Respiratory Tract Infections :

Pharmacotherapy
 Anatomy of the Respiratory Tract
 Sinuses
 Ear (otitic)
 Pharynx
 Lungs
▪ Bronchus
▪ Alveolus
 Mucocillary
clearance,
Secretory
IgA, Cough,
Mechanical
Barrier
 Upper Respiratory Tract
 Sinusitis
 Otitis Externa & Media
 Pharyngitis
 Lower Respiratory Tract
 Bronchitis
 Pneumonia
▪ Community Acquired
▪ Nosocomial (HAP)
▪ Aspiration…
 A 43-year-old man has a two-week history of
nasal congestion, postnasal drip, and fatigue. He
has used an over the- counter nasal decongestant
and acetaminophen, without relief
 During the past few days, facial pain and
pressure have developed and have not
responded to decongestants
 In addition, his nasal discharge has turned from
clear to yellow
 How should he be treated?
 Inflammation and/or infection of the paranasal sinuses,
or membrane-lined air spaces, around the nose
 Nasal congestion, purulent nasal discharge, maxillary tooth
discomfort, hyposmia or anosmia, cough
 Facial pain or pressure that is made worse by bending
forward, headache, fever, and malaise
 Viral: Usually improves in 5-7 days
 Bacterial: Symptoms > 10 days or worsens after 5-7 d
 50-60 % of cases: S. pneumoniae & H. influenzae
 Amoxicillin* 500 mg three times daily for 10
days
 Continued use of nasal saline and
decongestant therapy
 * Doxycycline or trimethoprim–sulfamethoxazole
also reasonable
 If patient’s symptoms did not improve after 72
hours
 Switch to azithromycin, levofloxacin, or high-dose
amoxicillin–clavulanate
Oral Dosing Guidelines for Acute Bacterial Sinusitis
 An otherwise healthy 17-month-old boy had a cold
accompanied by two days of rhinorrhea, cough, and
fever (temperature of up to 38.8°C [102°F]).
 On day 5 he became fussy and woke up crying multiple
times during the night.
 The following day he was afebrile, and a physical
examination was normal except for findings of slight
redness of the left tympanic membrane with no middle-
ear fluid and a bulging right tympanic membrane with
white fluid behind it obscuring the umbo.
 How should this child be treated?
 Otitis media: is an inflammation of the middle ear
 Three subtypes of otitis media:
 acute otitis media, otitis media with effusion, and
chronic otitis media
 are differentiated by onset, signs and symptoms of
infection, and the presence of fluid in the middle ear
 Acute otitis media is the subtype with the greatest role
for antibiotics
 Diffuse = Swimmers Ear
 Topical cleaning including hypertonic saline or alcohol
with acetic acid; topical antibiotics +/-
glucocorticoids
 Invasive malignant or necrotic
 Usually due to P. aeruginosa
 Early / mild with close follow up
▪ Oral and topical ciprofloxacin
 Everyone else
▪ Systemic antipseudomals (piperacillin/tazobactam) &
surgery
 Onset within 48 hours of symptoms that
parents rated > 3 on Acute Otitis Media
Severity of Symptoms (AOM-SOS) scale
 0 to 14 – higher scores indicating greater severity
 Middle-ear effusion
 Moderate or marked bulging of the tympanic
membrane or slight bulging accompanied by
either otalgia or marked erythema of the
membrane
 Seven discrete items: tugging of ears, crying,
irritability, difficulty sleeping, diminished
activity, diminished appetite, and fever.
 Parents rate comparison w/ child’s usual state
 ―none,‖ ―a little,‖ or ―a lot,‖
 0, 1, and 2 points
 Goal: Pain management, prudent antibiotic use, and
secondary disease prevention
 Consider: primary prevention of acute otitis media through the use
of bacterial and viral vaccines
 Differentiate acute otitis media from otitis media with effusion or
chronic otitis media
 Recognize that amoxicillin is the mainstay of therapy and that
penicillin resistance can be overcome, in many cases, with high-
dose amoxicillin therapy
 Acetaminophen or NSAID, such as ibuprofen, should be offered
early to relieve pain in acute otitis media
 One strategy to reduce antibiotic use in this setting is "delayed
therapy …. 48 to 72 hours
 Initial Antibiotics
 Amoxicillin 80-90 mg/kg/day divided Q12h
 Alternatives for non IgE allergy
▪ Cefdinir, Cefuroxime, Cefpodoxime, Cefprozil
 Alternative for IgE (anaphylactic) allergy
▪ Azithromycin, Clarithromycin
 Severe or fails initial therapy
 Amoxicillin / Clavulanate
 Ceftriaxone 50 mg/kg/day IM/IV for 3 days
▪ Clindamycin if penicillin allergy
 6 months to 2 years
 Amox / Clav (not placebo) should be given for 10
days if diagnostic criteria met
▪ N Engl J Med 2011;364:105-15
 Giving Amox / Clav will
▪ N Engl J Med 2011;364:116-26
 reduce treatment failures 62%
 Cause ADE’s almost twice as often vs placebo
▪ 47.8% diarrhea vs 26.6% in placebo (P<0.001
 Duration of treatment
 10 days standard [ < 2 years of age , Ethiopia]
 5-7 days (short course)
▪ Children > 6 years old with mild to moderate disease
 Observation without antibiotics for 48-72 hours:
 6 months to 2 years, otherwise healthy with non-severe
illness at presentation and an uncertain diagnosis
 2 years of age and older without severe symptoms at
presentation or with an uncertain diagnosis
 Bulging tympanic membrane with visible pus
 Immediate antibiotic therapy with high-dose
amoxicillin
 Acute otitis without bulging eardrums
 likely to clear spontaneously
 Consider delayed antibiotic-prescribing strategy
(waiting 48 to 72 hours to prescribe antibiotics
while giving the patient acetaminophen)
Case – Pharyngitis

 A 10-year-old girl presents

with a sore throat and fever that has lasted for 1 day. She
appears flushed and moderately ill
 Physical examination reveals a temperature of 39°C, tender
bilateral anterior cervical lymph nodes that are 1 to 2 cm in the
greatest dimension, and erythema and whitish-yellow exudate
over enlarged tonsils and the posterior pharynx.
 A rapid antigen-detection test from a throat-swab specimen is
positive for group A streptococcus.
 How should the patient be evaluated and treated?
 Pharyngitis is an acute infection of the oropharynx or
nasopharynx
 Viral causes are most common, GABHS is the primary
bacterial cause and is associated with rare but severe
sequelae if not treated appropriately
 Non suppurative complications
▪ acute rheumatic fever, acute glomerulonephritis, and reactive arthritis
 Suppurative complications, such as
▪ peritonsillar abscess, retropharyngeal abscess, cervical lymphadenitis,
mastoiditis, otitis media, sinusitis, and necrotizing fasciitis
 Children ages 5 to 15 years are most susceptible
 Sudden onset of sore throat, Pain on swallowing
 Fever, Headache, Abdominal pain
 Nausea and vomiting, Tonsillopharyngeal erythema
 Tonsillopharyngeal exudate
 Soft-palate petechiae (―doughnut‖ lesions)
 Beefy red, swollen uvula
 Anterior cervical lymphadenitis
 Scarlatiniform rash
 Symptoms suggestive of other diagnosis like
common cold (Rhinovirus, Coronovirus)
 Coryza, Hoarseness, Cough, Diarrhea, Conjunctivitis, Anterior
stomatitis, Discrete ulcerative lesions
 Scoring System: Modified Centor Criteria for Clinical
Prediction of Group a -Hemolytic Streptococcal Pharyngitis
 GOALS OF THERAPY — Goals of
antimicrobial therapy for eradication of GAS
from the pharynx in the setting of acute
streptococcal pharyngitis include:
 Reducing duration and severity of clinical signs and
symptoms, including suppurative complications
 Reducing incidence of nonsuppurative complications
(eg, acute rheumatic fever)
 Reducing transmission to close contacts by reducing
infectivity
 Symptomatic treatment (pain)
 Acetaminophen (better option than NSAID)
 Rest, fluid, lozenges, salt water gargles
 Antibiotics if clinical signs & symptoms consistent
with group A streptococcus and positive
laboratory test (rapid strep screen or culture)
 Goals of antibiotic therapy:
 Prevent suppurative complications (abscess etc.)
 Prevent rheumatic fever (reduces from 2.8 % to 0.2 %)
 Decrease infectivity
 Shorten clinical course by 1-2 days (if started early)
 Penicillin Benzathine 1.2 million Units IM once
 Ten days of:
 Penicillin VK 250 mg 3-4 times daily or 500 mg twice
daily
 Amoxicillin 500 mg 3 times daily
▪ Avoid if patient likely to have mononeucleosis as will cause rash
 Cephalexin 250 – 500 mg PO 4 times daily
 Macrolides
 Erythromycin 250 mg PO 4 times daily
 Azithromycin 12 mg / kg (max 500 mg) PO daily for 5
days
▪ 7 – 30 % of strains are now resistant
 A 40-year-old man with no underlying lung disease has a 7-
day history of mild shortness of breath with exertion, as well as
cough that is now productive of purulent sputum

 He reports no paroxysms of cough and no contact with ill

persons in his community. He does not appear to be in distress.
 His temperature is 37°C, his pulse 84 beats per minute, and his
respiratory rate 17 breaths per minute. On auscultation of the
lungs, no rales are heard; scattered wheezes are heard in the
lung bases.
 How should he be evaluated and treated?
 Bronchitis and bronchiolitis are inflammatory conditions of
the large and small elements, respectively, of the
tracheobronchial tree that is usually associated with a
generalized respiratory infection
 inflammatory process does not extend to the alveoli
 Bronchiolitis is a disease of infancy
• Bronchitis
• classified as either acute or chronic
• Acute bronchitis occurs in all ages, whereas chronic
bronchitis primarily affects adults.
• Acute bronchitis is one of the most common conditions
encountered in clinical practice
• a self-limited inflammation of the bronchi due to upper
airway infection
• Patients present with a cough lasting more than five days
(typically one to three weeks), which may be associated with
sputum production
• should be distinguished from chronic bronchitis(a condition in
patients with chronic obstructive pulmonary disease
distinguished by a cough for at least three months in each of
two successive years)
• Acute bronchitis is one of the most common conditions
associated with antibiotic misuse
• generally caused by a virus
• Reports indicate that more than 60 to 70 percent of patients
with acute bronchitis who seek care are given antibiotics
• Guidelines dissuade clinicians from prescribing antibiotics
for acute bronchitis
• guidelines state unequivocally that pertussis is the only
indication for antibacterial agents in the treatment of
acute bronchitis
 Respiratory viruses are by far the most common infectious
agents associated with acute bronchitis
 The common cold viruses, rhinovirus and coronavirus, and lower
respiratory tract pathogens, including influenza virus, adenovirus, and
respiratory syncytial virus
 Mycoplasma pneumoniae also appears to be a frequent cause
 Other bacterial causes include Chlamydia pneumoniae and Bordetella
pertussis
• Infection of the trachea and bronchi causes hyperemic an
edematous mucous membranes and an increase in bronchial
secretions
• Destruction of respiratory epithelium can range from mild to
extensive and may affect bronchial mucociliary function
• An increase in bronchial secretions( thick and
tenacious) further impairs muco-ciliary activity
• Recurrent acute respiratory infections may be
associated with increased airway hyper-
reactivity and possibly the pathogenesis of
chronic obstructive lung disease
 • Primarily a self-limiting illness and rarely a cause of death
• usually begins as an upper respiratory infection
• Typically ,has nonspecific complaints such as malaise and headache,
coryza, and sore throat
• Cough is the hallmark of acute bronchitis
• occurs early and will persist despite the resolution of nasal or
nasopharyngeal complaints.
• the cough is initially nonproductive but progresses, yielding
mucopurulent sputum.
• Chest examination may reveal rhonchi and coarse, moist rales
bilaterally
• Chest radiographs, when performed, are usually normal
• Goal of therapy : to provide comfort to the patient and, in the
unusually severe case, to treat associated dehydration and
respiratory compromise
 Treatment
• is symptomatic and supportive in nature
• Reassurance and antipyretics alone are often sufficient.
• Bed-rest and mild analgesic-antipyretic therapy are often helpful in
relieving the associated lethargy, malaise, and fever
• Patients should be encouraged to drink fluids to prevent dehydration and
possibly decrease the viscosity of respiratory secretions
• limited data to support the use of cough suppressants for acute bronchitis
• Persistent, mild cough, which may be bothersome,
may be treated with dextromethorphan
• more severe coughs may require intermittent codeine or other
similar agents
• Aspirin ,
• Acetaminophen (650 mg in adults or 10 to 15 mg/kg per dose in
children with a maximum daily adult dose of 4 g and 60 mg/kg
for children) or
• ibuprofen (200 to 800 mg in adults or 10 mg/kg per dose in
children with a maximum daily dose of 3.2 g for adults and 40
mg/kg for children) is administered every 4 to 6 hours
• Mist therapy and/or the use of a vaporizer may
further promote the thinning and loosening of
respiratory secretions
• The major therapeutic issue in most cases of acute
bronchitis is the decision to use or forgo antibacterial
agents
• Multiple studies indicate that patients with acute
bronchitis do not benefit from antibiotic therapy
• In one meta-analysis, nine placebo-controlled, double-blind
studies of antibiotic treatment of acute bronchitis were
reviewed; five of the nine showed no benefit for
doxycycline or erythromycin, two showed only slight clinical
differences in patients treated with erythromycin or
trimethoprim-sulfamethoxazole, and two demonstrated
superiority of albuterol to erythromycin
• Guidelines from the National Institute for Health and Clinical
Excellence (NICE) in the UK advise not treating acute bronchitis
with antibiotics, with the following exceptions
• Those at high risk of serious complications because of preexisting
comorbidity (heart, lung, renal, liver, neuromuscular disease, or
immunosuppression)
• Patients over 65 years of age with acute cough and two or more of the
following, or patients over 80 years of age with one or more of the
following:
• Admission to hospital in the previous year
• Type 1 or type 2 diabetes
• History of congestive heart failure
• Current use of oral glucocorticoids
 Mycoplasma pneumoniae or Chlamydophila
pneumoniae
 Occasional patients have acute bronchitis caused by M.
pneumoniae or C. pneumoniae
 should be suspected in patients with prolonged cough
and typical upper airway syptoms
 Both organisms are susceptible to tetracyclines,
macrolides, and fluoroquinolones
 do not suggest testing or empiric treatment for these
pathogens unless there is evidence of a local outbreak
 Pertussis
▪ Antibiotics provide clinical benefit only if begun early (within the
first week) in the course of pertussis
▪ Treatment regimens include erythromycin 500 mg four times daily
for 14 days, clarithromycin 500 mg twice daily for 14 days, or
azithromycin 500 mg once and 250 mg daily for four days
 Influenza
▪ Most influenza strains are treatable with neuraminidase inhibitors
(oseltamivir or zanamivir)
▪ for optimal benefit, these drugs should be given within 48 hours of
symptom onset for demonstrable clinical benefit
▪ Amantidine, Rimantidine etc.
 Definition
 A disease of the bronchi
 manifested by cough and excessive sputum
 occurs on most days of the week for a minimum of 3
consecutive months per year
 for at least 2 consecutive years
 unrelated to other pulmonary or cardiac disease.
 COPD:
 Chronic bronchitis
 Emphysema
 Adults (10% - 25% over 40 years of age)
 Incidence: more common in Men than women
 Cigarette smoking
 predominant factor; 10% nonsmokers
 Increase number of alveolar macrophages
 Others:
 Exposure to occupational dusts, fumes, and
environmental pollution; and host factors (e.g., genetic
factors and bacterial [and possibly viral] infections).
 Normal secretory and mucociliary function of
bronchial mucosa are affected.
 Thickened bronchial wall Increased number of goblet
cells
 hypertrophy of the mucous glands and dilation of the
mucous gland ducts
 Accumulation of mucus in their peripheral airways
(plugging of the smaller airways)
 changes are squamous cell metaplasia (edema,
and increased vascularity)
 Weakening of bronchial wall secondary to
residual scarring and peribronchial fibrosis
 Clinical Presentation of Chronic Bronchitis

Signs and symptoms

 Cyanosis (advanced disease); Obesity
Physical examination
 Chest auscultation reveals inspiratory and expiratory rales, rhonchi, and mild
wheezing with an expiratory phase;
 Normal vesicular breathing sounds are diminished
 Clubbing of digits (advanced disease)
Chest radiograph
 Increase in anteroposterior diameter of the thoracic cage
 Depressed diaphragm with limited mobility
Laboratory tests : Erythrocytosis (advanced disease)
Pulmonary function tests
 Decreased vital capacity
 Prolonged expiratory flow
 Microbial Pathogens in Acute Exacerbations of
Chronic Obstructive Pulmonary Disease (AECB)
 Haemophilus influenzae 20-30 %
 Streptococcus pneumoniae 10-15 %
 Moraxella catarrhalis 10-15 %
 Rhinovirus 20-25 %
 Parainfluenza virus 5-10 %
 Influenza virus 5-10 %
 Respiratory Syncytial virus 5-10 %
 Coronavirus 5-10 %
Oral Antibiotics Commonly Used for the Treatment of Acute
Respiratory Exacerbations in Chronic Bronchitis
 1. Consider Chest X-Ray (febrile &/or hypoxic)
 2. Inhaled anticholinergic bronchodialator
 1. Ipratroprium or tiotroprium
 3. Mucolytics
 4. Oral corticosteroid tapered over 2 weeks
 5. Discontinue tobacco use
 6. Non-invasive positive pressure ventilation
 Most likely has a viral
 Antibacterial agents are not recommended
 A 65-year-old man with hypertension and degenerative
joint disease presents to the emergency department with a
three day history of a productive cough and fever.
 He has a temperature of 38.3°C (101°F), a blood pressure
of 144/92 mm Hg, a respiratory rate of 22 breaths per
minute, a heart rate of 90 beats per minute, and oxygen
saturation of 92 percent while breathing room air.
 Physical examination reveals only crackles and egophony in the
right lower lung field. The white-cell count is 14,000 per cubic
millimeter, and the results of routine chemical tests are normal. A
chest radiograph shows an infiltrate in the right lower lobe.
 How should this patient be treated?
 Pneumonia is an infection of the lung tissue caused by
various bacterial species, viruses, fungi or parasites.
 Identification of the causative organism is the key to
correct treatment
 b/c of the serious nature of the infection, antibiotic
treatment should be started immediately based on one’s
estimation of the most probable cause before subsequent
laboratory confirmation of the causative agent
 Decision: need for hospital admission
 Pts at extremes of age, SOB, rapid pulse rate [ 120 per minute or
more], low BP <90/60mmHg, restlessness, confusion, or excessive
drowsiness, coexisting disease[ HF, hepatic failure, renal disease]
 Depressed cough reflex resulting in aspiration:
 – Impaired consciousness, endotracheal tube, obstructive
lung disease, malnutrition, neuromuscular disease
 Impaired mucociliary clearance:
 – Alcohol, cigarette smoke, endotracheal obstruction, cystic
fibrosis, viral infections
 Inhibition of alveolar function:
 Cigarette smoke, hypoxia, malnutrition, pulmonary edema,
cellular or humoral immunity deficiencies
 Bugs get there by inhalation of aerosolized particles
 Aspiration of oropharyngeal flora,Hematogenous, Trauma
 Signs and symptoms
 Abrupt onset of fever, chills, dyspnea, and
productive cough
 Rust-colored sputum or hemoptysis
 Pleuritic chest pain
 Laboratory tests
 Leukocytosis with predominance of
polymorphonuclear cells
 Low oxygen saturation on arterial blood gas or
pulse oximetry
 Physical examination
 Tachypnea and tachycardia
 Dullness to percussion
 Increased tactile fremitus, whisper pectoriloquy, and
egophony
 Chest wall retractions and grunting respirations
 Diminished breath sounds over affected area
 Inspiratory crackles during lung expansion
 Chest radiograph
 Dense lobar/segmental infiltrate
 All patients:
 History, Physical Exam, Chest Xray
 +/- Sputum Gram stain & culture
 Admitted to hospital:
 Sputum Gram stain & Culture, Urine antigens
 Blood culture (x2) before treatment (5-14 % yield)
 CBC with diff, Electrolytes +/- HIV, O2
 Healthcare Associated
 If intubated: tracheal aspirate, bronchoscopy
 Depends on severity & risk factors/site of
acquisition
 Community Acquired (CAP)
▪ Outpatient, Inpatient, Inpatient ICU
▪ S. pneumoniae, H. influenzae; Mycoplasms, Chlamydia
 Healthcare Associated (HCAP)
▪ Hospital – acquired (HAP), ventilator-associated (VAP)
▪ Early per CAP + MS-SA, Susceptible GNR
▪ Late includes MR-SA, MDR GNR (Pseudomonas, Acinetobacter)
 Specific organism risk factors
▪ Aspiration (anaerobes), Post-influenza (S. aureus)…
 Previously healthy & no risk factors for DRSP
(drug resistant S. pneumoniae)
 Macrolide (Azithromycin or Clarithromycin)
 Doxycycline
 Comorbidities (chronic heart, lung, liver or renal
disease, diabetes, malignancies; antimicrobial use
in past 3 months)
 Respiratory fluroquinolone (moxifloxacin or
levofloxacin)
 Macrolide (Azith or Clarith) plus Beta-lactam
(amoxicillin/clavulanate, cefuroxime, cefpodoxime)
 Respiratory fluroquinolone
 Levofloxacin (750 mg daily) or Moxifloxacin
 Beta-lactam plus a macrolide
 Ceftriaxone or cefotaxime with Azithromycin*,
Clarithromycin or Erythromycin
 * As monotherapy in some patients; not
recommended
 Beta-lactam (cefotaxime, ceftrixone OR
amoxicillin/clavulanate)
 With Azithromycin OR Respiratory fluoroquinolone
 If Pseudomonas risk
 Antipneumococcal, antipseudomonal beta-lactam
(Piperacillin/Tazo, Cefepime, Imipenem OR
Meropenem)
 With Ciprofloxacin OR Levofloxacin OR combination of
Aminoglycoside AND Azithromycin
 If Methicillin-Resistant S. aureus
 Add Vancomycin OR Linezolid
 Prescribing of 1st, 2nd and 3rd generation
FQ[ciprofloxacin, levofloxacin, etc] should be
avoided in managing CAP because they are
WHO recommended second line drugs for
MDR TB!!!!!!!!!!
 S. pneumoniae
 Penicillin non-resistant (MIC < 2):
▪ Penicillin G, Amoxicillin; lots of other stuff
 Penicillin resistant (MIC > = 2)
▪ Based on susceptibilities:
▪ Ceftriaxone or Cefotaxime; Vancomycin or Linezolid
 H. influenzae
 Beta-lactamase negative
▪ Amoxicillin; lots of other stuff
 Beta-lactamase positive
▪ Cefuroxime, amoxicllin/clav
 Mycoplasma or Chlamydophila
 Macrolide, tetracycline or respiratory fluoroquinolone
 Temperature < 37.8 C
 Heart rate < 100 beats/min
 Respiratory rate < 24 breaths/min
 Systolic blood pressure > 90 mm Hg
 O2 saturation > 90 %
 Able to maintain oral intake
 Normal mental status
 No need to observe inpatient on oral
antibiotics
 At least 5 days of therapy
 Afebrile for 48-72 hours
 No more than 1 sign of clinical instability
 Longer if needed per pathogen (P. aeruginosa)
 Prevention:
 Vaccination, smoking cessation
 Protocols reduce mortality, admissions & length
of stay without reducing quality
 Quality Measures
 Initial antibiotics consistent with guidelines
 1st antibiotic dose in the emergency department
 Collect mortality data
 Collect immunization rates
 Hemodynamically stable, adequate
oxygenation, no contraindications to outpatient
care
 Treated as an outpatient on oral antibiotic that
covers typical and atypical organisms
 Advanced macrolide or antipneumococcal
fluoroquinolone
 Pneumococcal & Influenza Vaccine if he has not
previously been immunized
 Hospital-acquired pneumonia (HAP)
 Develops 48 hours or more after admission (& wasn’t
incubating at admission)
 Ventilator-associated pneumonia (VAP
 Arises more than 48-72 hours after endotracheal
intubation
 Healthcare Associated Pneumonia (HCAP)
 Hospitalized > 2 days within last 90 days
 Nursing home / long term care facility, IV antibiotic
therapy, chemotherapy, wound care within past 30
days
 Attended hospital or hemodialysis clinic
 2nd most common nosocomial infection
 25% of all ICU infections, 50% of antibiotics
 Increases length of stay 7-9 days
 Attributable Mortality 33-50%
 Excess cost of $40,000 / patient
 5-15 per 1,000 admission
 Varies by ICU, found in environment on surfaces
etc. & transferred by hospital staff
 Colonizes patient within 48-72 hours
 Inoculates lung via intubation, aspiration
 S. aureus (MR-SA)
 P. aeruginosa
 K. pneumoniae (ESBL)
 Acinetobacter
 Antimicrobial therapy in preceding 90 d
 Current hospitalization of 5 d or more
 High frequency of antibiotic resistance in the community
or in the specific hospital unit
 Presence of risk factors for HCAP:
 Hospitalization for 2 d or more in the preceding 90 d
 Residence in a nursing home or extended care facility
 Home infusion therapy (including antibiotics)
 Chronic dialysis within 30 d
 Home wound care
 Family member with multidrug-resistant pathogen
 Immunosuppressive disease and/or therapy
 Empirical Antimicrobial Therapy for Pneumonia in Adults
Clinical Setting Usual Pathogen(s) Presumptive Therapy
Previously Pneumococcus, Mycoplasma Macrolide/azalide, tetracycline
healthy, pneumoniae
ambulatory
patient
Elderly Pneumococcus, gram– Piperacillin–tazobactam,
negative bacilli (e.g., cephalosporin, carbapenem
Klebsiella pneumoniae);
Staphylococcus aureus,
Haemophilus influenzae
Chronic Pneumococcus, H. influenzae, Amoxicillin, tetracycline,
bronchitis M. catarrhalis trimethoprim–sulfamethoxazole,
cefuroxime, amoxicillin–clavulanate,
macrolide/azalide, fluoroquinolone
 Empirical Antimicrobial Therapy for Pneumonia in
Adults
CLINICAL USUAL PATHOGEN(S) PRESUMPTIVE THERAPY
SETTING
Alcoholism Pneumococcus, K. pneumoniae, Ticarcillin–clavulanate, piperacillin–
S. aureus, H. influenzae, tazobactam, plus aminoglycoside;
possibly mouth anaerobes carbapenem, e fluoroquinolone f

Aspiration
Community Mouth anaerobes Penicillin or clindamycin
Hospital Mouth anaerobes, S. aureus, Clindamycin, ticarcillin–clavulanate,
gram-negative enterics piperacillin–tazobactam, plus
aminoglycoside
Nosocomial Gram-negative bacilli (e.g., K. Piperacillin-tazobactam,
pneumonia pneumoniae, Enterobacter carbapenem, e or extended spectrum
species, Pseudomonas cephalosporing plus aminoglycoside;
f
 Empirical Antimicrobial Therapy for Pneumonia in
Pediatric Patients
AGE USUAL PATHOGEN(S) PRESUMPTIVE THERAPY
1 month Group B streptococcus, Haemophilus Ampicillin–sulbactam, cephalosporinb
influenzae (nontypeable), Escherichia carbapenemc
coli, Staphylococcus aureus, Listeria,
CMV, RSV, adenovirus Ribavirin for RSV
1–3 Chlamydia, possibly Ureaplasma, CMV, Macrolide/azalide,d trimethoprim-
months Pneumocystis carinii (afebrile pneumonia sulfamethoxazole
syndrome)
RSV Ribavirin
Pneumococcus, S. aureus Semisynthetic penicilline or cephalosporinf
3 months– Pneumococcus, H. influenzae, RSV, Amoxicillin or cephalosporinf
6 years adenovirus, parainfluenza Ampicillin–sulbactam, amoxicillin–
clavulanate
Ribavirin for RSV
>6 years Pneumococcus, Mycoplasma pneumoniae, Macrolide/azalided cephalosporin,f
Evidence-Based Guidelines for Management of Community-
Acquired Pneumonia in Immunocompetent Adults
Preferred parenteral agents for treatment of pneumococcal pneumonia for strains with
reduced susceptibility to penicillin are cefotaxime or ceftriaxone.
For susceptible strains, amoxicillin is the preferred antibiotic for pneumococcal
pneumonia.
Recommended initial therapy for a hospitalized patient consists of a beta-lactam plus
macrolide combination or a fluoroquinolone alone.
For an intensive care patient and in the absence of a Pseudomonas infection, a
combination of a beta -lactam plus either a macrolide or a respiratory fluoroquinolone
should be prescribed.
For an intensive care patient and in the presence of a penicillin-resistant isolate,
cefotaxime, ceftriaxone, or a respiratory fluoroquinolone
For hospitalized patients, for Legionnaires' disease is azithromycin or a fluoroquinolone.
For nonhospitalized patients, erythromycin, doxycycline, azithromycin, clarithromycin, or a
fluoroquinolone.
Amantadine, rimantadine, oseltamivir, or zanamivir is effective for early (within 48 hrs)
 Dose adequately, switch to PO when able
 Use combinations if MDR likely
 Avoid inadequate therapy
 Monotherapy once C&S back
 Limit aminoglycosides to 5-7 days if able
 Treat for 14-21 days
 ? 7 days if not P. aeruginosa or S. aureus & good
clinical response with resolution.
 P. aeruginosa combination therapy recommended.
 Development of resistance on monotherapy
 Combination therapy may not prevent resistance, may
avoid Inappropriate and ineffective treatment
 Acinetobacter
 carbapenems, sulbactam, colistin, and polymyxin most
active; no data supporting combination regimen
 Enterobacteriaceae
 Use carbapenem
 Avoid monotherapy with 3rd gen cephalosporin
 Considered adjunctive therapy with an inhaled
aminoglycoside or polymyxin for MDR gram-
negative
 Linezolid is alternative to vancomycin for MRSA
VAP
 May be preferred on the basis of a subset analysis of
two prospective randomized trials
 Antibiotic restriction can limit epidemics of specific
resistant pathogens.
 Antibiotic cycling etc. may help but data not conclusive
/ not recommended
• Go through Ethiopian standard treatment guidelines for
specific conditions:
• Treatment recommendations for CAP in patients treated in
the outpatient setting
• Treatment recommendations for CAP in patients requiring
hospitalization
• Treatment recommendation for HAP ,VAP,HCAP
• Pneumonia in special populations, such as aspiration
pneumonia and immuno-compromised patients
• Reading assignment for submission
• The evidence for efficacy of different antibiotic
medications in the empiric treatment of CAP, HAP, VAP,
HCAP and issues related to drug resistance