LGIS VIII-IX Theme 3 Pneumonia PDF
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Shifa College of Pharmaceutical Sciences
Dr. Naila Jabeen
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Summary
These lecture notes cover Infectious Diseases, focusing on pneumonia. They detail different types of pneumonia, pathophysiology, epidemiology of specific types (HAP, VAP, CAP), clinical and laboratory findings, and treatment options.
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Theme III – Infectious Diseases Presented by: Dr. Naila Jabeen Lecturer, Program Coordinator (M.Phil. CPP) Pharm.D., M.Phil. (CPP), CCRP, AMS Expert (BSAC), Fellow (DEAL-YPPH) Dept. of Pharmacy Practice, Shifa College Of Pharmac...
Theme III – Infectious Diseases Presented by: Dr. Naila Jabeen Lecturer, Program Coordinator (M.Phil. CPP) Pharm.D., M.Phil. (CPP), CCRP, AMS Expert (BSAC), Fellow (DEAL-YPPH) Dept. of Pharmacy Practice, Shifa College Of Pharmaceutical Sciences) 1 Learning Objectives At the end of this lecture the students will be able to: o Define Pneumonia and its different types o Explain the Pathophysiology of the disease. o Brief its etiology. o Explain the epidemiology of HAP, VAP and CAP. o Identify pneumonia through clinical and laboratory findings. o Select the appropriate therapeutic regimen for empiric treatment. o Design the proper pharmaceutical care plan after confirmation of Pneumonia. o Describe the monitoring parameters Post-treatment. o Enlist CAM. 2 Pneumonia Pneumonia is an acute respiratory infection of one or both of the lungs caused by bacteria, viruses, or fungi. It is a serious infection in which the air sacs fill with pus and other liquid. o Lobar pneumonia affects one or more sections (lobes) of the lungs. o Bronchial pneumonia (also known as bronchopneumonia) affects patches throughout both lungs. 3 4 5 Epidemiology 6 7 8 9 Community-Acquired Pneumonia (CAP) Acute infection of the pulmonary parenchyma, accompanied by an acute infiltrate consistent with pneumonia on chest radiograph or auscultatory findings, acquired in the community 10 RSV = Respiratory syncytial virus, S.Pneumo = Streptococcus pneumoniae, M.Pna = Mycoplasma pneumoniae EtOH = Chemical name for ethyl alcohol 11 12 13 14 HAP and VAP HAP= Hospital Acquired Pneumonia, VAP = Ventilator Acquired Pneumonia HAP: Pneumonia in a non-ventilated patient that occurs 48 hours or more after admission and was not incubating at the time of admission. VAP: Pneumonia that arises more than 48 hours after endotracheal intubation. 15 16 17 18 19 20 21 Treatment CAP: Empiric Therapy Condition Treatment Empiric treatment of non- No comorbidities or risk factors for methicillin-resistant hospitalized patients Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa (a) Amoxicillin (b) Doxycycline (c) Macrolide (clarithromycin or azithromycin) if local pneumococcal resistance to macrolides is less than 25% Comorbidities (COPD, diabetes mellitus, alcoholism, chronic renal or liver failure, congestive heart failure, malignancy, asplenia, or immunosuppression) (a) Respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin dosing (b) Macrolide or doxycycline with amoxicillin/clavulanate or cefpodoxime or cefuroxime 22 Treatment CAP: Empiric Therapy Condition Treatment Empiric treatment of hospitalized a) Respiratory fluoroquinolone (moxifloxacin or levofloxacin) patients with non-severe b) β-Lactam (ampicillin/sulbactam, ceftriaxone, or pneumonia (may need to add ceftaroline) plus a macrolide (or doxycycline) other antibiotics if the patient has risk factors for Pseudomonas aeruginosa or MRSA) Empiric treatment of hospitalized a) Ampicillin/sulbactam plus either a respiratory patients with severe pneumonia fluoroquinolone or a macrolide necessitating intensive care unit b) Ceftriaxone plus either a respiratory fluoroquinolone or a treatment (may need to add macrolide other antibiotics if the patient c) Ceftaroline plus either a respiratory fluoroquinolone or a has risk factors for P. aeruginosa macrolide or methicillin-resistant S. aureus [MRSA]) 23 Treatment Empiric therapy for VAP/HAP: MRSA coverage can be added in patients with risk factors (Colonization with OR prior isolation of MRSA, hospitalization in a unit where >20% of S. aureus isolates are methicillin resistant, or if prevalence is not known). MRSA coverage should also be added in patients who have high mortality risk (need for ventilator support due to HAP and septic shock). For patients with no risk factors for MRSA or high risk of mortality, add an antibiotic with activity against MSSA. 24 Treatment Empiric therapy for VAP/HAP: Cefazolin is the preferred agent for the treatment of proven MSSA but is not necessary for the empiric treatment of VAP if a regimen includes piperacillin- tazobactam, cefepime, levofloxacin, imipenem, or meropenem. Patients with HAP who are being treated empirically may be prescribed a single antibiotic with activity against P. aeruginosa unless they have high likelihood for Pseudomonas or other gram-negative infection (Structural lung disease (bronchiectasis or cystic fibrosis), A respiratory specimen Gram stain with numerous and predominant gram-negative bacilli, Colonization with OR prior isolation of MDR Pseudomonas or other gram-negative bacilli) or a high risk for mortality, add 2 antipseudomonal agents from 2 different classes 25 Column A Column B Column C Risk Factors for Gram Positive Gram-Negative Antibiotics with Antipseudomonal Activity Multidrug-Resistant MRSA β-Lactam–Based Agents Non-β-Lactam–Based Agents Pathogens Vancomycin 15 mg/kg IV Piperacillin-tazobactam Ciprofloxacin 400 mg IV Prior q8–12h (consider a 4.5 g IV q6h q8h intravenous loading dose of 25–30 mg/kg × 1 for severe OR Cefepime 2 g IV q8h OR Levofloxacin 750 mg IV antibiotic use within 90 d Empiric therapy illness) OR q24h Septic shock at for VAP OR Ceftazidime 2 g IV q8h OR time of VAP Linezolid 600 mg IV OR Amikacin 15–20 mg/kg IV ARDS preceding q12h Imipenem 500 mg IV q24h VAP q6hd OR Five or more (Linezolid Considered OR Gentamicin 5–7 mg/kg IV days of non-inferior to Meropenem 1 g IV q8h q24h hospitalization vancomycin for OR prior to the treatment of MRSA Tobramycin 5–7 mg/kg IV occurrence of pneumonia. NOTE: q24h VAP vancomycin is Acute renal bactericidal versus replacement MRSA, but does not therapy prior to penetrate the lungs as VAP onset well as linezolid) Choose one gram-positive option from column A, one gram-negative option from column B, and one gram- negative option from column C. Note that the initial doses suggested in this table may need to be modified for patients with hepatic or renal dysfunction 26 Not at High Risk of Mortality and Not at High Risk of Mortality but High Risk of Mortality or Receipt of no Factors Increasing the With Factors Increasing the Intravenous Antibiotics During the Likelihood of MRSA Likelihood of MRSA Prior 90 d Empiric therapy for Two of the following, avoid 2 β- One of the following One of the following lactams: HAP Piperacillin-tazobactam 4.5 g Piperacillin-tazobactam 4.5 g Piperacillin-tazobactam 4.5 g IV IV q6h IV q6h q6h Cefepime 2 g IV q8h Cefepime or ceftazidime 2 g Cefepime or Ceftazidime 2 g IV Levofloxacin 750 mg IV daily IV q8h q8h Imipenem 500 mg IV q6h Levofloxacin 750 mg IV daily Levofloxacin 750 mg IV daily Meropenem 1 g IV q8h Ciprofloxacin 400 mg IV q8h Ciprofloxacin 400 mg IV q8h Imipenem 500 mg IV q6h Imipenem 500 mg IV q6h Meropenem 1 g IV q8h Meropenem 1 g IV q8h PLUS Amikacin 15–20 mg/kg IV daily Vancomycin 15 mg/kg IV q8– Gentamicin 5–7 mg/kg IV daily 12h with goal to target 15–20 Tobramycin 5–7 mg/kg IV daily mg/mL trough level (consider PLUS a loading dose of 25–30 Vancomycin 15 mg/kg IV q8–12h mg/kg × 1 for severe illness) with goal to target 15–20 mg/mL OR trough level (consider a loading Linezolid 600 mg IV q12h* dose of 25–30 mg/kg × 1 for severe illness) OR Linezolid 600 mg IV q12h* 27 28 Role of Inhaled Antibiotic Therapy For patients with VAP due to gram-negative bacilli that are susceptible to only aminoglycosides or polymyxins (colistin or polymyxin B), Add both inhaled and systemic antibiotics, rather than systemic antibiotics alone. Colistin Amikacin Tobramycin (off-label use/route) Inhalation: 400 to 500 mg every 12 hours in 300 mg every 12 hours in 30 to 150 mg CBA via nebulizer 1 combination with IV combination with IV to 2 times daily (maximum dose: antimicrobial therapy. antimicrobial therapy. 150 mg CBA 2 times daily) Note: Efficacy is uncertain and Note: Efficacy is uncertain. bronchospasm may limit use Some experts reserve for patients Note: An optimal dosing regimen with risk for multidrug-resistant has not been determined and pathogens. varies widely among studies; lower doses have been used in noncystic fibrosis patients with bronchiectasis (Steinfort 2007). Use in addition to systemic antibiotics. 29 Role of prolonged infusions Because of increasing resistance of pathogens associated with VAP and HAP, one potential strategy to use Prolonged infusions as they achieve pharmacodynamic efficacy targets defined for beta-lactam antibiotics more effectively than short infusions. Suitable agents for prolonged infusions include piperacillin- tazobactam, meropenem, imipenem, and cefepime. The decision to use this dosing strategy should also take into account logistical issues such as staffing or intravenous access availability. 30 Monitoring When a patient with bacterial pneumonia is treated in an outpatient setting, arranging adequate follow-up evaluations is mandatory. The patient should also be instructed to return promptly if their condition deteriorates. Patients should have a follow-up chest radiograph in approximately six weeks to ensure resolution of the consolidation and to assess persistent abnormality of the lung parenchyma (e.g., scarring, bronchiectasis). Chest radiograph findings indicating non-resolution of the infiltrate should raise the consideration of an endobronchial obstruction as a cause of post obstructive pneumonia or pleural effusion. Computed tomograph (CT) scanning may be of benefit in these cases. 31 Monitoring Although guidelines have routinely recommended follow-up chest radiography in order to exclude underlying lung cancer, studies have found that the incidence of lung cancer following pneumonia is relatively low. One study suggested that age 50 years and older, male sex, and smoking are the only patient characteristics that were independently associated with a new lung cancer diagnosis 32 CAM Cough home remedies 1. Peppermint, eucalyptus, and fenugreek tea 2. A saltwater gargle Shortness of breath 1. Caffiene in small amount 2. Warm water Chest Pain 1. Ginger or turmeric tea 33 34