Treatment of Respiratory Infections PDF

The treatment of respiratory infections Dr AD van Eyk Department of Pharmacy and Pharmacology GEMP 1: Respiratory block  AIM 1. Antibiotics used for respiratory infections 2. Revision of those antibiotics covered in the BCMH...

The treatment of respiratory infections Dr AD van Eyk Department of Pharmacy and Pharmacology GEMP 1: Respiratory block  AIM 1. Antibiotics used for respiratory infections 2. Revision of those antibiotics covered in the BCMH block  DELIVERY OBJECTIVES Identify which antibiotics are indicated for typical and atypical infections Know the pharmacokinetics & be able to compare the mechanism of action of the different drugs Be able to name the most common adverse effects of the specific drug/classes of drugs Be able to describe the precautions for use & contraindications of the drugs Be able to describe the drug interactions that can occur with other medications Be able to suggest alternative antibiotics in the case of resistance or allergies to Penicillins  Upper respiratory tract infections (URTI) Caused mostly by viruses < 2% caused by bacteria Sinusitis Pharyngitis Tonsillitis Epiglottitis Laryngitis Acute otitis media  Upper respiratory tract infections (URTI) If caused by bacteria – Most common Streptococcus pyogenes, Group A streptococcus ("strep throat") can result in rheumatic fever Streptococcus pneumoniae Haemophilus influenzae viridans streptococci Moraxella catarrhalis  Upper respiratory tract infections (URTI) Treatment Acute sinusitis/Otitis media (Streptococcus pneumoniae, Haemophilus influenzae) – High dose Amoxicillin (oral, 8 - 12 hourly, 5 - 10 days) OR – Co-amoxiclav (oral, 8 – 12 hourly, 5 - 10 days) (if amoxicillin in previous 30 days/poor response to 10 day course of amoxicillin) OR – A Macrolide/azalide (erythromycin or azithromycin (oral, 3 days)) in case of penicillin allergy Children: chronic otitis media (Fluoroquinolone drops e.g. ofloxacin, 8 hourly) Complicated sinusitis (children) IV ceftriaxone, 14 days, good response Co-amoxiclav (oral, 8 hourly)  Upper respiratory tract infections (URTI) Treatment Chronic sinusitis – Antibiotic treatment not always effective Pharyngitis/laryngitis/tonsillitis (Group A β-haemolytic streptococci e.g S. pyogenes) IM Benzathine benzylpenicillin (single dose) or Oral Phenoxymethylpenicillin (oral, 12 hourly, 10 days) or Oral amoxicillin or co-amoxiclav (10 days, do not give if Epstein Barr virus infection is suspected) – Penicillin allergy Macrolide/azalide (chlarithromycin or azithromycin, oral, 3 days)  Upper respiratory tract infections (URTI) Treatment Epiglottitis (Haemophilus influenzae) – 3rd generation cephalosporin (ceftriaxone IM single dose, cefotaxime) followed by co- amoxiclav (10 days) – Children ceftriaxone IV, once daily, 7 days – Penicillin allergy Macrolide/azalide (azithromycin, 3 days)  Conjunctivitis Purulent conjunctivitis (S. pneumoniae, S. aureus, Haemophilus sp) – Topical chloramphenicol (ophthalmic ointment, 8 hourly, 5-7 Days) Severe cases – Consider systemic therapy No response – Topical tobramycin OR – Topical ciprofloxacin OR – Topical fusidic acid OR – Bacitracin/polymyxin B ointment  Conjunctivitis Neonatal (N. gonorrhoeae) – Irrigate the eyes with saline – 3rd Generation cephalosporin (ceftriaxone, IM, single dose) even if jaundiced (warning with Ca2+- containing IV fluid) – Parents who develop symptoms 24h after birth IM ceftriaxone + oral azithromycin (single dose) Inclusion conjunctivitis/trachoma (C. trachomatis) – Macrolide/doxycycline  Lower Respiratory tract infections Acute bacterial bronchitis Bacterial pneumonia https://www.verywellhealth.com/is-it-bronchitis-or-pneumonia-770335  Lower Respiratory tract infections Acute bacterial bronchitis – Inflammation of airways – Usually after a viral infection – Resolves on its own within a few weeks Bacterial pneumonia – Infection in the lungs (alveoli, fill with pus/fluid) – Treated with antibiotics  Bacterial bronchitis Acute bronchitis – Antibiotics not indicated in absence of underlying COPD Acute exacerbations of chronic bronchitis in COPD (S. pneumoniae, H. influenza) – Amoxicillin (oral, 8 hourly for 5 days) OR – Doxycycline (oral, 12 hourly, 5 days) OR – Newer fluoroquinolones (moxifloxacin/levofloxacin)  Bacterial pneumonia Community-acquired pneumonia (S. pneumoniae, H. influenzae, S. aureus, K. pneumoniae, M. pneumoniae, C. pneumoniae, Legionella sp or B. pertussis) Streptococcus pneumoniae (most common) – Hospitalisation generally not needed – Treatment Rest, fluids & oral antibiotics – Hospitalization Patients with breathing difficulty Chronic medical conditions Age  Bacterial pneumonia Atypical or "walking“ pneumonia – Mycoplasma pneumoniae – Symptoms similar to flu – Generally less serious condition Legionnaires’ disease (atypical) – Legionella pneumophila – Quite severe Community-acquired atypical pneumonia – Chlamydophila pneumoniae  Bacterial pneumonia Treatment Choice of antibiotic – The nature of the pneumonia – The causative agent (usually empiric treatment, based on epidemiology) – The patient’s allergic status – The patient’s immune status – Underlying patient health, age, prior AB exposure & where treated (home, ICU, normal ward) – Antibiotic resistance patterns have to be considered  Bacterial pneumonia Treatment Treatment Period of treatment: 5 – 10 days Patients < 65 years, no co-morbidities: – Amoxicillin (high dose, oral, 8 hourly, 5 days) No response after 48H – Add a macrolide/azalide Penicillin allergy → Newer fluoroquinolones (e.g. moxifloxacin, oral, 5 days)  Bacterial pneumonia Treatment Treatment Patients ≥ 65 years or with co-morbidities: – Co-amoxiclav (oral, 12 hourly, 5 days) OR – 2nd or 3rd generation cephalosporin (cefuroxime or ceftriaxone or cefotaxime) Penicillin allergy – Gemifloxacin or moxifloxacin (oral, 5 days) Poor response after 48H – Add a macrolide/azalide  Bacterial pneumonia Treatment Severe pneumonia (S. pneumoniae, S. aureus, K. pneumoniae, Legionella spp) – (Co-amoxiclav OR – 2nd or 3rd generation cephalosporin (e.g. ceftriaxone, IM, single dose)) + – Macrolide/azalide (e.g. clarithromycin or azithromycin) Penicillin allergy – Gemifloxacin or moxifloxacin (oral, 5 days)  Bacterial pneumonia Treatment Atypical pneumonia (Mycoplasma pneumoniae or Chlamydophila pneumonia or Legionella pneumophila) Macrolide (azithromycin) OR Gemifloxacin, moxifloxacin P. jirovecii (HIV-patients) – Oral co-trimoxazole (6 hourly, 3 weeks) – Secondary prophylaxis – Oral co-trimoxazole daily  Bacterial pneumonia Treatment Children – Amoxicillin (oral, 12 hourly, 5 days) – Co-amoxiclav (severe or recurrent: IV, 8 hourly), good response co-amoxiclav oral, 12 hourly for total treatment of 10 days) – Poor response (also nosocomial infections) pepiracillin/tazobactam, IV,8 hourly + amikacin, IV daily – MRSA confirmed vancomycin, 6 hourly, 14 days  Pleural disease Children Purulent effusion co-amoxiclav (IV, 8 hourly, 10 days) OR cefazolin (IV, 8 hourly) good response cefalexin (oral, 6 hourly) OR co-amoxiclav (oral, 12 hourly) Penicillin allergy – Macrolide (azithromycin, oral, 3 days) Mycoplasma and Atypical severe illness: – Azithromycin IV, 2 days, then oral 3 – 5 days  Bronchiectasis Adults Only with symptoms of sepsis or sputum purulence/ volume Stable patients & before culture results: – Co-amoxiclav (oral, 12 hourly, 10 days or longer) Penicillin allergy – Macrolide (azithromycin, oral, 10 days or longer) Severely ill (require hospitalisation) – Ceftriaxone (IV daily until apyrexial for 24h) – Follow with Co-amoxiclav (oral, 12 hourly) If Pseudomonas infection confirmed – Add Ciprofloxacin (oral, 12 hourly, 7 days) Severe penicillin allergy – Moxifloxacin (oral, 7 days or IV)  Bronchiectasis Children Worsening cough, ↑dyspnoea, ↑tachypnoea and/or signs of sepsis – Empiric therapy: IV ampicillin, 6 hourly + – IV Gentamicin, once daily Good clinical response – Change to oral co-amoxiclav (45 mg/kg/dose amoxicillin component, 12 hourly) – Total antibiotic treatment duration: 14 days  Respiratory distress Neonates Requires hospitalization – Ampicillin (IV, 5 – 7 days) + – Gentamicin (IV, 5 – 7 days in 1st week) Review after 72 hours, adjust gentamicin levels, continue for 10 days  Lung abscess/Aspiration pneumonia Adults (4 - 6 weeks) − IV co-amoxiclav, 8 hourly, then oral, 12 hourly − Severe allergy moxifloxacin IV daily, then oral daily Children − Empiric therapy: IV co-amoxiclav, 8 hourly, 14 days Poor clinical response & no culture to guide choice of antibiotic consider local pathogens and change accordingly − Good clinical response Change to oral co- amoxiclav (45 mg/kg/dose amoxicillin component, 12 hourly)  Hospital-acquired pneumonia Empiric treatment (10 days) No prior IV ABs within 90 days – IV ceftriaxone & amikacin Severe allergy – Oral/IV moxifloxacin & IV amikacin Prior IV ABs within 90 days (depends on infective organism) – IV piperacillin/tazobactam & amikacin OR IV cefepime OR IV imipenem/cilastatin OR IV meropenem