4.

01 RESPIRATORY ANTIMICROBIALS PHARMACOLOGY

Lecturer: Dr. Henri de la Cruz | January 14, 2019 LE 4 TRANS 1
TRANS GROUP: Provido, Punay, Quebral, Quiminiano, Racho
TRANS HEADS: Publico, A. & Verzosa, B.

OUTLINE

I. Respiratory Tract Infection (RTI)

II. Upper Respiratory Tract Infection
A. Acute Rhinitis
B. Acute Tonsillopharyngitis
C. Acute Rhinosinusitis
D. Otitis Media
E. Pertussis
F. Epiglottitis
G. Croup
III. Lower Respiratory Tract Infections
A. Acute Bronchitis
B. Bronchiectasis
C. Community Acquired Pneumonia
D. Hospital Acquired Pneumonia Figure 1. Unnecessary Antibiotic Prescriptions. Most respiratory
IV. Other Challenges in Respiratory Infection Control & infections are given unnecessary antibiotic prescriptions (in green).
Management
A. SARS-CoV Notes for Figure 1:
B. MERS CoV • This shows how many antimicrobials are used and prescribed by
C. Influenza physicians. Leading misuse: common cold. There is no reason
D. Anthrax for giving antimicrobials when patient just have a common cold.
V. References • Differentiate and find if it can lead to complications like sore
VI. Quiz throat, nasal congestion, post-nasal drip leading to cough that
VII. Appendix can be mistaken for bronchitis, or if secretions occlude the ear
and cause otitis media. You also don’t want to be too late in
LEARNING OBJECTIVES
treating these secondary complications.
• Know antimicrobials to know when use is irrational. Don’t just be
1. Review antimicrobials used for common respiratory infections. trigger happy and give expecting patients prescriptions. 
2. Avoid irrational use of antimicrobials.
The larynx divides the upper and lower respiratory tracts.
LEGEND • URTI: many of the irrational prescriptions arise.
• WHO survey of outpatient prescriptions –higher risk for giving
Remember Lecturer Book Prev. Trans Notes wrong prescription for common cold because it’s viral and
doesn’t need antimicrobials.
     • 30-50% of outpatient prescribed antimicrobials are not needed.
o More than half of cases of common cold and bronchitis
I. RESPIRATORY TRACT INFECTION (RTI) involve the misuse of antibiotics. Upper respiratory tract
infections are more likely treated with unnecessary
Table 1. 2016 Guidelines for Respiratory Tract Infections. prescriptions.
Upper Respiratory Tract Lower Respiratory Tract
Infection (URTI) Infection (LRTI) II. UPPER RESPIRATORY TRACT INFECTION
• Acute Rhinitis • Acute Bronchitis*
• Acute Tonsillopharyngitis • Bronchiectasis*
• Sinusitis • Community Acquired Case
• Epiglottitis Pneumonia A 19-year-old complains of mild fever, headache, rhinorrhea,
• Croup • Atypical Pneumonia nasal congestion, sneezing, sore throat, cough and muscle ache
• Otitis Media • Healthcare Associated for the past 2 days.
Pneumonia
o Nosocomial Pneumonia PE: temp. 38, normal BP, CR, RR; with Congested turbinate;
o Ventilator Associated erythema in tonsillar area; clear breath sounds
Pneumonia
Diagnosis? Management?
Editor’s Note: In the PPT acute bronchitis and bronchiectasis are
categorized under URTI, but Doc de la Cruz has clarified that they
are under LRTI. A. ACUTE RHINITIS

In the previous cup noodles, NO QUESTIONS ABOUT DIAGNOSIS A. Viral Rhinitis

AND DIFFERNTIALS so do not focus on them. Just focus on the • Rhinitis happens 4-6 times a year normally.
drugs (which drugs are used for which, side effects, mechanisms) • Most cases of rhinitis are viral in origin and doesn’t need
treatment.
• Infectious causes
o Rhinovirus (92.5%)
o Coronavirus
o Influenza
o RSV
o Mixed viral and bacterial (3%)
o Bacterial (S. pneumoniae, C. pneumoniae, H. influenza) –
(1.5%)
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Table 2. Viral cause of common cold. Notes:

Virus
Estimated annual proportion If the patient comes on the 2nd week with cough, will you be
of cases alarmed?
Rhinoviruses 30 to 50 percent
As a doctor:
Coronaviruses 10 to 15 percent
• Ask the time course and progression of the symptoms.
Influenza viruses 5 to 15 percent
• Is the discharge still increasing?
Respiratory syncytial virus 5 percent • Is the cough still prominent?
Parainfluenza viruses 5 percent • Are the symptoms progressing further or are they resolving?
Adenoviruses <5 percent • If resolving, just observe, rest and drink a lot of water.
Enteroviruses <5 percent • If not worsening, then still in the progression of viral resolution so
Metepneumovirus Unknown just give supportive or non-[pharmacologic treatment.
Unknown 20 to 30 percent o For fever give analgesic and sponge bath, for sore throat just
give saline gargles.
Table 3. Viral vs Bacterial Infections. Use the relative time course to o Risk of antibacterial gargle: risk of killing normal flora
differentiate viral vs bacterial rhinitis. o Use saline gargle instead to help in the expectoration of
Characteristics Viral Bacterial secretions/. Increase in perfusion due to warmth and carry
Duration < 2 weeks > 2 weeks with it inflammatory cells what will help in the clearance of the
Symptoms Declining Progressive virus.
Course Self-limiting More morbid symptoms

Aches Fever Sore Throat

Notes:
What is the effect of antimicrobials use in a viral infection? • Warm shower or • Select a systemic • Recommend
Dangers include antimicrobial resistance. It will kill the normal flora, baths can reduce antipyretic saline gargles
hence causing more resistance to antimicrobials and more adverse aching (acetaminophen every 4 hours
effects. • Suggest and OTC or an NSAID; no • Consider local
analgesic to be aspirin in anesthetic sprays
used PRN children) or lozenges
As a doctor:
• Tell patient what to look for and when to come back.
• If patient comes in the first week, advice patient to increase • No cure for the common cold.
fluids and rest. If patient has sore throat, advice to eat soft food • Encourage active management of the illness
since it can help with the pain. Supportive management! o Explicitly plan treatment of symptoms with parents.
• In the second week, if progression is present then ask the o Describe the expected normal time course of the illness and
patient to return.
tell parents to come back if the symptoms persist or worsen.
• Biggest barrier to follow-up is cost. But if you are fair to your o Explain expected duration and symptoms
patients, then they will always come back to you.
o Expectant management: on follow-up, as for persistence or
progression
o Consider a delayed prescription

• Symptomatic relief of moderate to severe symptoms

o Anti-histamine- Decongestant combinations
o Intransal inhaled cromolyn sodium
o Intranasal ipratropium

• Therapies with Minimal or Uncertain Benefits

o Dextromethorpan
o Decongestants
o Saline nasal spray
o Expectorants
o Herbal products
Figure 2. Relative Time Course of Viral vs. Bacterial Rhinitis. o Zinc
(Left) Viral Rhinitis. Day 3-5: fulminant symptoms (fever, myalgia,
sneezing, sore throat). Peak of these symptoms is in the first 2-3 days. • Delayed (pocket) prescription
After Day 5: symptoms recede. Day 9-14: resolution o Delayed prescriptions with instructions can either be given to
(Right) Bacterial Rhinitis. Symptoms do not recede. the patient or left at an agreed location to be collected at a
later date
o Reduce antimicrobial use by 32%
o Advise to re-consult for any worsening of symptoms.

• When a no antibiotic prescribing strategy is adopted,

patients should be offered:
o Reassurance that antibiotics are not needed immediately-
they are likely to make little difference to symptoms and may
have side effects, for example, diarrhea, vomiting and rash.
o Advise if the condition worsens or becomes prolonged.

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 4.01 Respiratory Antimicrobials

B. Mucopurulent Rhinitis (Bacterial) Other Types of Rhinitis

• Only 1/6 need treatment after 10 days of observation • Rhinitis medicamentosa – due to chronic steroids, nasal spray
• Agents: use that cause obstructive symptoms
o Streptococcus pneumoniae • Medication induced rhinitis (eg. Aspirin, ACE inhibitors, beta
o Haemophilus influenzae blockers, NSAIDS)
o Moraxella catarrhalis • Hormonal induced rhinitis (eg. Pregnancy, menstrual)
• Medications: • Occupational
o Penicillin V
o Amoxicillin Common Treatments for Allergic Rhinitis
• Oral/intranasal antihistamines and decongestants
• Intranasal corticosteroids
• Intranasal anticholinergics
• Leukotriene receptor antagonists
• All of these have many ADR. Use is sparingly and the real
question is whether you need it or not.

B. ACUTE TONSILOPHARYNGITIS

Figure 3. Commonly mis-prescribed regimen in the outpatient rural Table 4. Common Pathogens for Acute Tonsillopharyngitis. 50% viral
setting (Cavite). 82% of the 200 children had symptoms of ARI 4 and only 15% are bacterial.
weeks preceding the study (left pie chart) and 75% of these children Viral (50%) Bacterial (15%) Other Causes
had used antibiotics within this 4-week period (right pie chart). As some (30%)
antibiotics were used in combination, the percentages total more than Rhinovirus, Grp A Streptococci- Allergy
100%. 74% of patients with rhinitis were given Ampicillin. There is Adenovirus, most common
more prescribing than actually needed. Influenza A and B, Grp C Streptococci
Parainfluenza, Grp G Streptococci
C. Allergic Rhinitis Coronavirus, Less common:
Coxsackie, Chlamydia,
Echovirus Acinetobacter,
Not discussed in class, but included in previous transes.
RSV, CMV, HSV, Mycoplasma,
From 2020A: EBV Corynebacterium,
Neisseria
Case
A 23-year old male medical student has a chief complaint of a Table 5. Signs and symptoms of Acute GAS pharyngitis vs. Viral
runny or stuffy nose, sneezing, red, itchy, watery eyes and clear Pharyngitis
nasal discharge after cleaning out his room. Group A Streptococcal Pharyngitis Viral Pharyngitis
PE is unremarkable except for congested turbinates and
hyperemic posterior pharynx. • Sudden onset of sore throat • Conjunctivitis
• Fever/ headache • Coryza
What is your diagnosis? • Nausea, vomiting, abdominal pain • Cough
a. Viral rhinitis • Tonsillopharyngeal inflammation • Diarrhea
b. Bacterial rhinitis • Patchy Tonsillopharyngeal exudates • Hoarseness
c. Allergic rhinitis • Palatal petechiae • Discrete ulcerative
d. Acute nasopharyngitis • Anterior cervical adenitis (tender stomatitis
Management: Remove the trigger. Reserve the antihistamine if nodes) • Viral exanthema
the trigger is seasonal, like the weather.

Figure 5. Signs in tonsillopharyngitis that indicate whether the infection

Figure 4. Common allergy cold, and flu symptoms. Allergic causes: 44- is bacterial or viral in origin. Note the white exudates present in
85%; viral: 40-60%; bacterial: 10-15% - smaller percentage of patients bacterial infection. Diagnosis: Throat swab C/S (gold standard) and
will need antimicrobials. Rapid Antigen Detection Test (RADT).

Allergic rhinitis is non-infectious and is distinguished by A. Tonsillopharyngitis CENTOR Score

seasonal episodic symptoms since it is triggered by allergens. • C- Can’t cough
Cough may also appear in the morning, upon waking. Common • E- Exudates
cold, viral in nature, is more likely the illness when systemic • N- Nodes
symptoms manifest (e.g. fever). • T- Temperature
• O- Young or Old

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B. Pharmacologic Treatment C. RHINOSINUSITIS

• If the patient is older than 65 years with a cough and two or more
of the following criteria, or older than 80 years with acute cough
and one or more of the following criteria no antibiotic prescribing
strategy and the delayed antibiotic prescribing strategy should
not be considered:
o Hospitalization in the previous year
o Type 1 or Type 2 diabetes
o History of congestive heart failure
o Current use of oral glucocorticosteroids
• Treatment prevents complications of rheumatic fever and
suppurative complications.

Table 6. Treatment for Acute GAS pharyngitis. *Give drugs with caution
because there is a cross reaction between Penicillins and
Cephalosporins like Cephalexin (1st generation) and Cefadroxil (MOA is
similar to B-lactams: cell wall inhibition). Figure 6. The sinuses.
Drug, Route Dosage Duration
Phenoxymethylpenicillin 500 mg four times a • An inflammation of the nasal sinuses often leading to obstruction
or Penicillin V, Oral day or 1,000 mg twice 10 days of the ostia, predisposing to infection
(First Line) a day for 5 to 10 days • Venous drainage from the sinuses empties into the cavernous
V for Vunganga sinuses of the brain
Amoxicillin, Oral 50 mg/kg once daily
(max: 1000 mg) SYMPTOMS DIFFERENTIAL BACTERIAL TREATMENT
10 days
Alternative: 25 mg/kg OR VIRAL OF CHOICE
(max: 500 mg) twice Purulent One or more of Acute Amoxicillin-
daily nasal the following: Bacterial clavulanate or
Benzathine Penicillin G, <27 kg: 600000 U; ≥ discharge Rhinosinusitis alternative
1 dose
IM (SINGLE DOSE) 27 kg: 1200000U 1. Persistent (bacterial)
For patients with penicillin allergy* Nasal symptoms
Cephalexin, Oral 20 mg/kg/dose twice obstruction Acute Viral Symptomatic
10 days 2. Severe
(1st generation) daily (max: 500 Rhinosinusitis control (pain
mg/dose) Facial pain- symptoms (viral) management,
Cefadroxil, Oral 30 mg/kg once daily 10 days pressure decongestants)
(max:1 g) fullness 3. “Double
Azithromycin, Oral 12 mg/kg once daily 5 days sickening”
(max: 500 mg) 1.
Figure 7. Diagnosis and treatment of rhinosinusitis algorithm. Follow
Clarithromycin, Oral 7.5 mg/kg/dose twice
the arrows in decision-making.
daily (max = 250
10 days
mg/dose)
Table 7. Conventional Criteria for the diagnosis of sinusitis. This is
7 mg/kg/dose 3 times
based on the presence of at least 2 major or 1 major and 2 minor
Clindamycin, oral daily (max = 300 10days
symptoms.
mg/dose)
Erythromycin 250-500mg 4 times a Major Symptoms Minor Symptoms
5days
day / 500-1000mg bid Purulent anterior nasal
Headache
discharge
Purulent or discolored posterior
NOTES Ear, pain, pressure, or fullness
nasal discharge
• GAS pharyngitis and Strep G: use targeted treatment e.g. Nasal congestion or obstruction Halitosis
first generation cephalosporins (FOUND IN PREVIOUS
Facial congestion or fullness Dental pain
CUP NOODLES)
Prominent ADR: GI disturbances Facial pain or pressure Cough
• Cephalosporins: know the generations Fever (for subacute or chronic
Hyposmia or anosmia
• You should be able to distinguish the generation they belong sinusitis)
to because the spectrum change and to avoid resistance. Fever (for acute sinusitis only) Fatigue
• Generally, 3rd and 4th Cephs have very wide coverage-
reserved for severe infections, therefore not used for simple A. Bacterial sinusitis
tonsillopharyngitis
• Erythromycin estolate: prominent GIT irritation (FOUND IN Table 8. Bacterial sinus infections.
PREVIOUS CUP NOODLES) Definitions of bacterial
Length of infection
sinusitis
Acute 10 days to 4 weeks
C. Diagnosis Recurrent acute 4 episodes of acute per year
• Throat swab is the gold standard for diagnosis of Subacute 4 – 12 weeks
tonsillopharyngitis. Chronic > 12 weeks

• Additional criteria for chronic sinusitis:

o Inflammation documented by one or more of the following
findings:
▪ Purulent mucus or edema in the middle meatus or
ethmoid region (not a single differentiating point)
▪ Polyps in the nasal cavity or middle meatus
▪ Radiographic imaging shows inflammation of the
paranasal sinuses
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• Common bacteria that cause sinusitis: • Alternative treatment for respiratory tract infections: 
o Streptococcus pneumoniae o Second generation cephalosporins
o Haemophilus influenzae ▪ Respiratory quinolones (levofloxacin2nd gen, and
o Pseudomonas aeruginosa moxifloxacin4th gen) with greater coverage for gram
o Staphylococcus aureus positive bacteria
o Moraxella catarrhalis
o Anaerobic bacteria
Editor Note: Remember that
B. Pharmacologic treatment
CIPROFLOXACIN is most effective for pseudomonas,
• Phenoxymethylpenicillin
and 4th generation quinolones (MOXIFLOXACIN) shows most
o First choice
potency for pneumococcus and anaerobes.
o Dosage for adults: 500 mg 4 times a day for 5 days
o Penicillin coverage: Amoxicillin HELPS kill Enterococci LEVOFLOXACIN not recommended for patients with QT
o Haemophilus influenza prolongation; can cause tendon rupture
o E. coli
o L. monocytogenes
o P. mirabilis D. OTITIS MEDIA
o Salmonella spp.
o Enterococci A. Etiology
• Co-amoxiclav
o First choice given the following conditions:
o Systematically very unwell or
▪ With symptoms and signs of a more serious illness or
condition or
▪ At high risk of complications
o Dosage for adults: 500/125 mg 3 times a day for 5 days
o Second choice when symptoms worsen upon taking the first
choice for at least 2 to 3 days
• Alternative first choices for penicillin allergy/ intolerance or when
the symptoms worsen upon taking the second drug of choice for
at least 2 to 3 days
o Consult local microbiologist
o Doxycycline Figure 8. Etiology of acute otitis media vs exudative types of otitis
▪ Dosage for adults: 200 mg on first day, then 100 mg once media.
a day for 4 days (5-day course in total)
▪ MOA: Inhibit 30s ribosomal unit  • Most common etiologic agents for acute otitis media:
o Clarithromycin o Streptococcus pneumoniae (35%)
▪ Dosage for adults: 500 mg 2 times a day for 5 days o Other bacteria (28%)
o Erythromycin o Haemophilus influenzae (23%)
▪ Used in pregnant patients o Moraxella (14%)
▪ Dosage for adults: 250 to 500 mg 4 times a day or 500 to • There is a greater risk of getting infected with Pseudomonas
1000 mg 2 times a day, for 5 days when you have otitis media. 
• Use shortest effective course
o There should be improvement seen in 2 to 3 days B. Pharmacologic treatment
o Continue treatment for 7 days after symptoms improve or
resolve, usually a 10 to 14-day course

Table 9. Alternative Regimen: Protein Synthesis Inhibitors.

CLEAN at 50 TAg at 30
• Chloramphenicol • Tetracycline
• Linezolid • Aminoglycosides
• Erythromycin Figure 9. Otitis media. A. Normal tympanic membrane (TM), B. TM
• Azithromycin with mild bulging, C. TM with moderate bulging, D. TM with severe
bulging.
Table 10. A practical microbiologic classification of quinolones.
First Second Third Fourth • Treatment is needed when there is:
Generation Generation Generation** Generation*** o Moderate to severe bulging of the tympanic membrane
Nalidixic acid Norfloxacin Sparfloxacin Trovafloxacin o New onset of otorrhea not due to acute otitis externa
Oxolinic acid Ciprofloxacin* Tosufloxacin Clinafloxacin o Mild bulging of the tympanic membrane and recent (<48
Cinoxacin Enoxacin Gatifloxacin Sitafloxacin hours) onset of ear pain or intense erythema of the tympanic
Piromidic Fleroxacin Pazufloxacin Moxifloxacin membrane or a temperature of 39OC.
acid Lomefloxacin Grepafloxacin Gemifloxacin
• Amoxicillin
Pipemidic Ofloxacin
acid Levofloxacin
o First choice
Flumequine Rufloxacin o Dosage for adults: 500 mg 3 times a day for 5 days
* most potent against Pseudomonas • Co-amoxiclav
o Second choice when symptoms worsen upon taking the first
** more potent against Pneumococcus and anaerobes than earlier
choice for at least 2 to 3 days
compounds were
o Dosage for adults: 500/125 mg 3 times a day for 5 days
*** most potent against Pneumococcus and anaerobes

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 4.01 Respiratory Antimicrobials

• Alternative first choices for penicillin allergy/ intolerance Editor Note: Remember (previous cup noodles)
o Doxycycline
▪ Dosage for adults: 200 mg on first day, then 100 mg once MACROLIDES can cause QT prolongation,
a day for 4 days (5-day course in total) and inhibit 50s ribosomal subunit
o Clarithromycin
▪ Dosage for adults: 500 mg 2 times a day for 5 days Table 12. Antimicrobials. (IMPORTANT)
Bactericidal Bacteriostatic
E. PERTUSSIS
Very Finely Proficient at Murder ECSTaTiC about bacteriostatics

Vancomycin Erythromycin
Fluoroquinolones Clindamycin
Penicillin Sulfamethoxazole
Aminoglycosides Trimethorprim
Metronidazole Tetracycline
Chloramphenicol

F. EPIGLOTTITIS

Figure 10. Disease progression of pertussis.

• Stage 1: Catarrhal stage

o May last for 1 to 2 weeks
o Symptoms: runny nose, low-grade fever, mild, occasional
cough
o Highly contagious
• Stage 2: Paroxysmal stage
o May last for 1 to 6 weeks, may extend up to 10 weeks
o Symptoms: fits of numerous, rapid coughs followed by
“whoop” sound; vomiting and exhaustion after coughing Figure 11. Epiglottitis.
fits, called paroxysms
• Stage 3: Convalescent stage • A potentially life-threatening condition occurs when the epiglottis
o May last for 2 to 3 weeks swells, blocking the air flow into the lungs
o Susceptible to other respiratory infections • Usually occurs in young children developing stridor 
o Gradual recovery
• Most common agent: Haemophilus influenzae type b (Hib)
o Coughing lessens but fits of coughing may return
• Other agents: S. pneumonia, Streptococcus A, B, C
A. Pharmacologic treatment • Signs and symptoms include:
o Sudden onset difficulty of breathing
o Inability to speak/swallow fluid
Table 11. Treatment of pertussis based on the age group. Also see
Appendix 1. o Fever
o Soft stridor
o Increased respiratory rate
o Rising sun sign: red “angry” epiglottis
▪ Inflamed epiglottis visible when looking inside the
mouth, which normally is not visible 
• True medical emergency
• Do not let the patient lie flat or examine the throat
• Intubation under anesthesia may be necessary

A. Pharmacologic treatment
• Blood CS and IV antibiotics
• Rifampicin prophylaxis to household contacts
• Choose from one the following drugs:
o Cefotaxime
▪ For children: 150 to 200 mg/kg/day IV/IM in divided
doses every 6 to 8 hours
• Macrolides, including Azithromycin and erythromycin, are the ▪ For adults: 1 to 2 g IV/IM in divided doses every 6 to
primary treatment for pertussis  12 hours; maximum of 12 g/day
• Azithromycin is given for only 3 days since it is the only o Ceftriaxone
macrolide with very significant post-antibiotic effect for 7 days  ▪ For children with mild to moderate infections: 50 to 75
• Co-trimoxazole inhibits sequential steps in folic acid synthesis by mg/kg/day IV/IM in divided doses every 12 to 24
inhibiting PABA, which is important in DNA synthesis.  This is hours
an option when macrolides are unavailable  o Ampicillin/ sulbactam
o Oxacillin
o Nafcillin

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G. CROUP III. LOWER RESPIRATORY TRACT INFECTION (LRTI)

• MOST IMPORTANT TAKE AWAY (TLDR): Most caused by A. ACUTE BRONCHITIS

VIRAL, therefore, SUPPORTIVE treatment only, NO
ANTIBIOTICS
• Inflammation of the upper airway below the epiglottis (trachea)
• Common childhood illness wherein there is gradual progression
of airway obstruction, unlike in the epiglottis which occurs
suddenly 

Figure 13. Differentiates normal bronchial tube and an inflamed

Figure 12. Croup.
bronchial tube.
• Commonly occurs between 6 to 36 months of age
• MOST IMPORTANT TAKE AWAY (TLDR): Most caused by
• Signs and symptom include barking cough with or without stridor VIRAL, therefore, SUPPORTIVE treatment only, NO
• Classification: ANTIBIOTICS; like croup
o Mild: no stridor • Self-limited inflammation of the large airways with cough lasting
o Moderate: with stridor/ chest wall retractions up to 6 weeks
o Severe: same as moderate but with agitation or
restlessness • Predominantly viral in nature (90%)
o Influenza
A. Etiology o Rhinovirus
o Coronavirus
Table 13. Viral presentations of croup. o Parainfluenza
Etiology Frequency Severity o RSV
Parainfluenza virus Frequent Variable (usually • Non-viral cause
types 1 to 3 (type 1 sever with type 3 o Mycoplasma
is most common) virus) o Chlamydia
Enterovirus Occasional to Usually mild
frequent
Human bocavirus Occasional to Usually mild FROM LECTURER’S PPT:
frequent
Influenza A and B Occasional to Variable (severe If the patient comes on the 2nd week with cough, Do not use
viruses frequent with influenza A antibiotics for:
virus) • Cough <10-14 days in well-appearing child without physical
Respiratory Occasional to Mild to moderate signs of pneumonia
syncytial virus frequent Consider antibiotics only for:
• Suspected pneumonia, based on fever with focal exam,
B. Pharmacologic treatment infiltrate on chest x-ray, tachypnea, or toxic appearance
• Treatment depends on severity • Prolonged cough (>10-14 days without improvement) may
• Purely supportive suggest specific illnesses (e.g. sinusitis) that warrant
•  Dexamethasone antibiotic treatment
o Used to reduce inflammation until the body can eliminate When parents demand antibiotics:
the virus but not always used  • Acknowledge the child’s symptoms and discomfort
•  Epinephrine • Promote active management with non- pharmacologic
treatments
Give realistic time course for resolution.

A. Signs and symptoms:

• Chronic, productive cough (which wakes you up sometimes in

the night)
• Progression is flatline
• Sputum color does not reliably differentiate viral from bacterial
infection
• Physical Exam: (-) fever, (-) rales
• Suspect pneumonia if the patient has cough of 3 weeks duration,
fever, rales, tachypnea and if there are infiltrates in chest x-ray.
In this case, start with antibiotics immediately

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B. Treatment:
• Purely supportive
C. COMMUNITY-ACQUIRED PNEUMONIA

B. BRONCHIETASIS • An acute infection of the pulmonary parenchyma in a patient who

has acquired the infection in the community (UpToDate, 2018)
• Top 10 mortality in the Philippines
• Typical Pneumonia – You have fever, cough, respiratory
infiltrates or audible crackles. You can determine the presence
of pneumonia through this triad.
• Atypical Pneumonia
o Any presentation other than the typical (without the triad of
fever, cough, crackles).
o Example: You have fever, with no cough, no respiratory
findings or you have respiratory findings but that patient is
asymptomatic.
o Occurs frequently in the elderly and immunocompromised.
o Guillain–Barré syndrome
▪ Ascending paralysis

Figure 14. Differentiation of normal airway and airway with Table 15. Pathogens in atypical pneumonia.
bronchiectasis. Organism Clinical Features Special Features
Mycoplasma • “Walking • Extrapulmonary
• Marked destruction of muscle and elastic tissue in the lungs from pneumoniae pneumonia” findings:
chronic infections and inflammation 
 • Young adults Gullain-Barré,
• E.g. cystic fibrosis, recurrent respiratory infections, history of • CXR: Patchy encephalitis, hemolysis,
recurrent sputum production and exacerbations 
 interstitial cold agglutinins, bullous
• Common agents in exacerbations myringitis, erythema
o Haemophilus influenza multiforme
o Pseudomonas aeruginosa Chlamydia • Non-toxic • Staccato cough
pneumoniae appearing • Conjunctivitis (in
A. Signs and symptoms: • Infants at 3-20 infant group)
weeks
• Coughing (worse when lying down) • Outbreaks in
• Shortness of breath young adults
• Abnormal chest sounds • CXR: Patchy
• Daily production of large amounts of coughed up mucus interstitial
• Chest pain Legionella • Contaminated • GI symptoms (N,V,D)
• Clubbing (flesh under your fingernails and toenails becomes pneumoniae water sources, • Low serum sodium
thicker) air conditioning • Abnormal LFTs
• Older, sickly • No person-to-person
B. Treatment men transmission
• Toxic patients, • No organisms on
Table 14. Recommended treatment based on the European altered with standard smear
Respiratory Society, 2016 relative • Confusion
Oral Treatment Parenteral bradycardia (hyponatremia)
Treatment • CXR: Unilateral
No risk of Amoxicillin- - lobar infiltrates
Psuedomonas spp clavulanate
Moxifloxacin • Treating pneumonia is very straightforward; classify the patients
Levofloxacin according to mild, moderate, and high risk (severe), then choose
Risk of Ciprofloxacin* Ceftazidime OR the drug groups appropriate for them. Hence, antimicrobial
Pseudomonas Carbapenem OR treatment for pneumonia is based on the symptoms.
spp** Piperacillin-
tazobactam
* - Levofloxacin 750 mg/24 hours OR 500 mg twice daily is an
alternative.
** - use the same criteria mentioned for chronic obstructive
pulmonary disease

• Clarithromycin 500mg 2x a day for 14 days (indicated for

Penicillin-allergic patients)
• Amoxicillin 500mg 3x a day
• High dose oral regimens (Amoxicillin 1g 3x a day or Amoxicillin
3g 2x a day indicated for patients with severe bronchiectasis
chronically colonized with Haemophilus influenzae)
• Ciprofloxacin should be used in patients colonized by
Pseudomonas aeruginosa but cautious use must be observed
when dealing with elderly patients

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 4.01 Respiratory Antimicrobials

Editor Note: Please check Appendix 2 for the actual table of CAP
risk categories taken from Doc’s PPT. It was broken down into 3
tables in this trans (Tables 16, 17, and 18) in order to fit the format.

Low Risk CAP

• All the signs of pneumonia and may have some of the co-
morbidities but are not active
• Triad of pneumonia: cough, fever, & presence of infiltrates
• Refer to Table 16 for the following bullets:
• Co-amoxiclav: Amoxicillin-Clavulanic Acid
• Sultamicillin: Ampicillin-Sulbactam
• 2nd gen cephalosporin: Cefuroxime

Moderate Risk CAP

• Refer to Table 17
• Has very active co-morbidities conditions present with severe
presentation, but not to the extent of shock
• Most common agent for mild, moderate & severe CAP:
Streptococcus pneumonia
• 2nd most common agent for mild, moderate & severe CAP:
Haemophilus influenza
Figure 15. Philippine Guidelines. Algorithm for the Management-oriented • Consider a broader range of organisms causing the patient’s
Risk Stratification of CAP Among Immunocompetent Adults. No one should
symptoms: Legionella pneumophila and anaerobes
be on chronic antimicrobial treatment
• Immediately start with same regimen as those of with stable
A. CRB-65 Scoring System comorbidity
• Assessment of severity of pneumonia • Very important to see here are the doses.
o High doses for Clindamycin, Ampicillin-Sulbactam &
• Recommended by the British Thoracic Society
Moxifloxacin
• Ask if the patient has (1 point for every feature present):
▪ Aspiration Pneumonia
o Confusion
• More prone: bed ridden patients, post-stroke patients
o Respiratory Rate: >30/min
o Blood Pressure: <90/60 mmHg • Gag reflex is weak therefore secretions can flow into
o Age: 65 y/o lungs, causing aspiration
• Scoring: • Bacteria expected: gram negatives, oral flora, gram
o 0-low severity positive mucosal agents, anaerobes
o 1-2 – moderate severity • The pathogens in moderate CAP are the same as mild CAP,
o 3-4 – high severity except you have more risk of having atypical presentation, gram
• If you have anyone of these factors, you are already eligible for (-) enteric bacteria, and anaerobes
monitoring • Antimicrobials with superior anti-anaerobic coverage:
• Just remember: Hypotensive and increased respiratory rate • Upper part (lungs): Clindamycin
• Lower part (GIT): Metronidazole

High Risk CAP

• Refer to Table 18
• Has severe sepsis, septic shock, and respiratory failure (shock,
respiratory distress, and requires mechanical ventilation)
• Criteria for Severe CAP
o Minor Criteria
▪ Respiratory rate ≥ 30 breaths/min
▪ PaO2/FiO2 ratio ≤ 250
▪ Multilobar infiltrates
▪ Confusion/disorientation
▪ Uremia (BUN level, ≥20 mg/dL): shows multiorgan
damage
▪ Leukopenia (WBC count, <4,000 cells/mm3)
▪ Thrombocytopenia (platelet count, <100,000 cells/mm3)
▪ Hypothermia (core temperature, <36⁰C)
▪ Hypotension requiring aggressive fluid resuscitation
o Major criteria
▪ Invasive mechanical ventilation
▪ Septic shock with the need for vasopressors
▪ Start 3rd line at once, you don’t consider Amoxicillin
anymore
▪ ALWAYS ADD YOUR MACROLIDES

Figure 16. CRB-65 Scoring System for the Assessment of Pneumonia.

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Table 17. Empiric Antimicrobial Therapy for Moderate-risk CAP

NOTES (emphasized drugs) (Philippine Clinical Practice Guidelines, 2016).
• Antipseudomonal cephalosporins: Risk Stratification Potential Empiric Therapy
o Ceftazidime and Cefoperazone (3rd gen) Pathogen
• Antipseudomonal fluoroquinolone with superior coverage: • Unstable vital • Streptococcus IV non-antipseudomonal
o Ciprofloxacin (superior coverage) signs pneumonia B-lactam (BLIC,
• Extended spectrum penicillin: Piperacillin-Tazobactam • RR ≥30/min • Haemophilus cephalosporin) +
• 4th gen cephalosporin: Cefepime • PR ≥ 125/min infuenzae extended macrolides or
• Carbapenem: Meropenem • SBP <90 mmHg • Chlamydia respiratory
• DBP ≤60 mmHg pnuemoniae fluoroquinolones (PO)
• Macrolide: Azithromycin
• Aminoglycosides (inhibit 30S): Gentamicin, Amikacin • Temp ≤36⁰C or • Mycoplasma
≥40⁰C pneumonia Ampicillin-Sulbactam
• For extended combination: Aminoglycosides 1.5g q6h IV or
• Moraxella
• Altered mental catarrhalis Cefuroxime 1.5g q8h or
state of acute • Enteric Gram- Ceftriaxone 2g OD
• High risk has individuals have: more gram (-) organisms, +
onset negative
Legionella pneumophila, anaerobes, Pseudomonas aeruginosa, Azithromycin 500mg OD
• Suspected bacilli
and Staphylococcus aureus (differentiating factors) • Legionella PO or Clarithromycin
aspiration
• There are more pathogens difficult to treat. • Unstable/ pneumophila 500mg BID PO or
Levofloxacin 500mg OD
Decompensated • Anaerobes
Table 16. Empiric Antimicrobial Therapy for Low-risk CAP (Philippine PO or Moxifloxacin
co-morbidities: (among those
Clinical Practice Guidelines, 2016). Most CAP are caused by Strep 400mg OD PO
uncontrolled with risk of
pneumonia. But if nosocomial, you’re looking at the more serious gram- diabetes aspiration)
negatives, mixed-infections, and anaerobes. That is the main difference If aspiration pneumonia
mellitus, active
between the CAP and HAP – the pathogens. is suspected and, a
malignancies,
Risk Potential Empiric Therapy regimen containing
neurologic
Stratification Pathogen ampicillin-sulbactam
disease in
• Stable vital • Streptococcus Without co-morbid and/or moxifloxacin is
evolution,
signs pneumonia illness: used, there is no need to
congestive heart
• RR <30/min • Haemophilus Amoxicillin 1g TID add another antibiotic for
failure (CHF)
• PR < 125/min infuenzae OR additional anaerobic
Class II-IV,
• Chlamydia coverage. If another
• SBP >90 Extended macrolides: unstable
pnuemoniae Azithromycin 500mg OD combination is used may
mmHg coronary
add clindamycin to the
• DBP > 60 • Mycoplasma or Clarithromycin 500mg disease, renal
BID regimen to cover
mmHg pneumonia failure on
microaerophilic
• Temp >36⁰C or • Moraxella dialysis,
With stable co-morbid streptococci.
<40⁰C catarrhalis uncompensated
• illness:
• No altered Enteric Gram- COPD, &
Clindamycin 600mg q8h
negative β-lactam/ β-lactamase decompensated
mental state of IV or Ampicillin-
bacilli (among inhibitor combination liver disease
acute onset Sulbactam 3g q6h IV or
(BLIC) +/- extended
• No suspected those with co-
macrolides Moxifloxacin 400mg OD
aspiration morbid PO
• No or stable illness)
Co-amoxiclav 1 g BID or
co-morbidities Sultamicillin 750mg BID or
Chest X-ray: Cefuroxime axetil 500mg
localized BID
infiltrates, no +/-
evidence of Azithromycin 500mg OD
pleural effusion or
Clarithromycin 500mg BID

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Table 18. Empiric Antimicrobial Therapy for Severe-risk CAP (Philippine E. COMPARISON OF TREATMENT GUIDELINES (LOCAL
Clinical Practice Guidelines, 2016). AND INTERNATIONAL)
Risk Potential Empiric Therapy
Stratification Pathogen Table 19. Comparison of Different Treatment Guidelines
• Any of the • Streptococcus No risk for P. Philippine Natl.
aeruginosa Infectious
clinical feature pneumonia College of Institute of
Disease Society
of Moderate- • Haemophilus IV non- CAP Chest Healthcare
antipseudomonal B- of America
risk of CAP infuenzae Physicians Excellence
(IDSA) 2007
plus any of the • Chlamydia lactam + IV extended 2016 (NICE) 2016
following: pnuemoniae macrolides or IV Mild Amoxicillin 1 gm Amoxicillin Macrolide
• Severe sepsis • Mycoplasma respiratory TID Macrolides Doxycycline
and septic pneumonia fluoroquinolones OR Tetracycline
shock • Moraxella Extended
OR catarrhalis Ceftriaxone 2g OD or macrolide with
• Need for • Enteric Gram- Ertapenem STABLE
Mechanical negative bacilli + comorbidity
Ventilation • Legionella Azithromycin dehydrate BLIC or 2nd gen
pneumophila 500mg OD IV or cephalosporin
Levofloxacin 500mg OD +/- Macrolide
• Anaerobes
IV or Moxifloxacin
(among those
400mg OD IV Mod. IV non- Dual: Respiratory
with risk of
aspiration) antipseudomonal Amoxicillin + Fluoroquinolone
Risk for P. aeruginosa B-lactam (BLIC, Macrolide (Levofloxacin or
• Staphylococcus
IV antipneumococcal cephalosporin or or Moxifloxacin) or
aureus
antipseudomonal B- carbapenem) ± Coamoxiclav Beta lactam +
• Pseudomonas lactam (BLIC,
aeruginosa macrolide or Macrolide
cephalosporin or respiratory Alt Cefuroxime,
carbapenem) + IV fluoroquinolone Cefpodoxime,
extended macrolides + Ceftriaxone
aminoglycoside
Severe CAP
Piperacillin-tazobactam High Nonantipseudomo Dual: BLIC Respiratory FQ or
4.5g q6h or Cefepime risk w/o nal BLIC, + Macrolide BLIC + Macrolide
2g q8-12h or Pseudo Cephalosporin or
Meropenem 1g q8h monas Carbapenem + For resistance:
+ Macrolide or FQ Cefotaxime,
Azithromycin dehydrate Ceftriazone or
500mg OD IV Ampicillin-
+ sulbactam + FQ
Gentamicin 3mg/kg OD High BLIC, BLIC anti- Anti pseudomonal
or Amikacin 15mg/kg risk w/ antipseudomonal pseudomo B-lactam plus
OD Pseudo BLIC, nal either
monas Cephalosporin, fluoroquinol azithromycin (level
OR Carbapenem one II evidence) or a
IV antipneumococcal respiratory
antipseudomonal - fluoroquinolone
lactam (BLIC,
cephalosporin or Low-Risk Pneumonia
carbapenem) + IV • The local and British guidelines are very similar
Ciprofloxacin/ high dose
• 1st line – Amoxicillin
Levofloxacin
Piperacillin-tazobactam • If w/ stable comorbidities add:
4.5g q6h or Cefepime o Macrolide (added coverage on atypicals)
2g q8-12h or o BLIC (Beta-Lactamase Inhibitor Complex)
Meropenem 1g q8h o 2nd gen Cephalosporins (i.e. Cefuroxime)
+ • US Guideline is different (recommends macrolide instead of
Levofloxacin 750mg OD amoxicillin) due to the higher resistance of Penicillins in the US.
IV or Ciprofloxacin You have to bother knowing these things because as physicians,
400mg q8-12h IV you have to be constantly updated about clinical trends and
guidelines.
If MRSA pneumonia is o 1st line in IDSA (US) – Macrolide, Doxycycline
suspected, add (tetracycline)
Vancomycin 15mg/kg
q8-12h or Linezolid
Moderate-Risk Pneumonia
600mg q12h IV or
Clindamycin 600mg q8h • Pneumonia with an active comorbidity but not yet into septic
shock
• Since you have more active comorbidities here (i.e. greater
risk of mixed infections), then you have to modify your amoxicillin
– add beta-lactamase inhibitors. (e.g. Co-amoxiclav,
amoxicillin+macrolides)
• Drugs with higher spectrum: Ampicillin with b-lactamase inhibitor
(sulbactam), cephalosporins (2nd gen, again know the
generations), macrolides, and respiratory quinolones.

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 4.01 Respiratory Antimicrobials

• We mentioned earlier that moderate-risk CAP has greater risk Table 20. Duration of Therapy of CAP Based on Etiologic Agents
for anaerobic infection. The most effective drugs for that are Etiologic Agent Duration of Therapy (Days)
clindamycin (for the upper parts) and metronidazole (for the
lower) Most bacterial pneumonias 5-7 days
• Macrolides (provides coverage for atypical infections) except enteric Gram-negative
o When should you add or not add a macrolide? pathogens, 3-5 (azalides) for S.
▪ In atypical presentations S. aureus (MSSA and MRSA), pneumoniae
▪ When you have Chlamydia and Mycoplasma in the and P. aeruginosa
presentation Enteric Gram-negative MSSA community-acquired
▪ You add macrolides or the respiratory quinolones pathogens, S. aureus (MSSA pneumonia
(LEVOFLOXACIN or MOXIFLOXACIN) and MRSA), and a. non-bacteremic - 7-14 days
o Advantage of Macrolides: P. aeruginosa b. bacteremic - longer up to 21
▪ Modification of the heat shock protein-70 and p38 days
signaling pathways
▪ Improvement of phagocytic functions of macrophages MRSA community-acquired
▪ Effect: Lower inflammatory response with gradual pneumonia
reduction (compared with Beta lactam proinflammatory a. non-bacteremic – 7-21 days
response) with gradual reduction in bacterial load b. bacteremic – longer up to
28 days
Severe Pneumonia
• There are signs of impending shock Pseudomonas aeruginosa
• The drugs here are quite easy to remember. They’re simply a. non-bacteremic – 14-21
either antipseudomonal or non-antipseudomonal. days
• Need broader spectrum carbapenems, cephalosphorins and b. bacteremic – longer up to
beta-lactamase inhibitors. 28 days
• And then again, compare the Philippine guidelines and the US Mycoplasma and 10-14 days
guidelines. They’re relatively the same this time, but note that Chlamydophila
the cephalosporins recommended by the latter are already 3 rd Legionella 14-21 days; 10 days
generation. (azalides)
• You need to add macrolides with severe CAP as opposed to
moderate CAP wherein you may or may not add. However, here
you have the liberty of choosing between a macrolide OR a D. HOSPITAL-ACQUIRED PNEUMONIA
fluoroquinolone (PCCP 2016)
• Cefipime is a 4th generation cephalosporin • Hospital Acquired Pneumonia (HAP) is a lower respiratory
tract infection that was not incubating at the time of hospital
• The addition of gentamicin to penicillin is synergistic
admission and that presents clinically 2 or more days after
hospitalization
Doc Henri’s Tips:
o Early-onset HAP: 48 hours - <4days; more likely to be
1. Review your antimicrobials. caused by antibiotic-sensitive bacteria
2. Know the generations of the cephalosporins. o Late onset HAP: 5 days or more; more likely to be caused
3. Know your carbapenems. by multidrug-resistant pathogens (worse prognosis)
4. Know which drugs per group are anti-pseudomonal o Both are treated similarly
(pseudomonas is a pathogen in severe CAP): • Ventilator-associated pneumonia (VAP) is defined as
a. Quinolones – ciprofloxacin pneumonia that develops 48-72 hours after endotracheal
b. Extended spectrum penicillin – piperacillin-tazobactam intubation
c. Cephalosporin – ceftazidime, and cefoperazone

• Beta-Lactamase Stable Beta Lactams

o Co-Amoxiclav
o Cefotaxime
o Ceftaroline (5th generation, the very first of its kind, naks.)
o Ceftriaxone
o Cefuroxime
o Piperacillin with tazobactam
F. TREATMENT BASED ON PATHOLOGIC AGENTS
• Pneumonia due to P. jiroveci (P. carinii)
o Cotrimoxazole (DOC)
o Pentamidine
• Notes on Table 20:
o How long to treat typical CAP: 5 – 7 days, but shorter for
Strep. pneumonia (3 – 5 days)
o Serious, HAP, gram-negative – without bacteremia 7 – 14
days, with bacteremia up to 21 days
o For atypicals, specifically legionella – 3 weeks (very long).
You cannot treat legionella in just 1 – 2 weeks. It will just
recur and you’ll end up with resistance.
o The durations are also important in the treatment
Figure 17. Breakdown of hospital-acquired pneumonia/intensive care
unit (HAP/ICU) and HAP/ventilator-associated pneumonia (VAP). Note
that in patients with HAP, 86% of those in the ICU would have VAP.
Half of all episodes of VAP occur within the first 4 days of mechanical
ventilation
• Nosocomial is further broken down into:
o Hospital-acquired
o Ventilator-acquired
o Healthcare-associated
o But what is important is that fortunately, all of them are
generally treated similarly. However, we still have to know
when to label pneumonia as a serious nosocomial infection.
• Half of all episodes of VAP occur within the first 4 days of
mechanical ventilation

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 4.01 Respiratory Antimicrobials

C. Treatment Guidelines
CASE
A 73-year-old man is admitted from a nursing home for an NSTEMI Table 22. Causative Organisms and Empiric Treatment.
and is treated on the telemetry floor. Three days into his Infection Causative Empiric Therapy
hospitalization he becomes febrile with a rising white blood cell count, Organisms
productive cough and evolving right middle lobe infiltrate. You Hospital-acquired H. influenza; S. Ceftriaxone 1g IV
fortunately work in a hospital with a MRSA prevalence of < 5%. The (early onset) pneumoniae; every 24 hrs OR
patient is well-appearing, with no underlying structural lung disease MSSA; gram-
and has not had antibiotics in a number of years. negative bacilli or Moxifloxacin 400
Enterobacteraciae mg IV PO every 24
What information is important in managing this patient (tell you it’s (Klebsiella, E. Coli, hrs
HAP)? Serratia);
• 73 years old anaerobes;
• From a nursing home Legionella
• (+) NSTEMI
• Became febrile three days after hospitalization (most Hospital-acquired Above organisms Piperacillin/
important! Nosocomial pneumonia is defined as that (late onset) and P. aeruginosa; tazobactam 4.5g IV
which begins after 48 – 72 hours in the hospital) MRSA every 6 hrs (3.375 g
• Rising WBC count if not
• Productive cough Pseudomonas), OR
• Evolving right middle lobe infiltrate
Cefepime 1g IV
Always note presence of co-morbidities, institutional care (if patient every 8 hrs, OR
is from a nursing home) and history of prior antibiotic exposure.
Ciprofloxacin 400g
IV every 8 hours
plus clindamycin
A. Healthcare-Associated Pneumonia (HCAP) 600g IV every 8hrs
Ventilator- S pneumonia; H Ceftriaxone 1g IV
Table 21. Diagnostic Criteria for Healthcare-Associated Pneumonia
associated (early influenza; MSSA; every 24 hrs OR
(HCAP). You don’t have to be in a hospital as long as you are confined.
Common elements of HCAP: Previous exposure and being onset, <5 days) Enterobacteracae
immunocompromised Moxifloxacin 400
Original Criteria Pneumonia mg IV/PO every 24
Specific Criteria hrs
• Hospitalization for > 2 days during the • Non-ambulatory Ventilator- Enteric gram- Piperacillin/
previous 90 days status associated (Late negative organisms; tazobactam 4. 5 g
• Residence in a nursing home or • Tube feedings onset, >5 days) Enterobacteraciae; IV every 6 hrs with
P aeruginosa; or without
extended care facility • Use of gastric
MRSA; aminoglycoside, OR
• Long term use of infusion/antibiotics acid suppressive
Acinetobacter spp
• Hemodialysis during the previous 30 agents
Ciprofloxacin 400
days
mg IV every 12 hrs
• Home wound care with or without
• Family member with multidrug resistant aminoglycoside, OR
pathogen
• Immunosuppressive disease or therapy Cefepime 1 g IV
every 8 hours with
or without
aminoglycosides;
B. Etiologic Agents of Hospital-Acquired Pneumonia (HAP) plus, vancomycin 15
• Usually caused by bacterial pathogens or may be polymicrobial. mg/kg IV every 12
In immunocompetent hosts, it is rarely caused by viral or fungal hrs, OR
pathogens.
• Common pathogens include aerobic gram-negative bacilli, such Linezolid 600 mg IV
as P. aeruginosa, Escherichia coli, Klebsiella pneumoniae, and every 12 hrs.
Acinetobacter species (gram negative, anaerobes, and Immunocompromised Legionella; fungal Azithromycin 500
pseudomonas) mg IV every 24 hrs,
• Infections due to gram-positive cocci, such as Staphylococcus fluconazole 200 mg
aureus, particularly methicillin-resistant S. aureus (MRS one of IV every 24 hrs.
the most common cause of death in nosocomial cases), is more
common in patients with diabetes mellitus, head trauma, and Table 23. Recommended Empiric Antibiotics for HAP (MSSA) You
those hospitalized in ICUs. pull out the big guns for MSSA.
Empiric Antibiotics
Not at High Risk of One of the following:
Mortality and No factors • Piperacillin-Tazobactam, 4.5g IV
increasing the likelihood q6h
of MRSA • Cefepime, 2g IV q8h
• Levofloxacin 750mg IV daily
• Imipenem, 500mg IV q6h
• Meropenem, 1g IV q8h

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 4.01 Respiratory Antimicrobials

Table 24. Recommended Empiric Antibiotics for HAP (with risk for Table 25. High Risk for Mortality HAP or VAP (A+B+C). Suggested
MRSA). If you’re treating MRSA, you add Vancomycin (mechanism: Empiric Treatment Options for Clinically Suspected VAP in Units
inhibition of cell wall synthesis). Where Empiric MRSA Coverage and Double Antipseudomonal/Gram-
Empiric Antibiotics Negative Coverage Are Appropriate.
Not at High Risk One of the following: A. Gram-Positive B. Gram-Negative C. Gram-Negative
of Mortality but • Piperacillin-Tazobactam, 4.5g IV q6h Antibiotics with Antibiotics With Antibiotics With
with factors • Cefepime or Ceftazidime 2g IV q8h MRSA Activity Antipseudomonal Antipseudomonal
increasing the • Levofloxacin, 750mg IV daily Activity: Beta- Activity; Non-Beta-
likelihood of • Ciprofloxacin, 400mg IV q8h lactam-Based Lactam-Based
MRSA • Imipenem, 500mg IV q6h Agents Agents
• Meropenem, 1g IV q8h Glycopeptides: Anti – Fluoroquinolones:
• Aztreonam, 2g IV q8h Vancomycin 15 pseudomonal Ciprofloxacin 400mg
mg/kg IV q8-12h penicillins: IV q8h
PLUS: Vancomycin, 15mg/kg IV q8-12h with (consider a loading Piperacillin – Levofloxacin 750mg
goal to target 15-20mg/mL trough level dose of 25-30 mg/kg tazobactam 4.5 g IV q24h
(consider a loading dose of 25-30 mg/kg x 1 x 1 for severe IV q6h
for severe illness), OR Linezolid, 600mg IV illness) Aminoglycosides:
q12h Cephalosporins: Amikacin 15–20
Oxazolidones: Cefepime 2g IV q8h mg/kg IV q24h
High Risk for Choose one drug per category (A+B+C):
Linezolid 600 mg IV Ceftazidime 2g IV Gentamicin 5-7
Mortality (A) Gram (+) Antibiotics with MRSA q12h q8h mg/kg IV q24h
HAP/VAP Activity: Tobramycin 5-7
• Vancomycin 15mg/kg IV q8-12h Carbapenems: mg/kg IV q24h
• Linezolid, 600mg IV q12h Imipenem 500mg
(B) Gram (-) Antibiotics with Anti- IV q8h Polymyxins:
psuedomonal Activity: ꞵ-lactamase-based Meropenem 1g q8h Colistin 5mg/kg IVx1
agents: (loading dose)
• Piperacillin-Tazobactam 4.5g IV q6h Monobactams: followed by 2.5 mg x
• Cefepime or Ceftazidime, 2g IV q8h Aztreonam 2g IV (1.5 x CrCl + 30) IV
• Imipenem, 500mg IV q6h q8h q12h (maintenance
• Meropenem, 1g IV q8h dose)
• Aztreonam, 2g IV q8h Polymyxin B 2.5-3.0
(C) Gram (-) Antibiotics with Anti- mg/kg/d divided in 2
pseudomonal Activity: Non-ꞵ-lactamase- daily IV dose
based agents:
• Ciprofloxacin, 400mg IV q8h
• Levofloxacin, 750mg IV q24h • If you’re treating MRSA, use glycopeptides and oxalidonones.
• Amikacin, 15-20mg/kg IV q24h • For anti-pseudomonal, then use piperazillin-tazobactam, 3rd-4th
• Gentamicin, 5-7 mg/kg IV q24h generation cephalosporin, carbapenems, and monobactams
• Tobramycin 5-7mg/kg IV q24h (aztreonam, classified under beta-lactams, like vancomycin. Use
• Colistin, 5mg/kg IV x 1 (loading dose) this for gram-negatives)
followed by 2.5mg x (1.5 x CrCl +30) IV • Very high doses for nosocomial antimicrobials
q12h • Just remember that when you are at high-risk of pseudomonas,
• Polymyxin B, 2.5-3 mg/kg/d divided in 2 use vancomycin, extended spectrum penicillins, plus quinolones. A
daily IV doses + B + C. You give it all that you have. (parang sa med lang).

VI. OTHER CHALLENGES IN RESPIRATORY INFECTION

CONTROL AND MANAGEMENT

SARS-CoV
• Causative Agent: Coronavirus
• Last outbreak: 2002
• Case Definition:
o Week 1: Prodome – influenza-like symptoms
o Week 2: Fever of >38°C, cough, shortness of breath,
diarrhea
• ARDS
o Radiographic evidence consistent with severe pneumonia
and RDS
• Treatment:
o Ribavirin
o Oseltamivir
o Lopinavir-Ritonavir
o IFN/steroids
• Prognosis
o 9-12% mortality in general; age >65 (50% mortality)

MERS-CoV
• A viral respiratory disease caused by a novel coronavirus that
was first identified in Saudi Arabia in 2012 (2020A)
• Outbreak last year
• Causative Agent: Coronavirus (believed to originate from bats,
transferred to camels)

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 4.01 Respiratory Antimicrobials

• Acquired via close contact, human-to-human transmission & VII. REFERNCES

contact with animal products • Lecture Ppt
o 10 new cases as of December 2016 • Lecture Recording
• Signs and Symptoms: • Trans group notes
o Mild cough, shortness of breath, +/- diarrhea, severe ARDS, • 2020A Trans
pericarditis, renal failure, DIC • 2020C Trans
• Mortality: 35%; 658/1864 from 2012-2016
• Treatment: Supportive (because the drugs for SARS were VIII. QUIZ
no longer effective)
1. Which of the following quinolones is a respiratory quinolone that
Influenza (Doc Henri sent an email stating that the slide deck are more prone to cause QT prolongation?
she used in class was not updated, so take note of these a. Levofloxacin
additional info on influenza she included in the PPT she sent.) b. Moxifloxacin
c. Ciprofloxacin
• Humans can be infected with avian, swine, and other zoonotic
d. A & B
influenza viruses, such as avian influenza virus subtypes
e. All of the above
A(H5N1), A(H7N9), and A(H9N2) and swine influenza virus
subtypes A(H1N1), A(H1N2), and A(H3N2)
2. Which of the carbapenems will a higher incidence of seizures?
• Which of the 4 types of influenza viruses (Types A, B, C, D) can
a. Imipenem
potentially cause an influenza pandemic?
b. Doripenem
o Influenza A virus infect humans and many different animals
c. Ertapenem
o Influenza B virus circulates among humans and cause
d. A & B
seasonal pandemics
e. All of the above
o Influenza C virus can infect both humans and pigs but
infections are generally mild and are rarely reported.
3. Which of the following antimicrobials is a bacteriostatic agent?
o Influenza D viruses primarily affect cattle and are not known
a. Aminoglycosides
to infect or cause illness in people
b. Macrolides
• Signs and Symptoms: c. Fluoroquinolones
o Fever, influenza-like illness (malaise, myalgia, cough, sore d. Penicillin
throat) +/-diarrhea → pneumonia → multi-organ failure,
sepsis-like syndromes, and encephalopathy. 4. Which is an oxalidinone drug used in the treatment of MRSA?
• Fatality is high (about 60%), from respiratory failure due to acute a. Vancomycin
respiratory distress syndrome (ARDS) b. Linezolid
• Treatment: Neuraminidase inhibitors (Oseltamivir, Zanamivir) c. Ceftobiprole
o MOA: Inhibits neuraminidase of both Influenza A and B d. Clindamycin
viruses preventing release of virions from infected cells
neuraminidase inhibition also prevents spreading of virions in 5. A drug of choice for the treatment of anthrax is:
respiratory tract by leaving mucus intact. a. Gentamicin
o Oseltamivir side effects: b. Aztreonam
▪ Nausea, vomiting, stomach pain c. Azithromycin
▪ Diarrhea d. Ciprofloxacin
▪ Headache
▪ Allergies: Rash, hives, or blisters on the skin, itching,
swelling of face or tongue, difficulty breathing or
swallowing, hoarseness
▪ Mouth sores
▪ Sudden confusion, delirium, hallucinations, unusual
behavior, or self-injury

Anthrax
• Causative Agent: Bacillus anthracis
• Produces spores that are dominant and can live in the
environment (2020A)
• Domestic and wild animals such as cattle, sheep, goats,
antelope and deer can become infected when they inhale or
ingest spores in contaminated soil, plants or water
• The type of illness a person develops depends on how it enters
the body. Different forms include cutaneous, gastrointestinal
and inhalational anthrax
• When anthrax spores get inside the body, they can be activated.
When they become active, anthrax bacteria can multiply, spread
out in the body, and produce toxins—or poisons
• Anthrax toxins in the body cause severe illness and death if they
are not treated with antibiotics.
• Treatment:
o Antibiotics: Ciprofloxacin & Tetracycline
o Antitoxin (currently, there are only a few types of antitoxins
that can be used for treating anthrax)

Answers: 1. D, 2. A, 3. B, 4. B., 5. D
LE 4 TRANS 1 15 of 16
 4.01 Respiratory Antimicrobials

APPENDIX

Age group Clarithromycin Azithromycin Erythromycin Co-trimoxazole

Neonates (under 1 Preferred in neonates: 7.5mg/kg 10mg/kg once a day for 3 Not recommended due to Not licensed for
month) twice a day for 7 days days association with hypertrophic infants below 6 weeks
pyloric stenosis
Infants (1 month-12 Under 8kgs: 7.5mg/kg twice a 1-12 months: 10mg/kg once a 1-12 months: 125mg every 6 6 weeks-6 months:
months) day for 7 days day for 3 days hours for 7 days 120mg twice a day for
8-11kg: 62.5mg twice a day for 7 7 days
days 6 months-1 year:
240mg twice a day for
7 days
Children 12-19kg: 125mg twice a day for Over 1 year: 10mg/kg (max: 1-2 years: 125mg every 6 1-5 years: 240mg
7 days 500mg) once a day for 3 days hours for 7 days twice a day for 7 days
20-29kg: 187.5mg twice a day 2-8 years: 250mg every 6 6-12 years: 480mg
for 7 days hours for 7 days twice a day for 7 days
30-40kg: 250mg twice a day for Over 8 years: 500 mg every 6 12-18 years: 960mg
7 days hours for 7 days twice a day for 7 days
Adults 500mg twice a day for 7 days 500mg once a day for 3 days 500mg every 6 hours for 7 960mg twice a day for
days 7 days
Pregnant women Not recommended Not recommended Preferred antibiotic. Not Contraindicated in
known to be harmful. pregnancy
Appendix 1. Treatment of Pertussis based on age group.

Appendix 2. Clinical features of patients with CAP according to risk categories.

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