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Pneumonia

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Pharmacotherapeutics of pneumonia

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Pneumonia

  1. 1. Pharmacotherapy of Infectious Diseases A Case-Based Approach Pneumonia Anas Bahnassi PhD Pharmacotherapy of Infectious Diseases Anas Bahnassi 2014 A Case-Based Approach
  2. 2. Pharmacotherapy of Infectious Diseases A Case-Based Approach Introduction •Community Acquired Pneumonia (CAP) –Common and serious disease. –80% of cases can be treated at home. –Mortality rate for patients requiring hospitalization is 8-10%, and can increase to 40% to those requiring ICU. –Clinical presentation of CAP does not allow for and etiological diagnosis. –Many organisms can be Anas Bahnassi 2014
  3. 3. Pharmacotherapy of Infectious Diseases A Case-Based Approach Common pathogens in CAP: Pneumonia treated on ambulatory basis Streptococcus pneumoniae Mycoplasm pneumoniae Haemphilus Influenzae Chlamydophila pneumoniae Respiratory viruses Moraxelia catarrhalis Anas Bahnassi 2014 Pneumonia requiring hospital admission Streptococcus pneumoniae Chlamydophila pneumoniae Haemphilus Influenzae Lagionella supp. Aspiration G –ve. Bacilli Mixed etiology Respiratory viruses Mycoplasm pneumoniae Pneumonia requiring ICU admission Streptococcus pneumoniae Staphylococcus aureus Lagionella supp. G –ve. Bacilli Haemphilus Influenzae
  4. 4. Pharmacotherapy of Infectious Diseases A Case-Based Approach Goals of Therapy •Assess severity of pneumonia. •Eradicate infecting pathogen. •Relieve symptoms. –Fever, cough, pleuritic chest pain, sputum, dyspnea. •Promptly recognize and minimize complications. –Metastatic infection, empyema, cavitation, pneumothorax, septic shock, respiratory failure, worsening of comorbid condition (IHD, DM). •Provide end-of-life care if emerges. Anas Bahnassi 2014 Empyema is a collection of pus in the space between the lung and the inner surface of the chest wall (pleural space). Pneumothorax: collapsed lung.
  5. 5. Pharmacotherapy of Infectious Diseases A Case-Based Approach Investigations •History and PI with particular attention to: –Symptoms: •Cough, SOB, pleuritic chest pain, hemoptysis, sputum, fever, chills, headache, confusion, …. –History of recent travel and other risk factors like: •Smoking, alcohol, comorbid illnesses. –Physical findings: •Objective measurements: –Vital signs: RR≥30 is the most sensitive and specific sign. –Oxygenation status: If O2 saturation is ≤ 92% then perform arterial blood gas. –Chest radiograph: consider a CT scan if radiograph is negative. Anas Bahnassi 2014
  6. 6. Pharmacotherapy of Infectious Diseases A Case-Based Approach Investigations •Laboratory testing: –Electorlytes, Glu, BUN, Cr, CBC, differential WBC. –Blood cultures. –Sputum culture from the lower respiratory tract. –Urine for Legionella antigens. –Rapid test for flu. –Serological studies. –Nucleic acid amplification. Anas Bahnassi 2014
  7. 7. Pharmacotherapy of Infectious Diseases A Case-Based Approach CURB-65 Anas Bahnassi 2014
  8. 8. Pharmacotherapy of Infectious Diseases A Case-Based Approach Anas Bahnassi 2014
  9. 9. Pharmacotherapy of Infectious Diseases A Case-Based Approach Anas Bahnassi 2014
  10. 10. Pharmacotherapy of Infectious Diseases A Case-Based Approach Initial Management of CAP Anas Bahnassi 2014 CAP diagnosed based on History, PE, Findings, chest X-ray PSI is for guidance not to replace clinical judgment < 90 and not hypo- oxynated > 90 treat in hospital Otherwise healthy, no use of antibiotics for 3 months, and no other risk factor use macrolide or doxycycline po Co-morbidities , lung or kidney disease, risk factors then respiratory fluroquinolone *po, or Amox HD or Amox/Clav + Macrolide No Erythromycin alone Treat at home *moxifloxacin, levofloxacin. Gemifloxacin is not approved for CAP
  11. 11. Pharmacotherapy of Infectious Diseases A Case-Based Approach Initial Management of CAP Anas Bahnassi 2014 CAP diagnosed based on History, PE, Findings, chest X-ray PSI is for guidance not to replace clinical judgment > 90 treat in hospital (Respiratory Fluroquinolone po/iv or B- lactam po/iv )+ Macrolide po/iv Antipnumococcal, antipsudomonal B- lactam*+ one of the followings: •Ciprofloxacin •Aminoglycoside + Macrolide •Aminoglycoside + Ciprofloxaxin Ward B-lactam iv + (Macrolide iv or respiratory fluroquinolone iv) ICU ICU S.aregunesa * Cefepime or imipenem or meropenem or piperacillin/tazopactam
  12. 12. Pharmacotherapy of Infectious Diseases A Case-Based Approach Antibiotic Treatment Recommendations Anas Bahnassi 2014 Class Drug Dose ADR Comments Cost Amino- glycosides Gentamicin Conventional: 1.5mg/kg DBW Q8H iv Extended: 4-6mg/kg DBW Once iv Nephro/ Ototoxicity Do not permeate pulmonary tissue very well. Exhibit conc. dependent bacterial killing and postantibiotic effect Co-administration with vancomycin or loop diuretics may increase the risk of nephro/ototoxicity $ Tobramycin Conventional: 1.5mg/kg DBW Q8H iv Extended: 4-6mg/kg DBW Once iv $ In obese patients >30 of ideal body weight (IBW) use dosing body weight (DBW) instead of total body weight (TBW) to prevent overdosing. DBW=0.4 (TBW-IBW) Ideal body weight in (kg) Males: IBW = 50 kg + 2.3 kg for each inch over 5 feet. Females: IBW = 45.5 kg + 2.3 kg for each inch over 5 feet.
  13. 13. Pharmacotherapy of Infectious Diseases A Case-Based Approach Antibiotic Treatment Recommendations Anas Bahnassi 2014 Class Drug Dose ADR Comments Cost Fluro- quinolones Cipro- floxacin PO: 500- 750mg BID IV: 400mg Q12H GI upset, HA, dizziness, photo- sensitivity, hepatitis. Avoid in children: Cartridge toxicity. Cipro is not a 1st line agent for CAP. Cipro available in suspension. Decreased absorption with antacids, metals, and sucrafate. Cipro may decrease theophylline or cyclosporin elimination.  Levo 750 BID X5d is equivalent to 500 BID X10d. May increase warfarin effect. Avoid in class Ia and III arrhythmia patients or prolonged QT intervals Can switch from iv to po $ Levo- floxacin PO: 500mg Q24H X10 days. or 750mg Q12H X5 days. IV: 500mg Q24H $ Moxi- floxacin 400mg Q24H po/iv`
  14. 14. Pharmacotherapy of Infectious Diseases A Case-Based Approach Antibiotic Treatment Recommendations Anas Bahnassi 2014 Class Drug Dose ADR Comments Cost Glyco- peptides Vanco- mycin 1g Q12H iv Nephro/ ototoxicity Infusion related ADRs may increase with shorter infusion times For MRSA pneumonia. Increase risk of nephrotoxicity when co- administered with aminoglycosides. $$$$ Ketolides Telithro-mycin 800mg daily X7-10 days Diarrhea, nausea, vomiting, elevated liver enzymes, hepatotoxicity. Can not be considered as a first line. Hepatotoxicity can be fatal. Telithromycin: Atorvastatin, Lovastatin, Simvastatin, Itraconazole, Ketoconazole. Digoxin levels. Contraindicated with ergot, pimozide and disopyramide.
  15. 15. Pharmacotherapy of Infectious Diseases A Case-Based Approach Antibiotic Treatment Recommendations Anas Bahnassi 2014 Class Drug Dose ADR Comments Cost Linco- semides Clindamycin 300-450mg Q6H po 600mg Q8H iv Diarrhea C.Difficile For suspected aspiration provide anareobic coverage $ Macro- lides Azithromycin Adults 500mg on day 1 then 250 on days 2-5 Lower GI effects than Eryth. Azi QD X5days = Ery QID X10days. More effective than clarithro-mycin for H.influenzae. $$ Clarithromycin 500mg BID X10d Or 1g ER QD X10d Contraindicated with pimozide. Rifampin  Conc. Warfarin levels. Conc. of CYP3A4 susbtrates (statins/digoxin) $$ Erythromycin 500mg QID po GI upset $
  16. 16. Pharmacotherapy of Infectious Diseases A Case-Based Approach Antibiotic Treatment Recommendations Anas Bahnassi 2014 Class Drug Dose ADR Comments Cost Nitro- imidazole Metronidazole 500mg po/iv Q12H Vertigo, HA, Ataxia, GI, taste change Avoid alcohol until 48h after the last dose (disulfram-like reaction) $ Oxazolidi- none Linezolide 600mg po/iv Q12H GI, HA, dose and time dependent bone marrow suppression, peripheral neuropathy. Preferred agent for MSRA –pneumonia.  Risk of serotonin toxicity with concurrent use of serotonergic drugs. $$
  17. 17. Pharmacotherapy of Infectious Diseases A Case-Based Approach Antibiotic Treatment Recommendations Anas Bahnassi 2014 Class Drug Dose ADR Comments Cost Carba- penems Ertapenam 1g daily iv Anaphylaxis, diarrhea, HA, increased seizure risk. Indicated for S.pneumonia (penicillin- susceptible), H.influenzae. M. Catarrhalis. $$$ Impenem 500 mg Q6H iv Hypotension, nausea with rapid infusion, seizure activity with high levels. Antipseudomonal for patients with high risk for P. aeruginosa. $$$$ Meropenam 1g Q8H iv Less than Impenem. $$$$
  18. 18. Pharmacotherapy of Infectious Diseases A Case-Based Approach Antibiotic Treatment Recommendations Anas Bahnassi 2014 Class Drug Dose ADR Comments Cost Carba- penems Ertapenam 1g daily iv Anaphylaxis, diarrhea, HA, increased seizure risk. Indicated for S.pneumonia (penicillin- susceptible), H.influenzae. M. Catarrhalis. $$$ Impenem 500 mg Q6H iv Hypotension, nausea with rapid infusion, seizure activity with high levels. Antipseudomonal for patients with high risk for P. aeruginosa. $$$$ Meropenam 1g Q8H iv Less than Impenem. $$$$
  19. 19. Pharmacotherapy of Infectious Diseases A Case-Based Approach Antibiotic Treatment Recommendations Anas Bahnassi 2014 Class Drug Dose ADR Comments Cost Cephalo- sporins Cefazolin 1st generation 1-2g Q8H iv Hyper- sensitivity $-$$ Cefaclor 2nd generation 250mg TID po $ Cefprozil 2nd generation 500mg BID po $ Cefotaxime 3rd generation 1-2g Q8H iv Can be used hepatobilliary disease. $$- $$$ Cefepim 4th generatrion 1-2g Q12H Antipseudomonal for patients with high risk for P. aeruginosa. $$$$
  20. 20. Pharmacotherapy of Infectious Diseases A Case-Based Approach Antibiotic Treatment Recommendations Anas Bahnassi 2014 Class Drug Dose ADR Comments Cost Penicillins Penicillin V K 300mg TID- QID po Anaphylaxis GI distress Diarrhea. $ Penicillin G 2MU Q4H iv $ Amoxicillin 500mg TID po GI distress Diarrhea. Consider HD if patient is with drug resistant S.pneumoniae risk factors $ Amox/Clav 500/125 TID po or 875/125 BID po $$ Rifamycin Rifampin 300mg BID po Rash, orange discoloration of body fluids, GI upset, liver toxicity, hematologic effects Never use as a single agent for CAP CYP inducer.
  21. 21. Pharmacotherapy of Infectious Diseases A Case-Based Approach Antibiotic Treatment Recommendations Anas Bahnassi 2014 Class Drug Dose ADR Comments Cost Sulfo- namides SMX/TMP 800/160mg BID po GI, rash, Stevenson- Johnson’s syndrome May  effects of sulfonylurea and warfarin. Caution with G6PD deficiency and impaired renal and hepatic function. $ Tetracyclins Doxycycline 100mg BID on 1st day then 100mg once GI, photosensitivity Fe/antacids  absorption. Alcohol. Barbiturates, phenytoin, rifampin, carbamazepin  levels. $
  22. 22. Pharmacotherapy of Infectious Diseases A Case-Based Approach Empiric Treatments for Adults Anas Bahnassi 2014
  23. 23. Pharmacotherapy of Infectious Diseases A Case-Based Approach Empiric Treatments for Adults Anas Bahnassi 2014
  24. 24. Pharmacotherapy of Infectious Diseases A Case-Based Approach Empiric Treatment in Children Anas Bahnassi 2014
  25. 25. Pharmacotherapy of Infectious Diseases A Case-Based Approach Prevention Measures •Smoking cessation. •Influenza vaccine. •Pneumococcal vaccine. •Chin down posture reduce the chance of aspiration both before and during the swallow. •Follow-up chest radiographs for smokers. Anas Bahnassi 2014
  26. 26. Pharmacotherapy of Infectious Diseases A Case-Based Approach Pharmacotherapy: Infectious Diseases: Anas Bahnassi PhD abahnassi@gmail.com http://www.twitter.com/abpharm http://www.facebook.com/pharmaprof http://www.linkedin.com/in/abahnassi Anas Bahnassi 2014

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