on day 1 then 250 on days 2-5
Lower GI effects than Eryth.
Azi QD X5days = Ery QID X10days. More effective than clarithro-mycin for H.influenzae.
$$
Clarithromycin 500mg BID X10d Or 1g ER QD X10d
Contraindicated with pimozide. Rifampin Conc. Warfarin levels. Conc. of CYP3A4 susbtrates (statins/digoxin)
$$
Erythromycin 500mg QID po GI upset $
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Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class Drug Dose ADR Comments Cost
Nitro-imidazole
Metronidazole 500mg po/iv Q12H
Vertigo, HA, Ataxia, GI, taste change
Avoid alcohol until 48h after the last dose (disulfram-like reaction)
$
Oxazolidi-none
Linezolide 600mg po/iv Q12H
GI, HA, dose and time dependent bone marrow suppression, peripheral neuropathy.
Preferred agent for MSRA –pneumonia. Risk of serotonin toxicity with concurrent use of serotonergic drugs.
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Antibiotic Treatment Recommendations
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Class Drug Dose ADR Comments Cost
Carba-penems
Ertapenam 1g daily iv Anaphylaxis, diarrhea, HA, increased seizure risk.
Indicated for S.pneumonia (penicillin-susceptible), H.influenzae. M. Catarrhalis.
$$$
Impenem 500 mg Q6H iv
Hypotension, nausea with rapid infusion, seizure activity with high levels.
Antipseudomonal for patients with high risk for P. aeruginosa.
$$$$
Meropenam 1g Q8H iv Less than Impenem.
$$$$
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Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class Drug Dose ADR Comments Cost
Carba-penems
Ertapenam 1g daily iv Anaphylaxis, diarrhea, HA, increased seizure risk.
Indicated for S.pneumonia (penicillin-susceptible), H.influenzae. M. Catarrhalis.
$$$
Impenem 500 mg Q6H iv
Hypotension, nausea with rapid infusion, seizure activity with high levels.
Antipseudomonal for patients with high risk for P. aeruginosa.
$$$$
Meropenam 1g Q8H iv Less than Impenem.
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Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class Drug Dose ADR Comments Cost
Cephalo-sporins
Cefazolin 1st generation
1-2g Q8H iv Hyper-sensitivity
$-$$
Cefaclor 2nd generation
250mg TID po $
Cefprozil 2nd generation
500mg BID po $
Cefotaxime 3rd generation
1-2g Q8H iv Can be used hepatobilliary disease.
$$- $$$
Cefepim 4th generatrion
1-2g Q12H Antipseudomonal for patients with high risk for P. aeruginosa.
$$$$
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Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class Drug Dose ADR Comments Cost
Penicillins Penicillin V K
300mg TID-QID po
Anaphylaxis GI distress Diarrhea.
$
Penicillin G 2MU Q4H iv $
Amoxicillin 500mg TID po GI distress Diarrhea.
Consider HD if patient is with drug resistant S.pneumoniae risk factors
$
Amox/Clav 500/125 TID po or 875/125 BID po
$$
Rifamycin Rifampin 300mg BID po Rash, orange discoloration of body fluids, GI upset, liver toxicity, hematologic effects
Never use as a single agent for CAP CYP inducer.
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Antibiotic Treatment Recommendations
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Class Drug Dose ADR Comments Cost
Sulfo-namides
SMX/TMP 800/160mg BID po
GI, rash, Stevenson-Johnson’s syndrome
May effects of sulfonylurea and warfarin. Caution with G6PD deficiency and impaired renal and hepatic function.
$
Tetracyclins Doxycycline 100mg BID on 1st day then 100mg once
GI, photosensitivity
Fe/antacids absorption. Alcohol. Barbiturates, phenytoin, rifampin, carbamazepin levels.
$
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h Prevention Measures
• Smoking cessation.
• Influenza vaccine.
• Pneumococcal vaccine.
• Chin down posture reduce the chance of aspiration both before and during the swallow.
• Follow-up chest radiographs for smokers.
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Ph
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Infectious Diseases:
Anas Bahnassi PhD
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