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ABX – Pneumonia

Outpatient Previously healthy – No Recent Antibiotic Therapy

Doxycycline 100 mg orally twice a day for 7 days

OR

Levaquin 750 mg orally once a day for 5 days

OR

Z-Pack (Azithromycin 500 mg orally once on day 1 then 250 mg every day for day 2 to 5)

Doxycycline is active against 90%-95% of strains of S. pneumoniae, also active against H. influenzae, atypical agents, and category A bacterial agents of bioterrorism. Generally well tolerated and inexpensive. Macrolides active against most common pathogens, including atypical agents. Macrolide resistance is reported for 20%-30% of Streptococcus pneumoniae.

Outpatient Previously Healthy – Recent Antibiotic Therapy

Z-Pack + Amoxicillin-clavulanate 2 g orally twice a day for 7 days.

OR

Z-pack+ Amoxicillin 1 g orally three times a day for 7 days

OR

Levaquin 750 mg orally once a day for 5 days

Antibiotic for treatment of any infection within the past 3 months. Recent use of a fluoroquinolone should dictate selection of a non- fluoroquinolone regimen, and vice versa. Compared with amoxicillin, amoxicillin-clavulanate spectrum in vitro includes B-lactamase producing bacteria, such as most H. influenzae, methicillin-susceptible Staphylococcus aureus, and anaerobes. Lacks activity against atypical agents, also is more expensive and has more gastrointestinal intolerance, when compared with amoxicillin. High dosages amoxicillin (3 g/day) required to achieve activity against >90% of S. pneumoniae. Lacks activity against atypical agents and B-lactamase producing bacteria.

Outpatient with Comorbidities* – No Recent Antibiotic Therapy**

Levaquin 750 mg orally once a day for 5 days

Outpatient with Comorbidities* – Recent Antibiotic Therapy**

Z-pack + Amoxicillin-clavulanate 2 g orally twice a day for 7 days.

OR

Levaquin 750 mg once a day for 5 days

* Comorbities = Malignancy, COPD, Diabetes, CHF, Renal or Liver Disease

** Recent Antibiotics = Antibiotic for treatment of any infection within the past 3 months. Recent use of a fluoroquinolone should dictate selection of a non- fluoroquinolone regimen, and vice versa.

Suspected Aspiration with Infection

Amoxicillin-clavulanate 2 g orally twice a day for 7 days

OR

Clindamycin 600 mg orally three times a day for 7 days Coverage of oral flora.

Inpatient Non-ICU

Community acquired Levaquin 750 mg orally once daily

OR

Z-pack + Ceftriaxone 1 g IV once daily

If multi drug resistant gram negative suspected or previously isolated or if recently hospitalized: Cefepime 1 gram IV every 12 hours.

Recent antibiotics: Antibiotic for treatment of any infection within the past 3 months. Recent use of a fluoroquinolone should dictate selection of a non- fluoroquinolone regimen, and vice versa. In obese patients use ceftriaxone 2g instead of 1g. Levaquin is active against >98% of S. pneumoniae strains in the United States, including penicillin-resistant strains. Concern for abuse with risk of increasing resistance by S. pneumoniae. Active against H. influenzae, atypical agents, methicillin-susceptible S. aureus. Expensive. Ceftriaxone is active in vitro against 90%-95% of S. pneumoniae, also active against H. influenzae and methicillin-susceptible S. aureus.

Aspiration with infection
Clindamycin 600 mg orally every 8 hours + Levaquin 750 mg orally once daily Coverage of oral flora.

ICU – Not recently hospitalized

Ceftriaxone 1g IV once daily + Azithromycin 500 mg po or IV once daily

For patients with CAP in the ICU, always cover S. pneumoniae and Legionella. Legionella must be treated for 21 days. Patients hospitalized for pneumonia in the ICU should have 2 pretreatment blood cultures and endotracheal aspirate sent for Gram stain and culture. In obese patients use ceftriaxone 2g instead of 1g.

ICU – Recently hospitalized

Cefepime 1g IV every 12 hours + Azithromycin 500 mg po or IV once daily

Cefepime retains excellent activity against s. pneumoniae but also covers more resistant gram negatives. In obese patients use Cefepime 2g instead of 1g.

Nursing Home Resident2

ICU – Hospitalized or ICU bound

Cefepime 1 g IV every 12 hours + Azithromycin 500 mg po or IV once daily

Elderly patients of long-term care facilities have been found to have a spectrum of pathogens that most closely resemble late-onset hospital acquired pneumonia and ventilator associated pneumonia. Coverage against More resistant gram negatives, including pseudomonas should be provided.

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1. Update of Practice Guidelines for the Management of Community-Acquired Pneumonia in Immunocompetent Adults. Mandell LA, Bartlett JG, Dowell SF, File TM, Musher D, and Whitney C. Clin Infect Dis 2003;37:1405-1433.
2. Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Health-care-associated Pneumonia?American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2005;171:388-416.

Written by phil

July 15th, 2006 at 3:33 pm

Posted in Antibiotics