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PNA Tx

Pulmonology

QuestionAnswer
CAP Outpatient tx IF healthy pt & no prior abx for 3 months: Macrolide or Doxy
CAP Outpatient tx IF comorbids / recent abx: Moxi/Lev OR Amox/Aug
CAP Outpatient tx IF comorbids (chronic htn, lung, liver, renal dz), DM, EtOH, Ca, asplenia, immunosuppression, or abx in past 3 months: Resp FQ (moxi or Lev 750) OR beta-lactam [(Amox 1g TID or Aug 2g BID); Alt: cefpod, rocephin, or ceftin] PLUS macrolide
CAP Inpatient (non-ICU) tx (briefly): Moxi/Lev OR Amox/Aug + Azithro
CAP Inpatient (non-ICU) tx: Resp FQ (moxi or Lev 750) OR beta-lactam plus macrolide
CAP Inpatient (ICU) tx (briefly): Rocephin/Unasyn + Azithro or Levaquin
CAP Inpatient (ICU) tx: Beta-lactam (cefotaxime/Claforan, Rocephin, or Unasyn) PLUS (Azithromycin OR resp FQ) [IF low pseudomonas risk]
Most common CAP Outpatient organisms: S pneumo, Mycoplasma pneumoniae, H flu, Chlamydophila, resp viruses
Most common CAP Inpatient (non-ICU) organisms: S pneumo, Mycoplasma pneumoniae, Chlamydophila, H flu, Legionella, aspiration, resp viruses
Most common CAP Inpatient (ICU) organisms: S pneumo, Staph aureus, Legionella, GN bacilli, H flu
Atypical pna organisms are so called bc: Not detectable on Gram stain or culturable on standard cx media
Atypical pna organisms = Mycoplasma pneumoniae, Chlamydophila, Legionella, resp viruses
CAP: likely GPC orgs S pneumo
CAP: likely GN orgs M Cat, H flu, Klebsiella, Chlamy, mycoplasma
CAP: GNDC = M cat
CAP: GNCB = H flu
CAP: M cat abx 1stline: rocephin, FQs. Alt: bactrim, augmentin, azithro
CAP: GNR orgs Klebsiella, Chlamydophila
CAP: Klebsiella abx 1stline: rocephin (+gent if severe). Alt: zosyn, unasyn, FQ, aztreonam
CAP bugs: COPD H flu, Pseudomonas, Legionella (also S pneumo, M cat, Chlamy)
CAP bugs: Legionella seen in which populations? Elderly, smokers, immunosuppressed
CAP bugs: GNRs / Klebsiella seen in which populations? EtOH, other aspirators
CAP bugs: S. aureus seen when? Post-viral infxn
CAP bugs: in young, healthy pts = Mycoplasma, Chlamydophila, viral
CAP bugs: viral Influenza A & B
Inpatient tx of PNA: CAP (non-ICU): IF necrosis/empyema: Regular abx + cover MRSA
Extended spectrum (ES) (antipseudomonal) PCNs = Amox, Ampicillin, Zosyn, Timentin
CAP: If Pseudomonas is a concern, firstline tx: Antipneumoccal / antipseudomonal beta-lactam (Zosyn, cefepime, ceftazidime, aztreonam, imipenem, meropenem) PLUS (Cipro or Lev)
CAP: If Pseudomonas is a concern, secondline tx: Beta-lactam (Zosyn, cefepime, imipenem, meropenem) PLUS (AG: Gent AND Azithro)
CAP: If Pseudomonas is a concern, thirdline tx: Beta-lactam (Zosyn, cefepime, imipenem, meropenem) PLUS AG (Gent) AND antipneumoccal FQ
CAP: If MRSA is a concern, add: Vanco or linezolid
CAP: firstline abx for S pneumo Pen G or amoxicillin
CAP: likely abx for S pneumo if PCN allergy: Cefotaxime (Claforan) or Rocephin or resp FQ
CAP: firstline abx for H flu (NON-beta-lactamase producing): Amoxicillin
CAP: firstline abx for H flu (beta-lactamase producing): 3G ceph (eg, Rocephin) or Augmentin
CAP: firstline abx for Myco pneumoniae and C. pneumoniae: Macrolide or tetracycline (doxy)
CAP: alternate abx for H flu FQ, Doxy, Azithro
CAP: alternate abx for Myco pneumoniae and C. pneumoniae: FQ
CAP: firstline abx for Legionella FQ or Azithro
CAP: alternate abx for Legionella Doxycycline
CAP: firstline abx for MSSA AntiStaph PCN (Nafcillin or Oxacillin)
CAP: secondline abx for MSSA Cefazolin or Clindamycin
CAP: firstline abx for MRSA Vancomycin or linezolid
CAP: secondline abx for MRSA Bactrim
Aspiration pna: MOA Chemical pneumonitis 2/2 aspiration of gastric contents. Bac PNA 24-72 hrs later 2/2 aspiration of oropharyngeal microbes
Aspiration pna: bugs (outpatient) Typical oral bugs: Strep, S aureus, oral anaerobes. GN enteric pathogens
Aspiration pna: bugs (inpatient or chronically ill) GNR (enteric pathogens) and S aureus
Aspiration pna abx: (3G ceph OR FQ) +/- (Clinda OR Flagyl, for anaerobes)
HCAP: GPC orgs MSSA, MRSA
HCAP: GNR orgs E coli, Legionella, Pseudo
HCAP: Legionella abx Abx combo for HAP with MDR RFs, EXCEPT use Azithro OR (Lev or cipro) instead of AG (gent)
HCAP: PCP abx 1stline: bactrim; Pentamidine isethionate plus prednisone. Alt: Dapsone + bactrim OR Clinda + primaquine
PNA: bugs in immunosuppressed pts CAP/HAP bugs, PCP, fungi, Nocardia, atypical Mycobacteria, CMV, HSV
PNA abx in immunocompromised pt: HCAP abx + bactrim +/- steroids (for PCP)
HAP (hosp acquired pna) bugs: GNR Pseudomonas, Klebs, E coli, Enterobacter, Serratia, Acinetobacter
HAP: this may increase risk of acquiring pna in hosp: Acid suppressant meds
HAP/VAP in pt with NO MDR risk factors: potential pathogens include: S pneumo, H flu, MSSA, abx-sensitive GNRs (E coli, Klebs, Enterbacter spp, Proteus spp, Serratia marcescens)
Initial empiric abx tx for HAP/VAP in pt with NO MDR risks factors: Ceftriaxone OR (Lev, moxi, or Cipro) OR Unasyn OR Ertapenem
HAP/VAP in pt WITH MDR risks factors: likely pathogens include: Pseudomonas, Klebsiella (ESBL), Acinetobacter spp (plus non-MDR pathogens)
Initial empiric abx tx for HAP/VAP in pt with MDR risks factors (or late-onset dz): [Antipseudomonal: (cefepime or ceftazidime) OR (imipenem or meropenem) OR Zosyn] PLUS [Antipseudo FQ (Lev or Cipro) OR (AG: amikacin or Gent)] PLUS [vanc or linezolid]
Transition from IV to PO abx - if on beta-lactam (eg rocephin) + azithro, switch to: Ceftin + azithro
Respiratory quinolone Moxifloxacin, gatifloxacin, levofloxacin, or gemifloxacin
Outpatient therapy for pneumonia in otherwise healthy patients Advanced generation macrolide (azithro or biaxin); doxycycline if allergic
Outpatient therapy for pneumonia in otherwise healthy patients azithromycin or clarithromycin
Outpatient therapy for pneumonia in otherwise healthy patients if patient is allergic to macrolides doxycycline
Outpatient therapy for pneumonia in patients with cardiopulmonary disease and/or other modifying factors Anti-pneumococcal FQ. Macrolide PLUS b-Lactam (oral cefpod, Ceftin, high-dose amoxicillin, Aug; or parenteral CTX then PO cefpodoxime)
Outpatient therapy for pneumonia in patients with cardiopulmonary disease and/or other modifying factors macrolide PLUS b-Lactam (oral cefpodoxime, cefuroxime, high-dose amoxicillin, amox/clavulanate; or parenteral ceftriaxone followed by oral cefpodoxime
MAC tx Clarithromycin plus (ethambutol or rifabutin)
Created by: Abarnard