PNEUMONIA TREATMENT PROTOCOL

BY SEHAM MOUSTAFA

FETOUHBCPS , MSc of clinical pharmacy , Pharm D

CONTENTS OF PROTOCOL

protocol By Clinical pharmacist

CAP Seham Moustafa Fetouh

HAP Eman Mohamed Elfakhrany

Aspiration pneumonia

Seham Moustafa Fetouh

COMMUNITY ACQUIRED PNEUMONIA

DEFINITION

•Acute infection of the pulmonary parenchyma in a

patient who has acquired the infection in the

community

INVESTIGATIONS WORKUP

• Signs and symptoms

• Chest examination

• plain chest radiograph

• CT scan

• lung ultrasound

• CBC

• C-reactive protein test

• blood cultures and sputum Gram stain and culture

• C-reactive protein test if clinical diagnosis is unclear. it can

reveal that you have inflammation somewhere in your body.

< 20 mg/litre no AB

20-100 delayed AB if symptoms worsen

>100 immediate AB

CLINICAL FEATURES OF CAP

• Chest manifestation

● cough, fever, rigors, chills , pleuritic chest pain, dyspnea, sputum

production

● Mucopurulent sputum with bacterial pneumonia, scant or watery sputum

with atypical

pathogen and on Chest examination audible crackles

● respiratory rate > 24 breaths/minute

● nausea, vomiting, diarrhea

● mental status changes, tachycardia

SEVERITY ASSESSMENT IN PRIMARY CARE

confusion Mental Test score ≤ 8 , or new disorientation in person, place or time

blood urea nitrogen > 7 mmol/litre

respiratory rate ≥30 breaths per minute

low blood pressure diastolic ≤ 60 mmHg , or systolic <90 mmHg

age ≥ 65 years

1 point for each of the following prognostic features:

CURB65 score

M.O SUSPECTED

Atypical pneumonia

(uncommon)

Typical organisms (Common)

Legionella spp

M. pneumonia

C. pneumonia

Chlamydia psittaci

S. pneumonia

Haemophilus influenza

Staphylococcus aureus

group A streptococci

Moraxella catarrhalis

anaerobes, and aerobic gram-negative bacteria

respiratory viruses

EMPERIC TREATMENT WITHIN 4 HOURS OF PRESENTATION TO

HOSPITALseverity duration TTT

Outpatient treatment

Low severity CURB65 0-1-Previously healthy- no use of antimicrobials within the previous three months

3-5 daysif symptoms do

not improve as expected after 3 days.course of the antibiotic > 5 days

amoxicillin 500/8hr

-patients who are allergic to penicillinMacrolide (azithromycin 500/24hr, clarithromycin

500/12hr OR Doxycycline 100/12hr

Low severity CURB65 0-1-Presence of comorbidities or -use of antimicrobials within the previous three months

7-10 days respiratory fluoroquinolone (levofloxacin 750 /24hr or moxifloxacin 400mg /24hr)

(high-dose amoxicillin 1g /8hr , or amoxicillin-clavulanate 2g /12hr or ceftriaxone1-2/12-24 hr, or cefpodoxime200/12hr) plus macrolide (azithromycin500/24hr , or clarithromycin 500/12 hr or doxycycline 100/12 hr

Inpatient, non-ICU treatment

-Moderate severityCURB65 2

-Presence of comorbidities

7-10 days respiratory fluoroquinolone (levofloxacin 750 /24hr or moxifloxacin 400 /24hr)

cefotaxime1-2g/8hr or ceftriaxone1-2g /12-24hr plusmacrolide OR doxycycline

Inpatient, ICU treatment

-high severityCURB65 3-5

7-10 days fluoroquinolone OR azithromycin plus

cefotaxime1-2g/8hr or ceftriaxone 1-2g /12-24hr or ampicillin-sulbactam 1.5-3g/ 6hr

ifPseudomonasrisk

10 days (Piperacillin-tazobactam3.375/6hr,cefepime2g/8hr,imipenem500/6hr,ormeropenem1g/8hr)plus

ciprofloxacin400/8hr or levofloxacin 750 mg/24hr(Piperacillin-tazobactam ,cefepime, imipenem, or meropenem)plusaminoglycoside and azithromycin

(Piperacillin-tazobactam,cefepime, imipenem, ormeropenem)plus

aminoglycoside and fluoroquinoloneCA-MRSA risk 7-21days Add vancomycin15-20mg/kg/day/8-12hr or linezolid

600/12hr

* comorbidities such as chronic heart, lung, liver, or renal disease;

diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing

conditions or use of immunosuppressing drugs.

* Do not routinely offer a glucocorticosteroid unless they have other

conditions for which glucocorticosteroid treatment is indicated.

* the preferable use of antibiotic is ordered in descending order

* the use of antipseudomonal and anti MRSA medications according to

microbiological data and with consultation of microbiologists

• Switching from intravenous to oral

when patients are hemodynamically stable and improving clinically, are

able to ingest medications, and have a normally functioning

gastrointestinal tract.

•

Monitoring in hospital

C-reactive protein baseline on admission and repeat the test if clinical progress is uncertain after 48 to 72 hours.

Do not routinely discharge patients if in the past 24 hours they have had 2 or more of the following :

TempRRHRSBP

PaO2

> 37.5°C≥24 breaths per minute> 100 beats per minute≤ 90 mmHg 90%abnormal mental statusinability to eat without assistance.

HOSPITAL ACQUIRED PNEUMONIA

DEFINITION

HAP is pneumonia that occur 48 hr or more

after admission and did not appear at the

time of admission and not associated with

mechanical ventilation during that time .

PATHOGENS

Gm – vebacilli

E-coli , klebsiella pneumoniae ,Enterobacter spp, Pseudomonas aeruginosa , Acinobacter spp .

Gm +ve cocci Staphylococcus aureus including MRSA , streptococcus spp.

Emperic Treatment

IF Not of high risk of mortality* Using one of the following:

Levofloxacin 750 mg /24hr

Cefepim 2 g /8hr

piperacillin –tazobactam 4.5 g/6hr

if suspected MRSA: add

vancomycin 15mg /kg / 8-12 hr.

(consider loading dose 25-30 mg

/kg x 1 for severe illness )

IF high risk of mortality* Using one of the following:

Levofloxacin 750 mg /24hr

Ciprofloxacin 400 mg /8hr

Amikacin 15-20 mg/kg /24hr

Gentamycin 5-7 mg /kg /24hr

PLUS

Using one of the following:

Cefepim 2 g /8hr

Ceftazidim 2g /8hr

Imipenem 500mg /6hr

Meropenem 1g /8hr

piperacillin –tazobactam 4.5 g/6hr

if suspected MRSA: add

vancomycin 15mg /kg / 8-12 hrs.

(consider loading dose 25-30 mg

/kg x 1 for severe illness )

* high risk of mortality

-Ventilator support due to HAP and septic shock

-Prior intravenous antibiotic use within 90 days

-the patient has structure lung disease (cystic fibrosis, bronchiectasis)

Duration : 7-10 days consider using procalcitonine levels plus clinical criteria

to define the treatment course .

ASPIRATION PNEUMONIA

DEFINITION

• refers to the pulmonary consequences resulting from the abnormal entry of

fluid, particulate exogenous substances, or endogenous secretions into the

lower airways.

Aspiration of gastric acidchemical pneumonitis ( Mendelson syndrome)

Aspiration of bacteria from oral and pharyngeal areas

aspiration pneumonia

Types of spiration

Risk factors of aspiration

INVESTIGATIONS WORKUP

• Signs and symptoms

• CBC With Differential

• Arterial blood gas (ABG)

• mixed venous gas measurement

• sputum culture

• chest radiograph

• Bronchoscopy

CHEMICAL PNEUMONITISClinical features

●Abrupt onset of symptoms within a few minutes to two hours of the

aspiration event

● dyspnea , respiratory distress, Tachypnea , audible wheezing, rales, and

cough with pink or frothy sputum.

● Cyanosis and diffuse crackles on lung auscultation

●Severe hypoxemia

●low grade Fever

●tachycardia

● infiltrates ( on Chest imaging ) on involving dependent pulmonary segments

.The dependent lobes in the upright position are the lower lobes. aspiration

that occurs while patients are in the recumbent position may result in infection

in the superior segments of the lower lobes and the posterior segments of the

ANTIBIOTIC TTT

•In patients who are severely ill, the empiric use of antibiotics is appropriate.

However, if no infiltrates develop after 48 to 72 hours, it is appropriate to

stop antibiotics

•repeat a chest radiograph and discontinue antibiotics if the infiltrates and

signs and symptoms of pneumonia have resolved

BACTERIAL INFECTION

Chest manifestation

● Cough with purulent sputum ,Shortness of breath, dyspnea on exertion

● Pleuritic chest pain

● Putrid expectoration (a clue to anaerobic bacterial pneumonia)

● Fever or chills

● Malaise, myalgias

● Rigors may be present of absent

●complication untreated aspiration pneumonia bronchopleural fistula Lung abscess, necrotizing pneumonia, or empyema.

M.O suspected

Community aspiration pneumonia

mixed bacterial infection anaerobes and facultative anaerobes such as oral streptococcilung abscess streptococci

Hospital-acquired or healthcare-associated aspiration pneumonia

aerobic bacteria, especially gram-negative bacilli and S. aureus, are more important than the anaerobes

Emperic Treatment

IV drugs Oral drugs dose considerationsampicillin-sulbactam 1.5 to 3 g IV /6hr first-line therapyceftriaxone or cefotaxime+metronidazole

1 or 2 g IV daily1 or 2 g IV /8hr

500 mg orally or IV /8hr

1st Alternative agents

Carbapenemimipenem/cilastatin 500 mg IV /6hr 1st Alternative agentsPipracillin/tazobactam 3.375g iv/ 6hr 1st Alternative agents

amoxicillin-clavulanate

875 mg /125 orally /12hr 1st Alternative agents

clindamycin clindamycin 600 mg IV /8hr followed by 300 mg orally /6hr or 450 mg orally /8hr

-for penicillin-allergicpatients added to regimens not containing Piperacillin/tazobactam-has high rate of C. difficile

moxifloxacin 400mg oral once Has high rate of resistance and higher risk of Clostridium difficile

•Community acquired aspiration pneumonia -oral antibiotics used in patients who are hemodynamically stable, able to take oral medications, and have a normally functioning gastrointestinal tract

Hospital-acquired or healthcare-associated aspiration pneumonia

aerobic bacteria, especially gram-negative bacilli and S. aureusCefepim 2 g /8hr Levofloxacin 750 mg /24hrCiprofloxacin 400 mg /8hrGentamycin 5-7 mg /kg /24 hr

-patients with poor dentition -patients known to be colonized with resistant gram-negative bacilli -patients who have received IV antibiotics within the past 90 days

regimen against both aerobes and anaerobesImipenem 500mg /6 hrMeropenem 1g /8 hrpiperacillin –tazobactam 4.5 g/6 hr

patients with risk factors for MRSA Add vancomycin 15mg /kg / 8-12 hor linezolid

•Hospital-acquired or healthcare-associated aspiration pneumonia

Prophylactic antibiotic are not recommended for patients who are at increased risk for aspiration.

Duration

• If not complicated by cavitation or empyema is 7 days

• Patients with lung abscess need a longer course of antibiotics, usually until

there is radiographic clearance or significant improvement

• Switch to oral antibiotics

when they are improving clinically, hemodynamically stable, able to take oral

medications, and have a normally functioning gastrointestinal tract

amoxicillin-clavulanate (875 mg orally twice daily).

or

clindamycin (450 mg orally three times daily) For patients who have a serious

allergy to penicillin.

Risk factors

-previous antibiotic therapy

-recent hospitalization

-immunosuppression

-pulmonary comorbidity (cystic fibrosis, bronchiectasis, or repeated exacerbations of COPD)

-probable aspiration, and multiple medical comorbidities

Pseudomonas or

drug-resistant

pathogens

-colonization with MRSA (ESKD, contact sport participants, injection drug users, those living

in crowded conditions, prisoners)

-recent influenza-like illness

-antimicrobial therapy (particularly fluoroquinolone) in the prior 3 months

-necrotizing or cavitary pneumonia, and presence of empyema

MRSA

-Age >65 years

-Beta-lactam, macrolide, fluoroquinolone therapy within the past 3-6 months

-Alcoholism

-Medical comorbidities

-Immunosuppressive illness or therapy

-Exposure to a child in a daycare center

-prior hospitalization or residence in a long-term care facility

drug-resistant

S. pneumonia

REFERANCES CAP• Uptodate

1-Epidemiology, pathogenesis, and microbiology of community-acquired pneumonia in adults

Authors:Thomas J Marrie, MDThomas M File, Jr, MDSection Editor:John G Bartlett, MDDeputy Editor:Sheila Bond, MD

2-Diagnostic approach to community-acquired pneumonia in adults

Author:John G Bartlett, MDSection Editor:Stephen B Calderwood, MDDeputy Editor:Sheila Bond, MD

3- Treatment of community-acquired pneumonia in adults who require hospitalization

Author:Thomas M File, Jr, MDSection Editor:John G Bartlett, MDDeputy Editor:Sheila Bond, MD

Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of

Community-Acquired Pneumonia in Adults

Lionel A. Mandell Richard G. Wunderink Antonio Anzueto John G. Bartlett G. Douglas Campbell Nathan C. Dean Scott

F. Dowell Thomas M. File, Jr. Daniel M. Musher Michael S. Niederman Antonio Torres Cynthia G. Whitney

clinical Infectious Diseases, Volume 44, Issue Supplement_2, 1 March 2007, Pages S27–S72

NICE clinical guideline 191

guidance.nice.org.uk/cg191

Diagnosis and management of community- and hospital-acquired pneumonia in adults

REFERANCES HAP

• Andre C. Kalil, Mark L. Metersky, Michael Klompas , et al .

Management of Adults With Hospital-acquired and Ventilator-

associated Pneumonia: 2016 Clinical Practice Guidelines by the

Infectious Diseases Society of America and the American

Thoracic Society.

REFERENCES ASPIRATION

-Uptodate

Aspiration pneumonia in adults

Author:John G Bartlett, MDSection Editor:Daniel J Sexton, MDDeputy Editor:Sheila Bond, M

-http://emedicine.medscape.com/article/296198-overview#a9

-Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the

Management of Community-Acquired Pneumonia in Adults

Lionel A. Mandell Richard G. Wunderink Antonio Anzueto John G. Bartlett G. Douglas Campbell Nathan

C. Dean Scott F. Dowell Thomas M. File, Jr. Daniel M. Musher Michael S. Niederman Antonio Torres

Cynthia G. Whitney

Clinical Infectious Diseases, Volume 44, Issue Supplement_2, 1 March 2007, Pages S27–S72

-Antibiotic Guidelines johns hopkins 2015-2016 Sara E. Cosgrove, M.D., M.S.

Director, Antimicrobial Stewardship Program, Edina Avdic, Pharm.D., M.B.A, ID Pharmacist

Associate Director, Antimicrobial Stewardship Program

-Sanford guide antimicrobial therapy electronic application