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MEDICINA INTERNA

NEUMOLOGÍA

Dr. Christiam Ochoa
UNMSM

TUBERCULOSIS PULMONAR
BACILO DE KOCH
• Mycobacterium tuberculosis
• Envoltura  Ac. Micolico
• 1-4x0.3-0.6 micras
• Inmóvil
• No esporulado
Define el
• Aerobio estricto
genero
• Desarrollo 35-37°C
Resiste a
• No es cromogeno
la
• Tincion:
decolorac
• Ziehl-Neelsen/Kinyoun
ión
• Auramina (+ sensible, pero no
distingue de los M. no tubercul..)
• Cultivo:
• Middlebrook 7H10 o 7H11
• Lowenstein-Jensen
• Pruebas Bioquimicas
• Niacina (+)
• Nitrato reductasa (+)
• Catalasa (debil +)
MEDICINA INTERNA qxmedic.edu@gmail.com www.qxmedic.com

com www. tos y perdida de peso TBC XDR (Extensamente) • Exposicion a un caso de TBC infecciosa activa • Resistente a H.qxmedic. fluroQ y 1 inyectable de 2da • PPD positivo (>10mm) linea (amikacina. histopatologico y/o clinica) CONTACTO EXTRADOMICILIARIO • La TB pleural es extrapulmonar y la +fr • Comparte ambientes comunes o frecuentan CASO TBC SISTEMICO pacientes BK+ (minimo6h) • No existe en la guia!!! TB pulmonar + otro lado  EXTRAPULMONAR TBC PANSENSIBLE TBC INFANTIL • Sensibilidad a todos los farmacos de 1ra linea TBC INFANTIL CONFIRMADO TBC MDR • Estudio bacteriologico + para Mycobacterium tuberculosis o muestra histologica compatible TBC INFANTIL PROBABLE • Resistente a H y R • Fiebre.com .edu@gmail. PCR. R. kanamicina o capreomicina) • Hallazgo en radiografia de torax compatible con TBC activa TBC MONORESISTENTE • Evidencia por otros examenes de apoyo diagnostico • Resistente a solo un farmaco anti-TB TBC POLIRESISTENTE • Resistente a >1 farmaco anti-TB (que no cumpla criterios de MDR o XDR) MEDICINA INTERNA qxmedic. TUBERCULOSIS PULMONAR DEFINICIONES OPERACIONALES SINTOMATICO RESPIRATORIO CASO TBC PULMONAR • Pac con Dx TB pulmonar c/ o s/ BK+ • Tos con flema >15 dias CASO TBC EXTRAPULMONAR CONTACTO DOMICILIARIO • Pac con Dx TB en organos diferentes a los pulmones • Mismo domicilio que paciente BK+ • Necesidad de demostracion (cultivo.

qxmedic. TUBERCULOSIS PULMONAR CONDICION DE INGRESO Y EGRESO • CASO NUEVO: 1er episodio de TB o q recibio tto por <30dias (o 25 dosis CONDICION DE CASO NUEVO CASO ANTES continuas) INGRESO TRATADO • CURADO: se vio BK(+) al inicio + termina tto + BK(–) al ultimo mes del tto.edu@gmail.com www. ABANDONO EGRESO DE TBC ABANDONO RECUPERADO • CASO ANTES TRATADO: pac con dx de TB y antec de haber recibido tto por SENSIBLE >30dias FRACASO • RECAIDA: otro episodio de TB despues de haber CURADO ó TTO COMPLETO FALLECIDO • ABANDONO RECUPERADO: paciente que fue ABANDONO y se reinicia tto desde 1ra dosis NO EVALUADO • FRACASO: idem • FALLECIDO: idem • NO EVALUADO: idem MEDICINA INTERNA qxmedic. • ÉXITO DE TRATAMIENTO: la suma de los casos CURADO y TTO COMPLETO TTO COMPLETO RECAIDA • ABANDONO: deja de recibir tto por >30 dias • FRACASO: BK(+) en esputo o cultivo apartir del 4to mes de tto ÉXITO DE TTO • FALLECIDO: muerte por cualquier causa durante el tto CONDICION DE • NO EVALUADO: paciente sin condicion de egreso.com . • TRATAMIENTO COMPLETO: se vio BK(+) al inicio + termino tto SIN tener CURADO prueba de BK al ultimo mes.

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qxmedic.edu@gmail.com www. Liquidación inmediata del organismo 2. La infección crónica o latente 3. Enfermedad activa rápidamente progresiva (o enfermedad primaria) 4. HISTORIA NATURAL 1. Enfermedad activa muchos años después de la infección (reactivación de la enfermedad) TBC 1° retenida TBC 1° no retenida TBC REACTIVADA: Miliar y ExtraPulm • Via hematogena x eso BK- TBC REACTIVADA: • Micronodular (<3mm) TBC 2° • 25% hacen MEC TB MEDICINA INTERNA qxmedic.com .

• Positivo (+++): Más de 10 BAAR Genotype MTBDplus) ahora a promedio por campo en 20 todo BK+. Griess. x IFN-gamma) bacilos ácido alcohol resistente • Anorexia • RADIOGRAFIA (BAAR) en 100 campos microscópicos. MEDICINA INTERNA qxmedic. SEGUIMIENTO DIAGNOSTICO • TAMBIEN • Broncograma aereo 3.qxmedic.edu@gmail. • Perdida de peso • BACILOSCOPIA • Paucibacilar: Se observan de 1 a 9 • Sudoracion nocturna • CULTIVO BAAR en 100 • Hemoptisis (cavernas) • BIOPSIA campos observados • Positivo (+): Menos de 1 BAAR • PRUEBAS DE promedio por campo en 100 PRONOSTICO SENSIBILIDAD campos observados (10-99 • 60% s/tto mueren a 2. MGIT. • Aspergiloma • Positivo (++): De 1 a 10 BAAR • PRUEBAS DE promedio por campo en 50 SENSIBILIDAD RAPIDA campos Observados.com .5 años CONVENCIONAL bacilos en 100 campos). DEFINICION DE CASO • Esputo no purulento • Tendencia a la cavitacion • Fiebre PRUEBAS Informe de resultados de baciloscopía: • Malestar general BACILOSCOPIA • PPD (>10mm[>5mm].com www. campos observados. medir • Negativo (-): No se encuentra • Astenia Generalmente Positivo induracion. DETECCION DE SINTOMATICO RESPIRATORIO • TOS • Infiltrado infreclavicular 2. (MODS. TUBERCULOSIS PULMONAR TBC REACTIVADA: TBC 2° DETECCION Y DIAGNOSTICO DE CASOS CLINICA RADIOGRAFIA 1.

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TUBERCULOSIS PULMONAR NT-TBC-MINSA-2013 QUIMIOPROFILAXIS ISONIACIDA • <15 años  10mg/Kg/dia x 6m (max 300mg/dia) • >15 años  5mg/Kg/dia x 6m (max 300mg/dia) • VIH (+)  dosis según la edad y x 12m + Piridoxina (por neuropatia x def VitB6) • Paciente < 5años con contacto de caso indice (no importa BK.qxmedic.com . no importa PPD) • Paciente 5-15 años con contacto de caso indice y PPD>10 • Paciente con conversion reciente de PPD (<2años) para trabajadores de Salud y personas que atienden a poblacion privada de libertad • Paciente con VIH(+) (no importa el PPD) MEDICINA INTERNA qxmedic.edu@gmail.com www.

En el mielitis transversa. FACTORES DE RIESGO ADULTO MAYOR.edu@gmail. algunos stafilococos. ETIOLOGÍA BATERIA TIPICAS (60-70%): VÍA DE INFECCION Neumococo 20-60% . VIRUS (5-10%): Influenza – deshidratación.ADVP MEDICINA INTERNA qxmedic. aspergillus. neisseria. Moraxella.L. aureus 3-5% .Haemophylus Clínica típica: Tos. pssitaci. pyogenes. pneumoniae . anemia INHALACION: mycoplasma. confusión y confusion.com . MICROASPIRACION: mas fc sanos. Mycoplasma.Rsv examen físico: miringitis bulosa. 3-10% . artromialgia. Haemofiilus. ATIPICOS (10-20): M. hematuria. virus. Coxiella burnetti. Parainfluenza . roncantes o crepitantes hemolitica. legionella. Pneumoniae . Neumococo.DM – EPOC . Expectoración. Enterobacteriaceae 3-5% Dolor pleurítico. CLINICA pneu. Disnea. HEMATOGENA: stafilococo aureus. Fiebre.Sf. pneumoniae hiporexia. En ancianos tos seca. etc clamidophila.com www.qxmedic. C. NEUMONIA ADQUIRIDA EN LA COMUNIDAD INFECCIÓN AGUDA DEL PARENQUIMA PULMONAR (ASOCIADA A UN INFILTRADO NUEVO EN LA RADIOGRAFÍA DE TÓRAX. Clinica atipica: febricula. C. TBC.BRONQUIECTASIA - ALCOHOLISMO – VIH . corynebacterium.

atypical mycobacteria Travel to Ohio or St. goats. M. Klebsiella pneumoniae. gram-negative enteric bacteria Lung abscess CA-MRSA. avian influenza virus Stay in hotel or on cruise ship in previous 2 weeks Legionella spp. Lawrence river valleys Histoplasma capsulatum Travel to southwestern United States Hantavirus. Legionella spp. stroke. pneumoniae. tuberculosis. Staphylococcus aureus Dementia. Local influenza activity Influenza virus. pneumoniae. Coccidioides spp. Acinetobacter Alcoholism spp. oral anaerobes. NEUMONIA ADQUIRIDA EN LA COMUNIDAD Table 257-3 Epidemiologic Factors Suggesting Possible Causes of Community-Acquired Pneumonia Factor Possible Pathogen(s) Streptococcus pneumoniae. endemic fungi.. Mycobacterium tuberculosis Haemophilus influenzae. parturient cats Coxiella burnetii MEDICINA INTERNA qxmedic. S. Chlamydia pneumoniae Structural lung disease P.com www. Moraxella catarrhalis.qxmedic. aureus Exposure to bats or birds H. COPD and/or smoking S. aeruginosa. capsulatum Exposure to birds Chlamydia psittaci Exposure to rabbits Francisella tularensis Exposure to sheep. decreased level of consciousness Oral anaerobes.edu@gmail. Burkholderia cepacia. S..com . oral anaerobes. Pseudomonas aeruginosa. Travel to Southeast Asia Burkholderia pseudomallei.

PSI class and mortality PNEUMONIA SEVERITY INDEX (PSI) CRITERIOS DE INGRESO A UCI EX. Sf.9 • EMPIEMA HEMOGRAMA IV 91-130 9.6 •ATELECTASIA COMPLEMENTO . and hypoxia 3 Cavitary infiltrates X X Cough 14 Leukopenia X X X Fatigue 14 Active alcohol abuse X X X X X Chronic severe liver disease X X X Infiltrates on chest radiograph 30 Severe obstructive/structural lung disease X X Asplenia (anatomic or functional) X X X •ANTIBIOTICOTERAPIA Recent travel (within past 2 weeks) X X • HIDRATACIÓN ADECUADA Positive Legionella UAT result ¥ X NA TTO • ANTIPIRÉTICOS / ANALGÉSICOS Positive pneumococcal UAT result X X NA • OXIGENOTERAPIA Pleural effusion X X X X MEDICINA INTERNA qxmedic. CMV. % GRAM-CULTIVO DE ESPUTO No COMPLICACIONES BRONCOFIBROSCOPÍA (CP.edu@gmail. AUXILIARES RADIOGRAFÍA DE TÓRAX: PA-L Class Points Mortality. NEUMONIA ADQUIRIDA EN LA COMUNIDAD ALVEOLAR: LOBAR: Gram+. Mycoplasma .0 Blood Sputum Legionella Pneumococcal Abnormality Days Indication Multiplex PCR¶ culture culture UAT UAT Tachycardia and hypotension 2 Intensive care unit admission X X X X X Failure of outpatient antibiotic therapy X X X X Fever. ELISA o FIJACIÓN II <70 0. CURB-65 CAVITADA: anaerobio.qxmedic.TEST • DERRAME PARANEUMÓNICO URINARIO – HEMOCULTIVO - III 71-90 0.CREATININA • BRONQUIECTASIA ELECTROLITOS. St neumoniae SEVERIDAD INTERSTICIAL: Mycoplasma. chlamydia. VHZ.1 predictors IFI.com www. P. St penumoniae serotipo III. carinii. BGN.MULTILOBAR: gram -.com . LBA) I 0. legionella. tachypnea.3 • ABSCESO PULMONAR GLUCOSA – UREA .aureus. hongos.AGA V >130 27. sarampión. TBC.

Severe sepsis lactate >2 mmol/L.25 mcg/kg/min to maintain mean BP at >60 mm Hg (80 mm Hg if previous hypertension) Need for dopamine at >15 mcg/kg/min. or >10 percent immature (band) response syndrome forms SIRS in response to documented infection (culture or Gram stain of blood.qxmedic. respiratory rate of >20 breaths/min or Systemic inflammatory PaCO2 of <32 mm Hg. or normally Sepsis sterile body fluid positive for pathogenic microorganism. urinary output of <0. NEUMONIA ADQUIRIDA EN LA COMUNIDAD Description >=2: temperature >38. capillary refilling of ≥3 s.com www. urine.25 mcg/kg/min to Refractory septic shock maintain mean BP at >60 mm Hg (80 mm Hg if previous hypertension) MEDICINA INTERNA qxmedic. or focus of infection identified by visual inspection) Sepsis and at least one of the following signs of organ hypoperfusion or organ dysfunction: areas of mottled skin. or PCWP between 12 and 20 Septic shock mm Hg. abrupt change in mental status or abnormal EEG findings.0°C. or norepinephrine or epinephrine of <0. and WBC count of >12. <4000 cells/mL.000 cells/mL or disseminated intravascular coagulation. platelet count of <100. or norepinephrine or epinephrine at >0. sputum.edu@gmail. acute lung injury/ARDS. and need for dopamine of >5 mcg/kg/min.5 mL/kg for at least 1 h or renal replacement therapy.5°C or <35. heart rate of >90 beats/min. and cardiac dysfunction (echocardiography) Severe sepsis and one of the following conditions: systemic mean BP of <60 mm Hg (<80 mm Hg if previous hypertension) after 20 to 30 mL/kg starch or 40 to 60 mL/kg saline solution.com .000 cells/mL.

qxmedic. cephalosporins (oral cefuroxime. Vancomycin. Macrolide. amoxiclav Fluoroquinolone. carbapenemΔ Beta-lactam/beta-lactamase inhibitor◊. fluoroquinolone Ciprofloxacin. streptomycin Yersinia pestis Streptomycin. fluoroquinolone microgram/mL) Haemophilus influenzae Non-beta-lactamase Amoxicillin Fluoroquinolone. cefdinir] or parenteral ceftriaxone. linezolid. colistin MEDICINA INTERNA qxmedic. respiratory fluoroquinolone* Penicillin resistant. azithromycin Doxycyline Chlamydophila psittaci A tetracycline Macrolide Coxiella burnetii A tetracycline Macrolide Francisella tularensis Doxycycline Gentamicin. azithromycin. NEUMONIA ADQUIRIDA EN LA COMUNIDAD Organism Preferred antimicrobial(s) Alternative antimicrobial(s) Streptococcus pneumoniae Penicillin nonresistant. chloramphenicol Enterobacteriaceae 3RA cephalosporin. doxycycline. beta-lactam. a tetracycline Fluoroquinolone pneumoniae Legionella species Fluoroquinolone. including cefotaxime. levofloxacin. Bacillus anthracis (inhalation) second agent) clindamycin. clarithromycin• Beta-lactamase producing 2-3RA generation cephalosporin. pneumoniae/C.com . ampicillin-sulbactam. clarithromycin• M. if susceptible.edu@gmail. MIC <2 Macrolide. gentamicin Doxycyline. doxycycline (usually with Other fluoroquinolones.com www. fluoroquinolone Antipseudomonal beta-lactam§ plus (ciprofloxacin or Pseudomonas aeruginosa Aminoglycoside plus (ciprofloxacin or levofloxacin¥) levofloxacin¥ or aminoglycoside) Acinetobacter species Carbapenem Cephalosporin-aminoglycoside. MIC ≥2 Basis of susceptibility. rifampin. azithromycin. doxycyline. amoxicillin microgram/mL clindamycin. high-dose amoxicillin (3 g/day with penicillin MIC ≤4 microgram/mL ceftriaxone. Penicillin G. doxycycline.

2 grams IV c/6h plus clarithromycin 500 mg IV c/12h Benzylpenicillin (penicillin G) 1. for therapy. consider c/24h. Doxycycine 200 mg carga + 100 mg orally or levofloxacin 500 mg Vo c/24h or Hospital Amoxicillin 500 mg IV c/8h or 9 percent mortality) moxifloxacin 400 mg VO c/24h benzylpenicillin (penicillin G) 1.com .com www. fluconazole Histoplasmosis Itraconazole** Amphotericin B** Blastomycosis Itraconazole** Amphotericin B** Treatment CURB65 Preferred treatment Alternative treatment site Low severity (eg.2 grams IV c/8h* plus OR High severity (eg. CURB65 = 0-1 <3 Home Amoxicillin 500 mg VO C/8H Doxycycline 200 mg carga . plus clarithromycin 500 mg IV c/12h adding levofloxacinΔ) (If Legionella strongly suspected.edu@gmail. (consider clarithromycin 500 mg IV c/12h* 40 percent mortality) critical care Cefuroxime 1. CURB65 = 2. Amoxicillin 500 mg IV C/8h Amoxicillin 1g VO C/8H plus clarithromycin 500 mg VO c/12h Moderate severity (eg. NEUMONIA ADQUIRIDA EN LA COMUNIDAD Staphylococcus aureus Methicillin susceptible Antistaphylococcal penicillin‡ Cefazolin. no therapy Coccidioides species Amphotericin B generally recommended.100 mg VO c/24h or clarithromycin 500 mg VO c/12h percent mortality) Low severity + comorbilidad o Amoxicillin 500 mg VO C/8H Hospital Doxycycline 200 mg carga . clindamycin Methicillin resistant Vancomycin or linezolid TMP-SMX Bordetella pertussis Macrolide TMP-SMX Anaerobe (aspiration) Beta-lactam/beta-lactamase inhibitor◊.5 grams IV c/8h or cefotaxime 1 gram IV c/8h or ceftriaxone 2 grams IV review) (If Legionella strongly suspected.qxmedic. consider adding levofloxacinΔ) MEDICINA INTERNA qxmedic. 15. clindamycin Carbapenem Influenza virus See associated topic reviews† For uncomplicated infection in a normal host. CURB65 = 3-5. itraconazole.2 grams IV c/6h plus either levofloxacin 500 mg IV Antibiotics given as soon as possible c/12h or ciprofloxacin 400 mg IV c/12h Hospital Co-amoxiclav 1.100 mg VO c/24h or clarithromycin 500 mg VO c/12h problema social.

or levofloxacin [750 mg]) OR An antipneumococcal beta-lactam (preferred agents: cefotaxime. or meropenem) PLUS either ciprofloxacin or levofloxacin (750 mg) OR The above beta-lactam PLUS an aminoglycoside PLUS azithromycin OR The above beta-lactam PLUS an aminoglycoside PLUS a respiratory fluoroquinolone (moxifloxacin. alcoholism. liver or renal disease. consider use of alternative agents listed in (2) above. or levofloxacin [750 mg]) OR A beta-lactam (first-line agents: high-dose amoxicillin. alternative agents: ceftriaxone. cefpodoxime. gemifloxacin. Inpatients. or ampicillin-sulbactam) PLUS azithromycin OR An antipneumococcal beta-lactam (cefotaxime. In regions with a high rate (>25 percent) of infection with high-level (MIC ≥16 µg/mL) macrolide-resistant Streptococcus pneumoniae. or use of antimicrobials within the previous 3 months (in which case an alternative from a different class should be selected): A respiratory fluoroquinolone (moxifloxacin. ICU treatment An antipneumococcal beta-lactam (cefotaxime. for penicillin-allergic patients. imipenem. immunosuppressing conditions or use of immunosuppressing drugs. asplenia. or erythromycin)* 3. gemifloxacin. substitute aztreonam for above beta-lactam If CA-MRSA is a consideration: Add vancomycin or linezolid MEDICINA INTERNA qxmedic. Presence of comorbidities such as chronic heart. lung. non-ICU treatment A respiratory fluoroquinolone (moxifloxacin. ceftriaxone. or ertapenem for selected patients)• PLUS a macrolide (azithromycin. antipseudomonal beta-lactam (piperacillin-tazobactam. or cefuroxime) PLUS a macrolide (azithromycin. cefepime. Previously healthy and no use of antimicrobials within the previous 3 months: A macrolide (azithromycin. gemifloxacin. clarithromycin. or erythromycin)*Δ Inpatients.com www.qxmedic. diabetes mellitus. or ampicillin-sulbactam. clarithromycin.com . gemifloxacin. ceftriaxone. ceftriaxone. or levofloxacin [750 mg]). a respiratory fluoroquinolone (moxifloxacin. or ampicillin-sulbactam) PLUS a respiratory fluoroquinolone (moxifloxacin. malignancies. or erythromycin) OR Doxycyline* 2. gemifloxacin. or levofloxacin [750 mg]) OR For penicillin-allergic patients. clarithromycin. NEUMONIA ADQUIRIDA EN LA COMUNIDAD Outpatient treatment 1. amoxicillin- clavulanate. or levofloxacin [750 mg]) PLUS aztreonam Special concerns If Pseudomonas is a consideration: An antipneumococcal.edu@gmail.

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qxmedic. avoidance of days within the prior 90 days endotracheal tube • ENTEROBACTER reintubation. lowering of hemoglobin transfusion hemodialysis clinic within the • ACINETOBACTER host defenses threshold. • PSEUDOMONA Abnormal swallowing or other long-term care facility Early percutaneous tracheostomya • OTROS SF. NEUMONIA INTRAHOSPITALARIA DEFINICION Table 257-6 Pathogenic Mechanisms and Corresponding Prevention Strategies for Pneumonia types Ventilator-Associated Pneumonia ●Hospital-acquired (or nosocomial) FACTORES DE RIESGO Pathogenic Mechanism Prevention Strategy pneumonia (HAP) 48H.com www. Oropharyngeal colonization with pathogenic bacteria ●Ventilator-associated pneumonia ALCOHOLISMO Elimination of normal flora Avoidance of prolonged antibiotic courses (VAP) 48 to 72 hours. care. selective pneumonia that occurs in a Bacterial overgrowth of ENDOTRAQUEAL decontamination of digestive tract with nonabsorbable nonhospitalized patient with stomach • USO DE SNG . • ADULTO MAYOR ●Healthcare-associated Postpyloric enteral feedingb. isolation. avoidance of high gastric • USO PREVIO A ATB . especially with alcohol-based hand rub. specialized enteral feeding formula prior 30 days MEDICINA INTERNA qxmedic.COMA antibioticsb extensive healthcare contact. as • CIRUGÍA MAYOR Hand washing. COLI Altered lower respiratory Tight glycemic controlb. proper following: colonized patients • FALLA MULTIORGÁNICA cleaning of reusable equipment •Intravenous therapy. Gastroesophageal reflux residuals. or intravenous • USO DE ANTI H2/IBP Large-volume aspiration decompression of small-bowel obstruction chemotherapy within the prior ETIOLOGÍA Microaspiration around endotracheal tube 30 days Endotracheal intubation Noninvasive ventilationa •Residence in a nursing home • MRSA.edu@gmail. continuous aspiration of subglottic care hospital for two or more Secretions pooled above PNEUMONIAE secretions with specialized endotracheal tubea. wound • NEUTROPENIA Endotracheal intubation. avoidance of sedation. •TABAQUISMO . defined by one or more of the Cross-infection from other • DESNUTRICIÓN intensive infection control educationa. minimization of sedation and patient transport •Attendance at a hospital or • E. function •Hospitalization in an acute • KLEBSIELLA Head of bed elevateda..com . prokinetic agents pneumonia (HCAP) is defined as UREMIA • INTUBACIÓN Prophylactic agents that raise gastric pHb.

5 or ≤38.5 or ≤38.edu@gmail. PAWP ≤18 mmHg and acute bilateral infiltrates) = 0 points PaO2/FIO2 ≤240 and no ARDS = 2 points Pulmonary radiography No infiltrate = 0 point Diffuse (patchy) infiltrate = 1 point Localized infiltrate = 2 points Progression of pulmonary infiltrate No radiographic progression = 0 point Radiographic progression (after HF and ARDS excluded) = 2 points Culture of tracheal aspirate Pathogenic bacteria cultured in rare or few quantities or no growth = 0 point Pathogenic bacteria cultured in moderate or heavy quantity = 1 point Same pathogenic bacteria seen on Gram's stain.<4000 or >11.000 = 1 point .qxmedic.com qxmedic.9 = 1 point .4 = 0 point .≥39 or <36.Band forms ≥50 percent = add 1 point Tracheal secretions Absence of tracheal secretions = 0 point Presence of non-purulent tracheal secretions = 1 point Presence of purulent tracheal secretions = 2 points Oxygenation PaO2/FIO2.5 = 2 points Blood leukocytes.≥38.000 = 0 points . add 1 point MEDICINA INTERNA www. microL ≥4000 or ≤11. mmHg >240 or ARDS (defined as PaO2/FIO2 ≤200.com Total (a score of >6 was considered suggestive of pneumonia) . NEUMONIA INTRAHOSPITALARIA Temperature ≥36.

NEUMONIA INTRAHOSPITALARIA TERAPIA EMPIRICA Table 257-8 Empirical Antibiotic Treatment of Health Care–Associated ATB: GUIA ATS Pneumonia Patients without Risk Factors for MDR Pathogens Ceftriaxone (2 g IV q24h) or Moxifloxacin (400 mg IV q24h). imipenem (500 mg IV q6h or 1 g IV q8h). Vancomycin (15 mg/kg. or meropenem (1 g IV q8h) plus 2. A -lactam: Ceftazidime (2 g IV q8h) or cefepime (2 g IV q8–12h) or Piperacillin/tazobactam (4. up to 1 g IV.qxmedic.edu@gmail. q12h) MEDICINA INTERNA qxmedic. or levofloxacin (750 mg IV q24h) or Ampicillin/sulbactam (3 g IV q6h) or Ertapenem (1 g IV q24h) Patients with Risk Factors for MDR Pathogens 1.com .com www. A second agent active against gram-negative bacterial pathogens: The serum gentamicin or tobramycin concentration should be obtained six hours (or up to 14 hours) after Gentamicin or tobramycin (7 mg/kg IV q24h) or amikacin (20 mg/kg IV q24h) or the initial dose of 7 mg/kg and plotted on the above nomogram. 3. The interval for drug administration of Ciprofloxacin (400 mg IV q8h) or levofloxacin (750 mg IV q24h) plus subsequent doses of 7 mg/kg is then determined based on the interval specified on the graph. An agent active against gram-positive bacterial pathogens: * Application of the nomogram for amikacin requires the measured concentration be divided by two. The Linezolid (600 mg IV q12h) or new value should be plotted on the nomogram in order to obtain the appropriate dosing interval. ciprofloxacin (400 mg IV q8h).5 g IV q6h).

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