pneumonia drugs

uncommon non-infectious causes

lung infarction

common non-infectious causes

pulmonary edema

ARDS

lung cancer

common infectious causes

streptococcus pneumoniae

Haemophilus influenzae

staphylococcus aureus

influenza and other viruses

uncommon infectious causes

pseudomonas aeruginosa

Pneumocystis jiroveci

Moraxella catarrhalis

typical CAP

Sudden onset of fever, chills, pleuritic chest pain, productive cough

typical CAP organisms

• Streptococcus pneumoniae

-Haemophilus influenzae

Atypical CAP

often preceded by mild respiratory illness

Atypical CAP caused by

• Legionella spp.

• Mycoplasma pneumoniae (walking pneumonia)

• Chlamydophila pneumoniae

Basics of pneumonia pharmacotherapy

• Start empiric therapy with a broad spectrum antibiotic

• Revise therapy once the causative organism is identified

• Revise therapy based on disease progression (and potential development of drug resistance)

• For hospitalized patients, once stabilized, move from IV to oral therapy prior to discharge

Streptococcus pneumoniae: CAP typical treatment

Usually susceptible to penicillin

give:

• Penicillin G (high doses)

• Aminopenicillins: Ampicillin (high doses)

Treatment of Penicillin-resistant Streptococcus pneumoniae

• Second Generation Cephalosoporins: Cefuroxime

• Third Generation Cephalosporins: Cefotaxime, Ceftriaxone

• Quinolones: Moxifloxacin, Levofloxacin

• Vancomycin

• Macrolides/ketolines: Telithromycin

what cephalosporin can treat MRSA

5th generation cephalosporins differ from ALL other betalactam antibiotics by being active against Methicillin-resistant Staphylococcus aureus (MRSA)

H.infleunzae treatment

Quinolone

macrolide

Legionella treatment

macrolide

quinolone

mycoplasma pneumoniae treatment

quinolone

macrolide

aerobic gram neg bacteria treatment

quinolone

chlamydophilia pneumoniae

quinolone

macrolide

staphylococcus aureus

quinolone

macrolide

outpatient with no comorbidities or MRSA risk in community more than 25%

either:

-amoxicillin

-doxycycline

outpatient with no comorbidities or MRSA risk in community less than 25%

either:

-amoxicillin

-doxycycline

-Clarithromycin

-Azithromycin

outpatient with co-morbidities

either:

-monotherapy of fluoroquinolone (levifloxacin/moxifloxacin/gemifloxacin)

-beta-lactam + macrolide

-beta-lactam + doxycycline

in-patient nonsevere

-monotherapy of fluoroquinolone (levifloxacin/moxifloxacin/gemifloxacin)

-beta-lactam + doxycyline

-beta-lactam + macrolide

MRSA in nonsevere and severe in patient

add vancomycin or linezolid

P.areguinosa consideration

switch the b-lactam to an antipsuedomonal beta lactam

antipseudomonal b-lactams

-piperacillin-tazobactam

-cefepime

-ceftazidime

-imipenem

-meropenem

-aztreonam

in-patient severe

-b lactam + macrolide

-b lactam + fluroquinolone

HAP is divided into two classes:

Early onset HAP

Late onset HAP

Early onset HAP

occurs within first five days of hospitalization

• Usually after 48 hrs from admission

Late onset HAP

occurs after 5 days of hospitalization

Bacterial Causes of Early Onset HAP

• Methicillin-sensitive Staphylococcus aureus (most)

• Haemophilus influenzae

• Enterobacteriaceae

• Streptococcus pneumoniae

Early Onset HAP treatment

ceftriaxone

Quinolone

ampicillin/sulbactam

Ertapenem

Bacterial Causes of Late Onset HAP

• Pseudomonas aeruginosa

• Acinetobacter spp.

• Enterobacteriaceae

• Methicillin-resistant S. aureus

Methicillin-resistant S. aureus treatment

either:

-antipsuedomonal b-lactam

-carbapenem

with:

quinolone

or

aminoglycoside (tobramycin/gentamycin)

if MRSA suspected:

add vancomycin or linezolid

b lactam adverse

diarrhea

nausea

vomiting

Doxycycline adverse

inhibits bone growth

teeth discoloration

Azithromycin and clarithromycin adverse

QT interval prolongation

fluoroquinolones adverse

Qt interval prolongation

torsades de pointes

vaginal candida

what should be separated from doxycycline and fluroquinolones

Calcium

Magnesium

Iron

-reduce drug absorption take several hours before or after

what drugs shouldnt be taken with QT interval prolonging drugs

azithromycin

clarithromycin

fluoroquinolones

what shouldnt be taken with hypoglycemic drugs

fluroquinolones

Clarithromycin inhibits

CYP3A4

dont give what with clarithromycin

CCB are metabolized by CYP3A4

-can lead to death, acute kidney injury, hypotension

pregnancy aviod

• Doxycycline: inhibition of bone growth.

• Clarithromycin: teratogenic in animals.

• Fluoroquinolones: arthropathy in animal studies, but observational data in pregnant women suggest that teratogenic effects are unlikely to occur at therapeutic doses.

pregnancy take

Amoxicillin or amoxicillin/clavulanate plus azithromycin can be used for outpatient treatment of pregnant women with CAP.