Nayri Hatsakorzian
Pharm.D/MPH candidate 2014
Touro University- CA
Who should be admitted to ICU?
Direct admission to ICU is required for patients with:
1- 2 major criteria
- Septic shock requiring vasopressors
- Acute respiratory failure requiring intubation and
mechanical ventilation
2- at least 3 of the minor criteria
- PaO2/FiO2 ratio 250 (arterial oxygen pressure/fraction of
inspired oxygen)
- Multilobar infiltrates
- Leukopenia (WBC <4000)
- Thrombocytopenia (PLT <100,000)
- Hypothermia (core temp <36C)
- Hyponatremia
- Hypoglycemia (in non-diabetic patients)
- Acute alcoholism/alcoholic withdrawal
- Unexplained metabolic acidosis
- Elevated lactate levels
- Cirrhosis
- Asplenia
- CURB-65
o Confusion/disorientation
o Uremia (BUN ≥ 20)
o RR ≥ 30
Diagnostic testing
Obtain blood culture, sputum culture, legionella UAT, Pneumococcal UAT
- ICU
- Pleural effusion
- Active alcohol abuse patients
Obtain blood and sputum culture
- Cavity infiltrates
Obtain blood cultures and Pneumococcal UAT
- Leukopenia
- Chronic severe liver diseases
- Asplenia
o Blood Pressure
o Hypotension requiring aggressive fluid resuscitation
Etiologies of CAP:
Outpatient:
- Streptococcus pneumoniae
- Mycoplasma pneumoniae
- Haemophilus influenzae
- Chlamydophila pneumoniae
- Respiratory viruses
Inpatient (non-ICU)
- Streptococcus pneumoniae
- Mycoplasma pneumoniae
- Haemophilus influenzae
- Chlamydophila pneumoniae
- Legionella species
- Aspiration
- Respiratory viruses
Inpatient (ICU)
- Streptococcus pneumoniae
- Staphylococcus aureus
- Legionella species
- Gram negative bacilli
- Haemophilus influenzae
CA-PNA
Empiric treatment
OUTPATIENT
Previously healthy with no ABX tx for the past 3 month
PO: 1st line: Macrolides
Azithromycin (Zithromax) 500 mg PO day1 then 250mg day 2-5
- Adjust azithromycin when CrCl <10
Clarithromycin (Biaxin) 250mg PO every 12 hours for 7-10 days
- Decrease clarithromycin by 50% when CrCl < 30
Alternative to macrolides is Doxycycline
- (Vibramycin, Doryx) 100 mg PO twice daily
- No renal adjustment is needed
- Macrolides active against most
common pathogens including
atypicals
- Erythromycin is not used d/t
major GI side effects and losing
efficacy against H. influenzae
OUTPATIENT
Presence of comorbidities (COPD, CHD, liver, renal diseases, DM, alcoholism, malignancies,
asplenia, immunosuppressing conditions or use of immunosuppressing drugs). Or ABX tx the past 3
months (use different ABX: If patient received FQ then use macrolide and V.V)
Respiratory FQ
Levofloxacin (Levaquin) 750mg PO daily for 5 days
o Adjust frequency when CrCl < 50
Moxifloxacin (Avelox) 400 mg PO daily for 7-10 days
o No renal or hepatic dose adjustment is necessary
Gemifloaxacin PO 320mg daily for 7 days
Or: B-lactam + macrolides
Amoxicillin 1g three times daily
o Adjust dose renally when CrCl < 30
Augmentin (Amoxicillin-Clavulanate) 2g twice daily for 7-10 days
o Adjust dose renally when CrCl < 30
o Hepatic adjustment is necessary
Ceftriaxone (Rocephin) 1g daily for 7-10 days
o No adjustments necessary
Cefpodoxime (Vantin) 200mg PO twice daily for 14 days
o Decrease frequency to every 24 hours when CrCl < 30
Cefuroxime (Ceftin) 750 mg every 8 hours
o Decrease frequency to every 24 hours when CrCl < 10
NON-ICU PATIENTS:
Respiratory FQ
Levaquin 750 mg IV daily
Moxifloxacin IV
Gemifloaxacin (Available PO only)
Or:
B-lactams + macrolides
Ceftriaxone 1-2g IV (IM) daily
Cefotaxime (Claforan) 1-2g IV (IM) every 8 or 12 hours depending on severity of infection
o Decrease dose by 50% when CrCl < 20
Ertapenem (Invanz) 1g IV (IM) daily for 10-14 days
o Decrease Ertapenem by 50% when CrCl < 30
o Ertapenem has activity against S. pneumoniae and similar coverage to CTX and cefotaxime,
but is inactive against atypicals and Pseudomonas aeruginosa.
ICU PATIENTS:
Pathophysiology
PNA is an acute infection that inflames the pulmonary
parenchyma. PNA is associated with a constellation of
features such as cough, sputum production, fever, chills,
difficulty breathing, and acute infiltrates that is demonstrable
on chest x-ray.
Some terminology from CXR impressions.
Pulmonary edema: build up of fluid in the alveoli leading to
SOB. Pulmonary edema is mainly caused by CHF. When blood
is not pumped efficiently from heart, the returning blood can
back up into the veins and lungs. The pressure and the fluid
build up the normal oxygen/carbon dioxide exchange leading
to SOB and the feeling of drowning.
Pneumothorax: is a collapsed lung due to collection of air in
the space around the lungs. The air build up exerts pressure
on the lungs causing it not to expand as much during
breathing
Pericardial effusion: pericardium is a double layered, sac
like structure that surrounds the heart and maintains its
normal function. This double layered sac usually has fluid
within, but when the fluid exceeds the limits due to blood
build up, inflammation or infection, it exerts pressure on the
heart causing SOB, heart failure and, if left untreated, death.
Duration
- 5 days
- Afebrile for 48-72h and
- No more than 1 CAP signs of clinical instability
- Longer duration of therapy may be needed if initial therapy
was not active against the identified pathogen or was
complicated with extrapulmonary infections such as
meningitis or endocarditis.
Switching from IV to PO and discharge
Hemodynamically stable and clinically improving
Able to ingest medications
Normally functioning GI
Discharge patients as soon as:
They are clinically stable with no other active
medical problems
o Temperature  37.8C
o HR  100 beats/min
o RR  24 breath/min
o SBP ≥ 90
o Arterial O2 saturation ≥ 90% or pO2 ≥60
on room air
o Able to maintain oral intake
o Normal mental status
Have safe environment for continuous care
Prevention:
Influenza vaccine
B-lactams + macrolides or FQ
Cefotaxime
Ceftriaxone
Ampicillin/sulbactam (Unasyn) 1500-3000 mg every 6 hours
o Decrease frequency to every 12 hours when CrCl <30
PLUS azithromycin or respiratory FQ
If PCN allergy then FQ + aztreonam recommended
Aztreonam (Azactam) 1-2 g IV (IM) every 6,8 or 12 hours depending on the severity of infection
o Decrease dose by 50% when CrCl < 30 but keep same interval
-
PPSV
Smoking cessation
Cases of public health concern should be reported
to state or local health department
Hygiene and patient education
Follow up evaluation
If pseudomonas  DOUBLE coverage
Antipneumococcal, antipseudomonal b-lactams:
Zosyn (piperacillin/tazobactam) 3.375g - 4.5 g IV every 6 hours for 7-14 days
Cefepime (Maxipime) 1-2g IV every 12 hours for 10 days
o Decrease frequency to every 24 hours when CrCl <60 rather than change dose
Antipseudomonal carbapenems:
Imipenem (Primaxin) 500mg IV every 6 hours or 1 g every 8 hours
o See Lexicomp for dosing adjustment based on weight and CrCl
Meropenem (Merrem) > 50kg 1g IV every 8 hours (< 50kg: 20-40 mg/kg q8hrs)
o CrCl <26 decrease frequency to every 12 hours
o CrCl < 10 decrease dose by 50% every 12 hours
PLUS
Ciprofloxacin (Cipro) 400mg every 8 hours
o Adjust Cipro when CrCl < 30
Levofloxacin 750mg
In Case of Allergies
If FQ allergy then b-lactams + aminoglycoside and azithromycin
If b-lactam allergy then aztreonam should be substituted  Aztreonam + FQ + aminoglycoside
If CA- MRSA then add vanco or Linezolid
Reference: Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of CommunityAcquired Pneumonia in Adults. Clinical Infectious Diseases 2007; 44: S27-72
Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia
Definitions:
HAP: Defined as pneumonia that occurs 48 hours or more after admission, which was not incubating at the time of admission. If patients
require intubation in case of severe HAP, then they should be manage similar to patients with VAP.
VAP: pneumonia that arises more than 48-72 hours after endotracheal intubation.
HCAP: Cover MDR pathogens
- Any patient who was hospitalized in an acute care hospital for two or more days within 90 days of the infection
- Resides in a nursing home or long term care facility
- Received recent IV ABX tx, chemotherapy, or wound care within the past 30 days of the current infection
- Attended a hospital or hemodialysis clinic
- Family member with MDR pathogens
- Immunocompramised patients
Consider MDR pathogens when:
- Antimicrobial therapy in the preceding 90 days
- Current hospitalization of 5 days or more
- High frequency of antibiotic resistance in the community or in the specific hospital unit
- Presence of risk factors for HCAP
Empiric Antibiotic Therapy for HAP
HAP, VAP or HCAP Suspected
Late onset (>5days) or risk factors
for MDR pathogens
Yes-See
table 2
No- See
table 1
Table 1: Initial empiric therapy for HAP/VAP/HCAP in patients with no known risk factors for MDR pathogens, early onset, and any disease severity
Potential Pathogens
Treatments (one of the following options only)
Streptococcus pneumoniae
Ceftriaxone
Haemophilus influenzae
Levofloxacin
Methicillin-sensitive Staphylococcus aureus
Moxifloxacin
Antibiotic-sensitive enteric gram negative bacilli
Ciprofloxacin
Escherichia coli
Unasyn
Klebsiella pneumoniae
Ertapenem
Enterobacter species
Proteus species
Serratia marcescens
Table 2: Initial empiric therapy for HAP/VAP/HCAP in patients with late onset disease or risk factors for MDR pathogens and all disease severity
Potential Pathogens
Treatments
Streptococcus pneumoniae
Antipseudomonal cephalosporin (OR)
Haemophilus influenzae
Cefepime 1-2g q8-12h
Methicillin-sensitive Staphylococcus aureus
Ceftazidime 2g q8h
Antibiotic-sensitive enteric gram negative bacilli
Antipseudomonal carbapenem (OR)
Escherichia coli
Imipenem 500mg q6h or 1g q8h
Klebsiella pneumoniae
Meropenem 1g q8h
Enterobacter species
B-lactam/B-lactamase inhibitor
Proteus species
Zosyn 4.5g q 6h
Serratia marcescens
PLUS
MDR pathogens include:
Antipseudomonal FQ (OR)
Pseudomonas aeruginosa
Ciprofloxacin 400mg q8h
Klebsiella pneumoniae (ESBL)
Levofloxacin 750mg daily
Acinetobacter species
Aminoglycoside
Legionella pneumohila
Amikacin 20mg/kg daily (Tr goal < 4-5 mcg/ml)
Gentamycin 7mg/kg daily (Tr goal < 1 mcg/ml)
Tobramycin 7mg/kg daily (Tr goal <1 mcg/ml)
Methicillin Resistant Staphylococcus aureus
ADD
Linezolid 600mg q12h or
Vancomycin 15mg/kg q12h (Tr goal should be 15-20 mcg/ml)
Common & Possible Side Effects for Common Antibiotics
Penicillin
Unasyn, amoxicillin
Cephalosporins
Ceftriaxone
Cefepime
Fluoroquinolone
Levaquin
Avelox
Cipro
Macrolides
Azithromycin
Rash, urticaria, diarrhea, ALT/AST elevation, pseudomembraneous colitis, bronchospasm, and hypotension.
Rash, diarrhea, BUN elevation (~1%), alk phos elevation, hemolytic anemia, aplastic anemia, allergic dermatitis, edema,
angioedema, and creatinine elevations.
Fever, HA, rash, pruritis, N/V/D, elevation of alk phos, BUN, creatinine, and bilirubin. Hyperkalemia, hyperphosphotemia, and
hypercalcemia
HA, insomnia, dizziness, rash, pruritis, abdominal pain, dyspepsia, diarrhea-can be C.diff associated, constipation, arrhythmias,
QT prolongation, TdP, and psychosis.
Above mentioned plus AST/ALT, alk phos, BUN, and creatinine elevation, hypokalemia, hyperglycemia, hyperlipidemia,
triglycerides and uric acid increase
PT/INR prolongation
- All FQ have category C interactions with Warfarin
QTc prolongation- have category C interaction with Warfarin
Combination with Amiodarone should be avoided