Essay About Mg Po And Days14 Days

Cap/vap Topic Discussion
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DefinitionsPneumonia: Inflammation of the lung most often caused by infection with bacteria, viruses, and other microorganisms or inhalation of substances such as food, liquid, gas, or dust[pic 1]Clinical Presentation[pic 2]DiagnosisNew infiltrate on imaging with clinical signs/symptomsChest x-ray (gold standard)CT or ultrasoundOther testing:Sputum grain stain and cultureUrine antigen assay – S. pneumoniae and LegionellaBlood culturesBronchoscopyCommon Etiologies[pic 3][pic 4]Curb-65 Severity Score for CAPPrognostic VariablesCriteriaScoreConfusionDisorientation to person, place, or time1UreaBUN > 20 mg/dL1Respiratory Rate> 30 breaths/min1Blood PressureSBP < 90 mmHg or DBP < 60 mmHg1Age> 65 years of age10-1: Treat as outpatient2: Treat as inpatient> 3: Often admitted to ICUPORT Pneumonia Severity IndexStratifies patients into 5 individual mortality risk classesGenerally preferred compared to CURB-65 due to validationMore time consuming, therefore not utilized as often as CURB-65Several calculators available onlineComorbidities and Risk Factors for Antimicrobial Resistance[pic 5]Treatment Duration (OSUWMC) CAP: 5 daysHAP: 8 daysVAP: 8 days14 days if caused by S. aureus, Pseudomonas spp., Acinetobacter spp. Stenotrophomonas spp., and BurkholderiaTreatment Duration (IDSA)CAP: Minimum 5 daysPatient should be afebrile for 48-72h before discontinuationHAP/VAP: 7 days preferredCOMMUNITY ACQUIRED PNEUMONIA TREATMENT[pic 6]Outpatient Empiric Treatment:Previously healthy + No Abx prior 3 monthsMacrolide: clarithromycin or azithromycinTetracycline: doxycyclineComorbidities, high risk of S. pneumoniae macrolide resistance, or Abx therapy in previous 3 monthsRespiratory fluoroquinolone (levofloxacin, moxifloxacin)Macrolide (or doxycycline) + B-lactamHigh dose amoxicillin, amoxicillin/clavulanate, cephalosporin (ceftriaxone, cefuroxime, cefpodoxime)DrugDoseRespiratory Fluoroquinolones-Levofloxacin 750 mg PO daily-Moxifloxacin 400 mg PO dailyMacrolide-Azithromycin 500 mg PO x 1 day, then 250 mg PO daily x  2-5 days (alternative 500 mg PO x 3 days)-Clarithromycin 500 mg x 1 day then 250 mg daily x 2-5 daysTetracycline-Doxycycline 100 mg PO BIDβ-lactam-Amoxicillin 1g PO TID-Amoxicillin/clavulanate 2 g PO BID-Ceftriaxone 1-2g IV Q24H-Cefpodoxime 200 mg PO BID-Cefuroxime 500 mg PO BIDInpatient Empiric Treatment:Inpatient, non-ICU Respiratory fluoroquinolone alone ORMacrolide or doxycycline PLUS Beta-lactamAmpicillin, cefotaxime, ceftriaxone, ertapenemPCN allergic patients: respiratory fluoroquinolone or aztreonam are recommendedInpatient, ICURespiratory fluoroquinolone OR azithromycin PLUSBeta-lactamAmpicillin/sulbactam, cefotaxime, ceftriaxone, ertapenemInpatient, ICU – P. aeruginosaRisk factors: chronic PO steroids, severe underlying pulmonary disease, prior abx therapy, smokingBeta-lactam + fluoroquinolone ORFluoroquinolone: ciprofloxacin or levofloxacinBeta-lactam: Zosyn, cefepime, meropenem, imipenemFluoroquinolone + aminoglycoside + azithromycin ORAminoglycoside: tobramycin, amikacinBeta-lactam + fluoroquinolone + aminoglycoside Inpatient, ICU – MRSARisk factors: ESRD, IVDU, prior Abx therapy, prior influenzaLinezolid ORVancomycinNOT daptomycin!HOSPITAL-ACQUIRED & VENTILATOR-ASSOCIATED PNEUMONIA TREATMENT[pic 7]All patientsS. aureus + P. aeruginosa + other gram-negative bacilli coverageZosyn OR cefepime OR levofloxacinImipenem and meropenem also included in guidelines but typically not usedMRSA coverageRisk factors: prior IV Abx within 90 days, in a unit with > 20% MRSA isolates or prevalence not known, or high risk of mortalityOne of the agents mentioned above PLUS vancomycin OR linezolidPseudomonas double coverageRisk factors: prior IV Abx within 90 days, high risk of mortality, structural lung diseaseRisk for methicillin-resistant Pseudomonas and other GNBOne of the agents mentioned above under “All patients” PLUS an aminoglycosideAmikacin, gentamicin, tobramyciProcalcitoninProcalcitonin is a serum biomarker that helps distinguish bacterial infection from other causes of infection or inflammationIn healthy patients, procalcitonin is synthesized in thyroid neuroendocrine cells and the protein is not released into the blood until it is cleaved into calcitoninIn the presence of bacterial infection, procalcitonin synthesis is induced in nearly all tissue and is released into the bloodstreamCan be used in conjunction with clinical judgement for guiding antibiotic therapyMore helpful for discontinuing antibiotics instead of starting treatmentTrends in procalcitonin are more valuable than absolute quantityReferencesKalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, Napolitano LM, Ogrady NP, Bartlett JG, Carratalà J, El Solh AA. 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. Clinical Infectious Diseases. 2016 Jul 14;63(5):e61-111.Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, Napolitano LM, Ogrady NP, Bartlett JG, Carratalà J, El Solh AA. 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. Clinical Infectious Diseases. 2016 Jul 14;63(5):e61-111.Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, Coley CM, Marrie TJ, Kapoor WN. A prediction rule to identify low-risk patients with community-acquired pneumonia. New England journal of medicine. 1997 Jan 23;336(4):243-50.[pic 8]