Beruflich Dokumente
Kultur Dokumente
Guided by:
• disease-specific prognostic indicators to assess
the initial severity of pneumonia
• physician’s clinical judgement, supplemented by
objective findings
Current Approaches to CAP Therapy
CURB 65
Score 1 point for each:
•Confusion
•Urea >7 mmol/L
•RR ≥30/min
•BP (SBP <90 mmHg or DBP ≤60
mmHg
•Age ≥65 years
0 or 1 2 >3
• Applicable to 0 0
office-based
settings 1 4.1
• Scores: 2 18.7
0=home
treatment 3 43.5
1=hospital-
supervised
4 54.6
treatment Capelastegui A et al. Eur Respir J. 2006;27:151-157.
≥2=hospitalizati
Which patient will need
hospital admission?
Which patient will need hospital
admission?
Pts w/ stable VS:
RR < 30 breaths/min, PR < 125 beats/min,
SBP > 90 mmHg or DBP > 60 mmHg &
Temp >36oC and <40oC
No altered mental status of acute onset (NEW)
No or stable comorbid condition *
No evidence of aspiration
CXR: localized infiltrates; no evidence of pleural
effusion nor abscess
LOW Ris k C A P -- -> Ou tpa ti ent Ca re
* Comorbid conditions include:
Diabetes mellitus (DM)
Neoplastic disease
Neurologic disease
Congestive heart failure (CHF)
Coronary artery disease (CAD)
Renal failure
COPD
Chronic liver disease
Chronic alcohol abuse
Which patient will need hospital
admission?
ANY OF THE FOLLOWING
Kollef, 1998
Anti biot ics sh oul d be ini tia ted w it hi n 4
Ibrahim, 2000
hours of D x of CAP
Luna, 1997
0 20 40 60 80 100
% Mortality
Alvarez-Lerma F, et al. Intensive Care Med. 1996;22:387-394. Kollef MH, et al. Chest. 1998;113:412-420.
Ibrahim EH, et al. Chest. 2000;118L146-155. Luna CM, et al. Chest. 1997;111:676-685.
Kollef MH, et al. Chest. 1999; 115:462-474. Rello J, et al. Am J Respir Crit Care Med. 1997;1
56:196-200.
Antibiotic
Treatment
Major goal of therapy:
Major goal of therapy:
eradication of the infecting
organism, with resultant
resolution of clinical disease
•S. pneumoniae
S. pneumoniae •Staphylococcus
M. pneumoniae
aureus
C. pneumoniae •Legionella species
H. influenzae
•Gram-negative bacilli
•H. influenzae
Legionella species
Aspiration
Respiratory viruses
Evidences – Aetiologic distribution of
Community-acquired pneumonia in Asian Countries
Co- 15 16 14 18
trimoxazole
Chloramphe 5 4 5 5
nicol
Co- 36 15 16 13
trimoxazole
Chloramphe 10 20 14 8
nicol
Co- 1 7 5 11.4
amoxiclav
Co- 38 50 59 49.6
trimoxazole
Erythromyci 27 32 24 32.7
n
Celia C. Carlos, ARSP, DOH
What is the empiric
treatment for CAP?
IDSA/ATS Consensus Guidelines on CAP 2007
(Clinical Infectious Diseases 2007;44:S27-
OU TPAT IENT 72)
IN PAT IENT: INPA TIENT:
GENERAL W ARD ICU ( SE VERE C AP)
Previou sly heal th y, no Re spirat or y No Pseudomonal risk:
antib io ti cs th e pas t 3 Flu oroq uin olon e Beta-lactam (cefotaxime,
mont hs: (le vo, mox i or gemi) (I ) ceftriaxone, ampicillin-
A ma cro lid e (I) OR sulbactam)
Doxy cy cli ne (III ) Be ta-lac ta m* + Ma crolide PLUS
(I) IV Macrolide (II) or
Co -mor bid it y or rece nt or Dox ycyclin e (II I) IV Fquinolone (I)
anti bio tic use:
Pseudomonal risk factors present:
Re spirat or y FQ (L evo *ce fot ax im e, ce tria xo ne , Anti-Pseudo, Anti-pneumo
750) ampic illi n-sulbact am
Blactam (cefepime, piptazo,
(I ) ertapenem imipenem, meropenem)
Hig h-dose beta -la ct am*
PLUS
+ For ca refully selec te d Cipro or Levofloxacin (750 mg)
macrolid e (I) patie nts wit ho ut ris k Above beta-lactam PLUS
fact or s for DRS P or GNR,
mo no the ra py w it h IV aminoglycoside or
* Amox 1g tid
azit hr omy cin ca n be IV antipneumococcal FQ
Co-am ox 2g bid
co nsid ered *Add Vanco or Linezolid for CA-
MRSA
Ce ftria xo ne,
LOW RISK CAP
What is the empiric treatment for
Low Risk CAP?
Low Risk CAP with no co morbid conditions
2004 2009
Recommendation Recommendation
Amoxicillin
Amoxicillin OR
Extended macrolides
Alternative
Extended Macrolides:
Alternative azithromycin dihydrate,
Co-trimoxazole clarithromycin
What is the empiric treatment for
Low Risk CAP?
Low Risk CAP with stable co morbid conditions
Recommendation (2004/2009):
co-amoxiclav or sultamicillin
or
or
Recommendation (2004/2009):
Moxifloxacin
Levofloxacin
High Risk CAP with No risk for
Pseudomonas aeruginosa
Recommendation (2009):
IV nonpseudomonal antipneumococcal β-
lactam
+/- β-lactamase inhibitor
+ IV macrolide
Alternative:
IV antipneumococcal FQ
High Risk CAP with Risk for
Pseudomonas aeruginosa
Recommendation (2009):
+
IV macrolide or IV antipneumococcal FQ
+/-
Aminoglycosides or IV Ciprofloxacin
Antipseudomonal
Antipneumococcal β-lactam
IV β-lactams
Those without anaerobic activity
4th gen cephalosporin (cefepime)
Those with anti-anaerobic activity
Carbapenem (Imipenem-cilastatin, Meropenem)
mg/day
Severe underlying bronchopulmonary
ATS Guidelines
Dur ati on of Ant ibi oti c Use
Base d o n Et iolog y
S. au reus, P. ae rugi no sa
10- 14
My co pl asma & Chl am ydo ph ili a
14- 21
Legio nel la sp .
Oral Agents with Good Bioavailability
and Convenient Dosing Schedule for
Switch Therapy
Se cond/ Thir d Genera ti on
Cepha lo spo ri ns
Ext ende d Mac rol ide s
Fluo ro quinol ones