HKCEM College Tutorial
Author
Dr. Shek Kam Chuen
Oct 2013

History
▪ M/39
▪ Good past health
▪ Fever one day, 38.8
o C
▪ Cough with yellowish sputum
▪ Right pleuritic chest pain

Any other important history?
▪ FTOCC
▪ Travel: Middle East, Avian flu
▪ Occupation: virus laboratory worker, poultry worker, work in wet market
▪ Contact: Poultry contact or index case
▪ Cluster: any, ?Amoy Garden in 2003 March

▪ FTOCC –ve
▪ What is clinical diagnosis?
▪ CAP, clinically stable
▪ What antibiotics shall we give?
▪ What are the common pathogens in HK?

What are possible pathogens?
▪
▪
▪

▪ Local pathogens in order of commonest :
▪ Haemophilus influenzae (13.7%-60%)
▪ Streptococcus pneumoniae
▪ Moraxella catarrhalis
Big 3
▪ Chlamydia pneumoniae
▪ Legionella
▪ Mycoplasma
Atypical
▪ Not to forget TB (esp elderly) or viral agents
▪ Local A&E sputum culture (QEH & PMH) data suggests H. influenzae is much more common than S. pneumoniae .

Subsequent treatment
Augmentin 1g BD 1/52
+Azithromycin 500mg daily for 3/7
Sputum CST + AFB CST saved
Follow up in 5/7

What are components of Augmentin?
▪ β-lactam/β-lactamase inhibitors combinations
▪ Amoxicillin-clavulanate
(Augmentin)
▪ MSSA ,
▪ S. pneumoniae,
▪ H. influenzae,
▪ M. catarrhalis,
▪ some E-coli, anaerobes
▪ 1. Augmentin 375mg tds
=(amoxil250 + clavulanate125)x3
=amoxil 750 + clavunanate 375 /D
▪ 2. Augmentin 375+ amoxil250 tid
=amoxil 1500 +clavunanate 375 /D
▪ 3. Augmentin 1 gm bd
=(amoxil 875+caluvulanate 125)x2
=amoxil 1750 +calvunanate 250 /D

Why Azithromycin added?
▪ Macrolides are good at CAP atypical agents and campylobacter(GE).
▪ Newer macrolides (clarithromycin, azithromycin) have a better coverage of H. influenzae. But there are wide spread resistance among the common Gram-positive bacteria including MSSA,
Pneumococcus, Group A Streptococcus.
▪ not be used as single empirical treatment of CAP and soft tissue infections to substitute penicillin in penicillin-allergy patients

At Follow-Up, Afebrile for 3 days, Feel better but still cough, CXR: more or less the same
Sputum grew:
 Streptococcus Pneumoniae
▪ Levofloxacin: S
▪ Penicillin (CNS): R
▪ Penicillin (non CNS): S
▪ Vancomycin : S

What is subsequent MX?
A. levofloxacin 500mg daily x 7 days
B. iv vancomycin
C. Change Klacid 500mg BD 1/52
D. Continue high dose Augmentin
E. Consult microbiologist whether the S. Pneumoniae is S to
Augmentin

▪ Higher dose Augmentin or Unasyn in view of drug resistant S. Pneumoniae
DRSP infection
Augmentin 1gm BD or
(Augmentin 375mg tds + amoxycillin 250mg tds)
+
Azithromycin ( Zithromax ) is preferred in view of no major drug interaction 9
Clarithromycin (Klacid) is P-450 cytochrome inhibitor with multiple drug interactions

What is the role Fluoroquinolones?
▪ Fluoroquinolone inhibit DNA gyrase and useful in G+ve and G-ve bacteria. But the resistance is increasing.
▪ Not for 1 st line for CAP in HK
▪ Which quinolones?
▪ Levofloxacin is more potent than ciproxin against S. Pneumoniae

▪ for adults when the first line regime is failed
▪ Allergic to alternative agents
▪ Documented infection due to pneumococci with high level penicillin resistance (Penicillin MIC >=4UG /mL .)
▪ (it is not used as first line since it resistance in future.) may mask TB and may cause drug
▪ levofloxacin 750mg QD for 5/7 because it is concentration dependent.
Impact
CID 2007;44 (Suppl 2) S27-S72