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PNA Tx
Pulmonology
| Question | Answer |
|---|---|
| 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
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