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Confusion,
Uremia (blood urea nitrogen >20 mg/dL),
Respiratory rate greater than 30 per minute,
Blood pressure less than 90 mm Hg systolic or 60 mm Hg diastolic,
and age 65 years or older.
0 - 1 risk factors - mortality low (0.7% and 2.1%, respectively).
These rules perform poorly in extreme or unusual
circumstances. (eg: 20yr bp low, tachycardia, hypoxia).
Are antibiotics indicated
Antibiotic Therapy
• Pneumonia –
o Empiric Antibiotic Tx initially
o treatment for 10 - 14 days.
• Acute bronchitis - is usually of viral origin -
empiric use of antibiotics does not improve
outcomes!!!
Rule: Acute Bronchitis – No Abx!
• Most cases are viral
• Spontaneous resolution 1-2 weeks with or w/o Tx
• Overprescription of antibiotics in this population
is a major source of resistance.
• Also if Abx - X2 risk for an individual of later
contracting a resistant infection!
:Exception to the rule
1.antibiotics are indicated for COPD patients with
acute exacerbation:
2.severe underlying disease (eg, congestive heart
failure)
3.patients who are symptomatic for more than 10 days
1.Mycoplasma infection becomes a greater possibility.
2.Pertussis “ “ “
If an antibiotic is to be used, a macrolide is a
reasonable first choice!
because the macrolides are active against mycoplasmal
and chlamydial and B pertussis.
:Bordetella pertussis
• Young adults (childhood immunity wanes after 15-20 yrs )
• 25% of patients with bronchitis lasting 2 weeks or more.
• three phases of disease:
o catarrhal phase - rhinorrhea, low-grade fever, and mild congestion
-1 to 2 weeks.
o paroxysmal phase severe paroxysms of nonproductive cough,
with 10-30 coughs in a row. 2 to 4 weeks
Posttussive syncope and vomiting.
the characteristic “whoop” is absent in adults
o convalescent phase – symptoms gradually resolve during the next
1 to 3 months.
• A single elevated pertussis serology has been
advocated as a rapid means of diagnosing pertussis.
Pertusis Tx
• Antibiotics are advocated if the first 4 weeks of
illness (still infective).
• The preferred drugs are the following:
• Erythromycin: 500mg X4/d - 14 days
• Azithromycin: 500 mg day 1- then 250 mg for 4
additional days
• Clarithromycin: 500mgX 2/d - 7 days
• Alternative: Resprim (800/160) X 2/d - 14 days
• צריך להנתן לכל בני הבית טיפול מניעתי באותה תרופה ומינון
o TMP-SMZ- not useful in mycoplasmal infections
o Doxycycline – not useful for Pertussis
- Amoxicillin – not so useful for pertusis or mycoplasma
טיפול בברונכיטיס – לפי המלצות
בכללית
.1אם יש חום מעל 38.5או ממצאים ממוקמים
בריאות – לשלוח לצילום לשלול דלקת ריאות
.2בד"כ – טיפול סימפטומטי בלבד.
.3נשקול אנטיביוטיקה רק אם:
.1אין שיפור לאחר 3-5ימים או
.2יש מחלות לב COPD ,או סכרת
.3חום מעל 38.5או כיח מוגלתי
טיפול אנטיביוטי בדלקת ריאות
(מפחית תמותה וסיבוכים)
Tx for persons less than 60 years old:
• S. pneumoniae, Mycoplasma, Chlamydia,Legionella.
Covered with:
• Erythromycin 500 mg X 4/d = first-line. or
• Azithromycin 500 mg on day 1, followed by 250 mg daily for 4 days,
• or Clarithromycin 500 mg twice daily for 10 days
Second-line:
• doxycycline (100 mg twice daily).
• Respiratory fluoroquinolones: levofloxacin (TAVANIC
500 mg), moxifloxacin (MEGAXIN 400 mg) = X 1/day.
• Older quinolones (e.g., ciprofloxacin) = less activity
against the pneumoco = not recommended.
•
Penicillins /cephalosporins - not cover atypical pneum.
Older Adults (>60) and Patients with Comorbidities:
. S.pneumoniae remains the most common BUT:
• H. influenzae, M. catarrhalis, and other gram-negative
are possibilities.
• New Evidence: Mycoplasma and Chlamydia
still important!
• also for patients with recent (within 3 months) exposure
to antibiotics (pneumococal resistance).
• first-line: is
• a 2nd-generation macrolide (azithromycin or clarithromycin)
PLUS a high-dose β-lactam:
o amoxicillin, 1 g X 3/d, or
o amoxicillin-clavulanate, 2 g twice daily.
o Alternative a respiratory fluoroquinolone.
For hospitalized patients:
First-line:
3rd-generation cephalosporin (1 g of ceftriaxone
daily) PLUS a second-generation macrolide
in a dose sufficient for Legionella infection:
azithromycin 500 mg daily or clarithromycin 500 mg X2/d
Provides coverage for resistant S. pneumoniae.
Therapy narrowed after diagnostic test results: such as
Legionella urinary antigen and blood cultures.
The alternative empiric treatment:
• respiratory fluoroquinolone.
concern about emerging resistance.
penicillin resistance of pneumococci
• mutations in penicillin-binding proteins
• 30% intermediate resistance ([MIC] of 0.1 to 1.0 µg/mL),
• 10% are highly penicillin resistant (MIC >2.0 µg/mL).
• These highly resistant are often cross-resistant to
multiple antibiotics, including
trimethoprim/sulfamethoxazole and erythromycin.
• Fluoroquinolone resistance has been very low in S.
pneumoniae (<2%); now increasing.
• emphasize the need to vaccinate high-risk patients.
• more than 85% of resistant organisms are serotypes
contained in the 23-valent vaccine
• 80% by prevnar (year 2000).
Monitoring
• PORT study: temperature, RR, HR, and BP - reliable
measures of stability.
• average: “normal” vital signs at 3 days after hospitalization
• Often: Completely afebrile: 6 days.
• Repeating CXR at frequent intervals is wasteful.
• particularly true of pneumocc or Legionella - still show an
infiltrate a months later.
• However, when worsening or fever not resolving, CXR for
complications (abscess and empyema)
• unusual or resistant organisms should be considered in these
patients and antibiotic therapy appropriately adjusted.
• More than 50% of patients with pneumonia continue to report
fatigue and cough 1 month after diagnosis
Pneumococcal and Flu Vaccine
pneumococcal vaccine 23 capsular types of pneumococci, which
together account for about 90% of cases.
Indications: recovery from CAP, elderly (older than 65 years), CHF
or COPD/ASTHMA, are immunosuppressed, or have undergone
splenectomy.
One-time revaccination after 5 years is recommended for:
immunosuppressed , functional asplenia, and elderly persons who
received the initial vaccination before age 65 years.
influenza vaccine - inactivated virus,
modified each year to include prevalent strains of influenza A and B.
Indications: all patients older than age 50, pregnant women, and the
high-risk groups mentioned previously.
C/I: Hypersensitivity to eggs .
**The vaccines may be given at the same time without an increase in
side effects or decrease in immunogenicity.
Pathogens
Gram-Positive Organisms
• Streptococcus pneumoniae –
o 30% to 50% of all cases of bacterial
pneumonia.
o especially young ambulatory patients
o also acute exacerbations in COPD
Staphylococcus aureus –
o 10% of bacterial pneumonia
o most commonly follows a viral URI (influenza)
o Patients - usually extremely ill.
Gram-Negative Organisms
H. influenzae
• common cause of bronchitis in COPD
• Bronchitis – untypeable H.Flu
• Pneumonias - especially type B.
• CXR - Bronchopneumonia
• Complications are uncommon – unless
COPD (hypoxia)
Gram-Negative Organisms
Klebsiella pneumoniae:
• In debilitated patients, especially
alcoholics,
• usually - acute illness;
• Rarely, chronic pneumonitis.
• tissue necrosis -> hemoptysis, Abcess.
• CXR - dense lobar consolidation,
Sputum may appear dark red and
mucoid (“currant jelly” sputum).
Other Gram-Negative- Hospitally
acquires Pneumonias
• Rare in Ambulatory setting
• Patients: Chronic disease or elderly
and frequently have received antibiotic
therapy.
1.Moraxella (Branhamella) catarrhalis.
– Bordetella pertussis.
– Legionnaires' Disease
:Moraxella (Branhamella) catarrhalis