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Treatment of CAP in adults who require hospitalization.pptx

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Dr.Amjed Alnatsheh

1. The document provides guidelines for treating community-acquired pneumonia (CAP) in adults requiring hospitalization. It discusses likely pathogens, risk factors for resistant organisms, and initial empiric antibiotic therapy regimens for medical wards and ICUs. 2. For medical wards, recommendations include beta-lactam plus macrolide or fluoroquinolone for most patients. For MRSA or pseudomonas risk, combination therapy with anti-pseudomonal drugs is advised. 3. For the ICU, recommendations are similar but include more potent beta-lactams. Adjunctive steroids are advised for severe sepsis/shock. Antiviral therapy is recommended for influenza.

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Treatment of CAP in adults who require hospitalization
Likely pathogenes 01 Risk facto Risk factor for organism resistant 02 Initial Empiric Therapy 03
Likely pathogenes
Likely Pathogens Streptococcus pneumoniae, Respiratory viruses (eg, influenza, parainfluenza, respiratory syncytial virus, rhinovirus), and, less often, Mycoplasma pneumoniae, Haemophilus influenzae, and Legionella spp S. pneumoniae is the most common, but Legionella, gram- negative bacilli, Staphylococcus aureus, and influenza are also important Medical Ward ICU
MRSA :Strong risk factors Known MRSA colonization Prior MRSA infection Detection of gram-positive cocci in clusters on a good- quality sputum Gram stain
MRSA : Other factors that should raise suspicion for infection Recent hospitalization or antibiotic use, particularly hospitalization with receipt of IV antibiotics in the prior 3 months Recent influenza-like illness Risk factors for MRSA colonization, including: End-stage renal disease Crowded living conditions (eg, incarceration) Injection drug use Contact sports participation Men who have sex with men Necrotizing or cavitary pneumonia Empyema Immunosuppression
Pseudomonas Known Pseudomonas colonization Recent hospitalization or stay in a long-term care facility Detection of gram-negative rods on a good-quality sputum Gram stain Prior Pseudomonas infection Hospitalization with receipt of IV antibiotics in the prior 3 months Frequent COPD exacerbations requiring glucocorticoid and/or antibiotic use Other structural lung diseases (eg, bronchiectasis, cystic fibrosis)
Determining whether a patient with CAP can be safely treated as an outpatient or requires admission to an observation unit, general medical ward, or higher acuity level of inpatient care, such as an ICU, is an Essential First Step. Severity of illness is the most critical factor in making this determination, but other factors should also be taken into account.
Antibiotic recommendations for hospitalized patients with CAP are divided by the site of care (Medical ward or ICU]). Most hospitalized patients are initially treated with an IV regimen but can transition to oral therapy as they improve. Start antibiotic therapy as soon as we are confident that CAP is the appropriate working diagnosis and, ideally, within four hours of presentation for patients being admitted to the general medical ward . In patients with septic shock, antibiotics should be started within one hour.
Treatment of CAP in adults who require hospitalization.pptx
Treatment of CAP in adults who require hospitalization.pptx
Pneumonia Severity Index
CURB-65 pneumonia severity score
Among the available scoring systems for determining the need for admission in patients with CAP, we prefer the PSI because it is the best studied and validated. If a less complex scoring system is desired, the CURB- 65 score is a reasonable alternative, although its effectiveness and safety in guiding the initial site of treatment have not been empirically assessed.
Medical Ward Therapy
1. Without suspicion for MRSA or Pseudomonas 1. Combination therapy with Ceftriaxone (1 to 2 g IV daily), Cefotaxime (1 to 2 g IV every 8 hours), Ceftaroline ( 600 mg IV every 12 hours), ertapenem (1 g IV daily), or Ampicillin- Sulbactam (3 g IV every 6 hours) PLUS a Macrolide (azithromycin [500 mg IV or orally daily] or clarithromycin [500 mg twice daily] or clarithromycin XL [two 500 mg tablets once daily]). Doxycycline (100 mg orally or IV twice daily) may be used as an alternative to a macrolide.
2. Monotherapy with a respiratory fluoroquinolone (Levofloxacin [750 mg IV or orally daily] or Moxifloxacin [400 mg IV or orally daily] or Gemifloxacin [320 mg orally daily]) is an appropriate alternative for patients who cannot receive a beta-lactam plus a macrolide.
2.With suspicion for Pseudomonas Combination therapy with an antipseudomonal/antipneumococcal beta-lactam antibiotic and an antipseudomonal fluoroquinolone, such as the following regimens:: 1. Piperacillin-tazobactam (4.5 g every 6 hours) or 2. Imipenem (500 mg every 6 hours) or 3. Meropenem (1 g every 8 hours) or 4. Cefepime (2 g every 8 hours) or 5. Ceftazidime (2 g every 8 hours; activity against pneumococcus more limited than agents listed above) PLUS 1. Ciprofloxacin (400 mg every 8 hours) or 2. Levofloxacin (750 mg daily) The dose of levofloxacin is the same when given IV and orally, while the dose of ciprofloxacin is 750 mg orally twice daily
3.With suspicion for MRSA Either Vancomycin or Linezolid (600 mg IV every 12 hours).
Antiviral treatment is recommended as soon as possible for all persons with suspected or confirmed influenza requiring hospitalization or who have progressive, severe, or complicated influenza infection, regardless of previous health or vaccination status . 4.Influenza therapy
1. Beta-lactam plus either a Macrolide OR 2. Monotherapy with a Respiratory fluoroquinolone OR 3. Beta-lactam plus Doxycycline. 1. Without suspicion for MRSA or Pseudomonas Antipseudomonal/antipneumococcal beta-lactam (eg, Piperacillin- Tazobactam, Cefepime, Ceftazidime, Meropenem, or Imipenem) PLUS Antipseudomonal fluoroquinolone (eg, Ciprofloxacin or Levofloxacin) 2. With suspicion for Pseudomonas Anti-MRSA activity, such as Vancomycin or Linezolid 3. With suspicion for MRSA Medical Ward Empiric Antibiotic for CAP MRSA Risks Pseudomonas Risks Strong risk factors Known MRSA colonization Known Pseudomonas colonization Prior MRSA infection Prior Pseudomonas infection Detection of gram-positive cocci in clusters on a good-quality sputum Gram stain Detection of gram-negative rods on a good-quality sputum Gram stain Hospitalization with receipt of IV antibiotics in the prior 3 months Other factors that should raise suspicion for infection Recent hospitalization or antibiotic use, particularly hospitalization with receipt of IV antibiotics in the prior 3 months Recent hospitalization or stay in a long-term care facility Recent influenza-like illness Recent antibiotic use of any kind Necrotizing or cavitary pneumonia Frequent COPD exacerbations requiring glucocorticoid and/or antibiotic use Empyema Other structural lung diseases (eg, bronchiectasis, cystic fibrosis) Immunosuppression Immunosuppression Risk factors for MRSA colonization, including:ESRD Crowded living conditions (eg, incarceration) Injection drug use Contact sports participation Men who have sex with men
ICU Therapy
1. Without suspicion for MRSA or Pseudomonas 1. IV combination therapy with a potent antipneumococcal beta-lactam (Ceftriaxone [1 to 2 g daily], Cefotaxime [1 to 2 g every 8 hours], Ceftaroline [600 mg every 12 hours], Ampicillin-sulbactam [3 g every 6 hours], or Ertapenem [1 g IV daily]) plus an advanced macrolide (Azithromycin [500 mg daily]). an alternative to Azithromycin is a respiratory fluoroquinolone (Levofloxacin [750 mg daily] or Moxifloxacin [400 mg daily]).
2.With suspicion for Pseudomonas Combination therapy with an antipseudomonal/antipneumococcal beta-lactam antibiotic and an antipseudomonal fluoroquinolone, such as the following regimens:: 1. Piperacillin-tazobactam (4.5 g every 6 hours) or 2. Imipenem (500 mg every 6 hours) or 3. Meropenem (1 g every 8 hours) or 4. Cefepime (2 g every 8 hours) or 5. Ceftazidime (2 g every 8 hours; activity against pneumococcus more limited than agents listed above) PLUS 1. Ciprofloxacin (400 mg every 8 hours) or 2. Levofloxacin (750 mg daily) The dose of levofloxacin is the same when given IV and orally, while the dose of ciprofloxacin is 750 mg orally twice daily
3.With suspicion for MRSA Either Vancomycin or Linezolid (600 mg IV every 12 hours). Empiric therapy for CA-MRSA should be given to hospitalized patients with septic shock or respiratory failure requiring mechanical ventilation.
Antiviral treatment is recommended as soon as possible for all persons with suspected or confirmed influenza requiring hospitalization or who have progressive, severe, or complicated influenza infection, regardless of previous health or vaccination status . 4.Influenza therapy
5.Adjunctive glucocorticoids For patients with CAP who have septic shock that is refractory to fluid resuscitation and vasopressor administration or respiratory failure with a FiO2 requirement of >50 % plus one or more of the following features (metabolic acidosis with an arterial pH of <7.3, lactate >4 mmol/L, or a CRP >150 mg/L). These patients are at high risk of mortality and are likely to benefit the most. Methylprednisolone (0.5 mg/kg IV every 12 hours) and treat for a total of 5 days
IV combination therapy with a potent antipneumococcal beta-lactam (Ceftriaxone [1 to 2 g daily], Cefotaxime [1 to 2 g every 8 hours], Ceftaroline [600 mg every 12 hours], Ampicillin-sulbactam [3 g every 6 hours], or Ertapenem [1 g IV daily]) plus an advanced macrolide (Azithromycin [500 mg daily]). Alternative to Azithromycin is a respiratory fluoroquinolone (Levofloxacin [750 mg daily] or Moxifloxacin [400 mg daily]). 1. Without suspicion for MRSA or Pseudomonas Antipseudomonal/antipneumococcal beta-lactam (eg, Piperacillin- Tazobactam, Cefepime, Ceftazidime, Meropenem, or Imipenem) PLUS Antipseudomonal fluoroquinolone (eg, Ciprofloxacin or Levofloxacin) 2. With suspicion for Pseudomonas Anti-MRSA activity, such as Vancomycin or Linezolid 3. With suspicion for MRSA ICU Empiric Antibiotic for CAP MRSA Risks Pseudomonas Risks Strong risk factors Known MRSA colonization Known Pseudomonas colonization Prior MRSA infection Prior Pseudomonas infection Detection of gram-positive cocci in clusters on a good- quality sputum Gram stain Detection of gram-negative rods on a good-quality sputum Gram stain Hospitalization with receipt of IV antibiotics in the prior 3 months Other factors that should raise suspicion for infection Recent hospitalization or antibiotic use, particularly hospitalization with receipt of IV antibiotics in the prior 3 months Recent hospitalization or stay in a long-term care facility Recent influenza-like illness Recent antibiotic use of any kind Necrotizing or cavitary pneumonia Frequent COPD exacerbations requiring glucocorticoid and/or antibiotic use Empyema Other structural lung diseases (eg, bronchiectasis, cystic fibrosis) Immunosuppression Immunosuppression Risk factors for MRSA colonization, including:ESRD Crowded living conditions (eg, incarceration) Injection drug use Contact sports participation Men who have sex with men
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Treatment of CAP in adults who require hospitalization.pptx

  • 1. Treatment of CAP in adults who require hospitalization
  • 2. Likely pathogenes 01 Risk facto Risk factor for organism resistant 02 Initial Empiric Therapy 03
  • 4. Likely Pathogens Streptococcus pneumoniae, Respiratory viruses (eg, influenza, parainfluenza, respiratory syncytial virus, rhinovirus), and, less often, Mycoplasma pneumoniae, Haemophilus influenzae, and Legionella spp S. pneumoniae is the most common, but Legionella, gram- negative bacilli, Staphylococcus aureus, and influenza are also important Medical Ward ICU
  • 5. MRSA :Strong risk factors Known MRSA colonization Prior MRSA infection Detection of gram-positive cocci in clusters on a good- quality sputum Gram stain
  • 6. MRSA : Other factors that should raise suspicion for infection Recent hospitalization or antibiotic use, particularly hospitalization with receipt of IV antibiotics in the prior 3 months Recent influenza-like illness Risk factors for MRSA colonization, including: End-stage renal disease Crowded living conditions (eg, incarceration) Injection drug use Contact sports participation Men who have sex with men Necrotizing or cavitary pneumonia Empyema Immunosuppression
  • 7. Pseudomonas Known Pseudomonas colonization Recent hospitalization or stay in a long-term care facility Detection of gram-negative rods on a good-quality sputum Gram stain Prior Pseudomonas infection Hospitalization with receipt of IV antibiotics in the prior 3 months Frequent COPD exacerbations requiring glucocorticoid and/or antibiotic use Other structural lung diseases (eg, bronchiectasis, cystic fibrosis)
  • 8. Determining whether a patient with CAP can be safely treated as an outpatient or requires admission to an observation unit, general medical ward, or higher acuity level of inpatient care, such as an ICU, is an Essential First Step. Severity of illness is the most critical factor in making this determination, but other factors should also be taken into account.
  • 9. Antibiotic recommendations for hospitalized patients with CAP are divided by the site of care (Medical ward or ICU]). Most hospitalized patients are initially treated with an IV regimen but can transition to oral therapy as they improve. Start antibiotic therapy as soon as we are confident that CAP is the appropriate working diagnosis and, ideally, within four hours of presentation for patients being admitted to the general medical ward . In patients with septic shock, antibiotics should be started within one hour.
  • 14. Among the available scoring systems for determining the need for admission in patients with CAP, we prefer the PSI because it is the best studied and validated. If a less complex scoring system is desired, the CURB- 65 score is a reasonable alternative, although its effectiveness and safety in guiding the initial site of treatment have not been empirically assessed.
  • 16. 1. Without suspicion for MRSA or Pseudomonas 1. Combination therapy with Ceftriaxone (1 to 2 g IV daily), Cefotaxime (1 to 2 g IV every 8 hours), Ceftaroline ( 600 mg IV every 12 hours), ertapenem (1 g IV daily), or Ampicillin- Sulbactam (3 g IV every 6 hours) PLUS a Macrolide (azithromycin [500 mg IV or orally daily] or clarithromycin [500 mg twice daily] or clarithromycin XL [two 500 mg tablets once daily]). Doxycycline (100 mg orally or IV twice daily) may be used as an alternative to a macrolide.
  • 17. 2. Monotherapy with a respiratory fluoroquinolone (Levofloxacin [750 mg IV or orally daily] or Moxifloxacin [400 mg IV or orally daily] or Gemifloxacin [320 mg orally daily]) is an appropriate alternative for patients who cannot receive a beta-lactam plus a macrolide.
  • 18. 2.With suspicion for Pseudomonas Combination therapy with an antipseudomonal/antipneumococcal beta-lactam antibiotic and an antipseudomonal fluoroquinolone, such as the following regimens:: 1. Piperacillin-tazobactam (4.5 g every 6 hours) or 2. Imipenem (500 mg every 6 hours) or 3. Meropenem (1 g every 8 hours) or 4. Cefepime (2 g every 8 hours) or 5. Ceftazidime (2 g every 8 hours; activity against pneumococcus more limited than agents listed above) PLUS 1. Ciprofloxacin (400 mg every 8 hours) or 2. Levofloxacin (750 mg daily) The dose of levofloxacin is the same when given IV and orally, while the dose of ciprofloxacin is 750 mg orally twice daily
  • 19. 3.With suspicion for MRSA Either Vancomycin or Linezolid (600 mg IV every 12 hours).
  • 20. Antiviral treatment is recommended as soon as possible for all persons with suspected or confirmed influenza requiring hospitalization or who have progressive, severe, or complicated influenza infection, regardless of previous health or vaccination status . 4.Influenza therapy
  • 21. 1. Beta-lactam plus either a Macrolide OR 2. Monotherapy with a Respiratory fluoroquinolone OR 3. Beta-lactam plus Doxycycline. 1. Without suspicion for MRSA or Pseudomonas Antipseudomonal/antipneumococcal beta-lactam (eg, Piperacillin- Tazobactam, Cefepime, Ceftazidime, Meropenem, or Imipenem) PLUS Antipseudomonal fluoroquinolone (eg, Ciprofloxacin or Levofloxacin) 2. With suspicion for Pseudomonas Anti-MRSA activity, such as Vancomycin or Linezolid 3. With suspicion for MRSA Medical Ward Empiric Antibiotic for CAP MRSA Risks Pseudomonas Risks Strong risk factors Known MRSA colonization Known Pseudomonas colonization Prior MRSA infection Prior Pseudomonas infection Detection of gram-positive cocci in clusters on a good-quality sputum Gram stain Detection of gram-negative rods on a good-quality sputum Gram stain Hospitalization with receipt of IV antibiotics in the prior 3 months Other factors that should raise suspicion for infection Recent hospitalization or antibiotic use, particularly hospitalization with receipt of IV antibiotics in the prior 3 months Recent hospitalization or stay in a long-term care facility Recent influenza-like illness Recent antibiotic use of any kind Necrotizing or cavitary pneumonia Frequent COPD exacerbations requiring glucocorticoid and/or antibiotic use Empyema Other structural lung diseases (eg, bronchiectasis, cystic fibrosis) Immunosuppression Immunosuppression Risk factors for MRSA colonization, including:ESRD Crowded living conditions (eg, incarceration) Injection drug use Contact sports participation Men who have sex with men
  • 23. 1. Without suspicion for MRSA or Pseudomonas 1. IV combination therapy with a potent antipneumococcal beta-lactam (Ceftriaxone [1 to 2 g daily], Cefotaxime [1 to 2 g every 8 hours], Ceftaroline [600 mg every 12 hours], Ampicillin-sulbactam [3 g every 6 hours], or Ertapenem [1 g IV daily]) plus an advanced macrolide (Azithromycin [500 mg daily]). an alternative to Azithromycin is a respiratory fluoroquinolone (Levofloxacin [750 mg daily] or Moxifloxacin [400 mg daily]).
  • 24. 2.With suspicion for Pseudomonas Combination therapy with an antipseudomonal/antipneumococcal beta-lactam antibiotic and an antipseudomonal fluoroquinolone, such as the following regimens:: 1. Piperacillin-tazobactam (4.5 g every 6 hours) or 2. Imipenem (500 mg every 6 hours) or 3. Meropenem (1 g every 8 hours) or 4. Cefepime (2 g every 8 hours) or 5. Ceftazidime (2 g every 8 hours; activity against pneumococcus more limited than agents listed above) PLUS 1. Ciprofloxacin (400 mg every 8 hours) or 2. Levofloxacin (750 mg daily) The dose of levofloxacin is the same when given IV and orally, while the dose of ciprofloxacin is 750 mg orally twice daily
  • 25. 3.With suspicion for MRSA Either Vancomycin or Linezolid (600 mg IV every 12 hours). Empiric therapy for CA-MRSA should be given to hospitalized patients with septic shock or respiratory failure requiring mechanical ventilation.
  • 26. Antiviral treatment is recommended as soon as possible for all persons with suspected or confirmed influenza requiring hospitalization or who have progressive, severe, or complicated influenza infection, regardless of previous health or vaccination status . 4.Influenza therapy
  • 27. 5.Adjunctive glucocorticoids For patients with CAP who have septic shock that is refractory to fluid resuscitation and vasopressor administration or respiratory failure with a FiO2 requirement of >50 % plus one or more of the following features (metabolic acidosis with an arterial pH of <7.3, lactate >4 mmol/L, or a CRP >150 mg/L). These patients are at high risk of mortality and are likely to benefit the most. Methylprednisolone (0.5 mg/kg IV every 12 hours) and treat for a total of 5 days
  • 28. IV combination therapy with a potent antipneumococcal beta-lactam (Ceftriaxone [1 to 2 g daily], Cefotaxime [1 to 2 g every 8 hours], Ceftaroline [600 mg every 12 hours], Ampicillin-sulbactam [3 g every 6 hours], or Ertapenem [1 g IV daily]) plus an advanced macrolide (Azithromycin [500 mg daily]). Alternative to Azithromycin is a respiratory fluoroquinolone (Levofloxacin [750 mg daily] or Moxifloxacin [400 mg daily]). 1. Without suspicion for MRSA or Pseudomonas Antipseudomonal/antipneumococcal beta-lactam (eg, Piperacillin- Tazobactam, Cefepime, Ceftazidime, Meropenem, or Imipenem) PLUS Antipseudomonal fluoroquinolone (eg, Ciprofloxacin or Levofloxacin) 2. With suspicion for Pseudomonas Anti-MRSA activity, such as Vancomycin or Linezolid 3. With suspicion for MRSA ICU Empiric Antibiotic for CAP MRSA Risks Pseudomonas Risks Strong risk factors Known MRSA colonization Known Pseudomonas colonization Prior MRSA infection Prior Pseudomonas infection Detection of gram-positive cocci in clusters on a good- quality sputum Gram stain Detection of gram-negative rods on a good-quality sputum Gram stain Hospitalization with receipt of IV antibiotics in the prior 3 months Other factors that should raise suspicion for infection Recent hospitalization or antibiotic use, particularly hospitalization with receipt of IV antibiotics in the prior 3 months Recent hospitalization or stay in a long-term care facility Recent influenza-like illness Recent antibiotic use of any kind Necrotizing or cavitary pneumonia Frequent COPD exacerbations requiring glucocorticoid and/or antibiotic use Empyema Other structural lung diseases (eg, bronchiectasis, cystic fibrosis) Immunosuppression Immunosuppression Risk factors for MRSA colonization, including:ESRD Crowded living conditions (eg, incarceration) Injection drug use Contact sports participation Men who have sex with men