PHRM 541 Community Acquired Pneumonia: Treatment and Duration

What are empiric treatment options for outpatients with CAP with no comorbidities or risk factors for MRSA or PsA?

Amoxicillin OR

Doxycycline OR

Azithromycin or Clarithromycin (if local pneumococcal resistance is < 25%)

What are empiric treatment options for outpatients with CAP with comorbidities and without risk factors for MRSA or PsA?

Amoxicillin/clavulanate or cephalosporin

AND

Azithromycin/clarithromycin or doxycycline

OR

Monotherapy with respiratory fluoroquinolone

What are examples of comorbidities?

Chronic heart: HFrEF, CAD, congenital heart disease, rheumatic heart disease

Lung: COPD, emphysema, interstitial lung disease, bronchiectasis

Liver: cirrhosis

Renal disease: ESRD

Diabetes mellitus, alcoholism, malignancy, asplenia

What are examples of respiratory fluoroquinolones?

Moxifloxacin and levofloxacin, NOT ciprofloxacin

Why is ciprofloxacin not considered a respiratory fluoroquinolone and is NOT used empirically for CAP?

Poor empiric coverage of S. pneumoniae

Which penicillins can be used for outpatient empiric treatment of CAP?

Amoxicillin 1 g PO TID

Amoxicillin/clavulanate

Which cephalosporins can be used for outpatient empiric treatment of CAP?

Cefpodoxime

Cefuroxime

Which tetracyclines can be used for outpatient empiric treatment of CAP?

Doxycycline

Which macrolides can be used for outpatient empiric treatment of CAP?

Azithromycin 500 mg x 1, then 250 mg PO daily x 4 days OR Azithromycin 500 mg PO x 3 days

Clarithromycin

Which respiratory fluoroquinolones can be used for outpatient empiric treatment of CAP?

Levofloxacin

Moxifloxacin

What are empiric treatment options for inpatients with non-severe CAP without risk factors for MRSA or PsA?

Ceftriaxone PLUS azithromycin/clarithromycin OR doxycycline

Monotherapy with respiratory fluoroquinolones

What are empiric treatment options for inpatients with non-severe CAP with prior PsA respiratory culture?

Use cefepime OR piperacillin/tazobactam to REPLACE the beta-lactam in a non-severe CAP regimen

What are empiric treatment options for inpatients with non-severe CAP with prior MRSA respiratory culture?

ADD vancomycin to a non-severe CAP regimen

What are empiric treatment options for inpatients with non-severe CAP with recent hospitalization with IV ABX?

Obtain cultures and treat with a typical non-severe CAP regimen (withhold MRSA/PsA coverage) UNLESS positive cultures or MRSA nasal PCR positive

What are risk factors for isolation of MRSA or PsA?

Prior respiratory isolation of MRSA or PsA

Recent hospitalization AND receipt of IV ABX in the last 90 days

Which antimicrobial agents can be used empirically in patients with risk factors for MRSA?

Vancomycin

Linezolid

Why do we not use daptomycin in the setting of CAP?

Daptomycin gets degraded by respiratory surfactant so it is not effective against CAP

Which antimicrobial agents can be used empirically in patients with risk factors for P. aeruginosa?

Piperacillin/tazobactam

Cefepime

Ceftazidime

Aztreonam

Meropenem

Imipenem

What are empiric treatment options for inpatients with severe CAP without risk factors for MRSA or PsA?

Ceftriaxone PLUS azithromycin/clarithromycin/doxycycline OR levofloxacin/moxifloxacin

What are empiric treatment options for inpatients with severe CAP with prior PsA respiratory culture?

Use cefepime OR piperacillin/tazobactam to REPLACE beta-lactam in severe CAP regimen

What are empiric treatment options for inpatients with severe CAP with prior MRSA respiratory culture?

ADD vancomycin to severe CAP regimen

What should be included in a severe CAP regimen for a patient who has undergone hospitalization with IV antibiotics in past 90 days?

Include PsA and MRSA coverage

Which penicillins can be used inpatient for CAP?

Ampicillin-sulbactam

Which cephalosporins can be used inpatient for CAP?

Cefotaxime

Ceftriaxone

Ceftaroline

Which tetracyclines can be used inpatient for CAP?

Doxycycline

Which macrolides can be used inpatient for CAP?

Azithromycin 500 mg IV daily

Clarithromycin

Which respiratory fluoroquinolones can be used inpatient for CAP?

Levofloxacin

Moxifloxacin

What is the recommended regimen for empirically treating outpatient CAP in a previously healthy patient?

Amoxicillin OR doxycycline OR azithromycin

What is the recommended regimen for empirically treating outpatient CAP in a patient with comorbidities?

Levofloxacin/moxifloxacin

OR

Amoxicillin/clavulanate

PLUS

Azithromycin/doxycycline

What is the recommended regimen for empirically treating inpatient non-severe CAP?

Ceftriaxone PLUS

Azithromycin OR levofloxacin/moxifloxacin

What is the recommended regimen for empirically treating inpatient severe CAP?

Ceftriaxone PLUS azithromycin

OR

Ceftriaxone PLUS levofloxacin/moxifloxacin

How long does it take to get culture and sensitivity results?

~48 hr

Define aspiration pneumonia

Lower respiratory tract infection that occurs after the aspiration of colonized oropharyngeal secretions

Define aspiration pneumonitis

Chemical injury to the lungs after aspiration of gastric contents

What is the duration of therapy for adult outpatients with CAP who reach clinical stability?

< 5 days antibiotics

(3 days minimum)

What is the duration of therapy for adult inpatients with non-severe CAP who reach clinical stability?

< 5 days antibiotics

(3 days minimum)

What is the duration of therapy for adult inpatients with severe CAP who reach clinical stability?

≥ 5 days of antibiotics

What are examples of patients with contraindications to shorter antibiotic courses (< 5 days)?

Severe chronic lung disease: bronchiectasis, necrotizing pneumonia, lung abscesses, empyema

Extrapulmonary infection

Confirmed infection with S. aureus (7 days minimum), PsA (7 days minimum), or legionella pneumophilia

Define clinical stability

Afebrile, resolution of tachycardia, tachypnea, hypotension, hypoxia, and altered mental status

Patients should achieve clinical stability prior to antibiotic discontinuation

Define post-antibiotic effect

Suppression of bacterial growth after exposure to antimicrobial agents

Which antibiotic for CAP has a long half life and post-antibiotic effect?

Azithromycin

What are the guideline recommendations for corticosteroid administration in adult inpatients with non-severe CAP?

Do NOT administer corticosteroids

Strong recommendation

What are the guideline recommendations for corticosteroid administration in adult inpatients with severe CAP?

Administer corticosteroids (excluding CAP secondary to influenza)

Conditional recommendation

When is a conversion from IV to PO medications made?

When ALL of the following criteria are met:

-clinical stability

-able to ingest oral medications

-functioning GI tract

What are the criteria for clinical stability?

Temperature ≤ 37.8ºC

Heart rate < 100 beats/min

Respiratory rate < 24 breaths/min

Systolic blood pressure ≥ 90 mmHg

Arterial oxygen saturation ≥ 90% or pO2 ≥ 60 mmHg on room air

Normal mental status

ALL CRITERIA NEED TO BE MET!