Monday, November 22, 2010
Antibiotics and Pneumonia
Today we talked today about a patient with community acquired pneumonia (CAP) and the appropriate antibiotics and investigations for CAP.
Here's a link to the 2007 IDSA/ATS CAP Guidelines (scroll down to CAP). The BTS also released guidelines in 2009.
1) While it seems obvious, an infiltrate on CXR (in the right clinical context) is required for the diagnosis of pneumonia.
2) Generally, all patients with pneumonia admitted to hospital should have blood and sputum cultures drawn.
3) In patients with severe pneumonia, urinary antigens for Legionella pneumophila and Streptococcus pneumoniae should be sent.
4) Options for outpatient treatment:
a) If previously healthy, can use a macrolide or doxycyline.
b) In patients with comorbidities or recent Abx use, give a respiratory FQ or a (beta- lactam + a macrolide).
c) Remember, if the presence of macrolide resistant S.pneumo is greater than 25% in your practice area, macrolides should be avoided.
5) Inpatient, non-ICU treatment:
a) (Respiratory FQ) or a (beta-lactam + a macrolide).
6) Inpatient, ICU treatment:
a) A beta-lactam plus either a macrolide or a FQ (better evidence for FQ over macrolide).
b) If concerned re: pseudomonas, give an anti-pseudomonal beta-lactam that has anti-pneumococcal activity (PipTazo, Cefepime, Imipenem or Meropenem) plus either (Cipro of Levo) or (an aminoglycoside + azithromycin) or (an aminoglycoside + an anti-pseudomonal FQ).
c) Add Vano or Linezolid if MRSA risk factors present.
7) The beta-lactam in the outpatient and in-patient not ICU treatment arms can be high dose amoxicillin/ampicillin.