Empiric Treatment:

Pneumonia
Overview of Pneumonia
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What is
pneumonia?
Pneumonia is an inflammatory illness of the
lung.
Frequently, pneumonia is described as lung parenchyma/alveolar
(microscopic air-filled sacs of the lung responsible for absorbing
oxygen from the atmosphere) inflammation and (abnormal)
alveolar filling with fluid.
What Causes
Pneumonia?
Pneumonia can result from a variety of
causes, including infection with bacteria,
viruses, fungi, or parasites, and chemical or
physical injury to the lungs.
Pneumonia
The alveoli are tiny air sacs within the
lungs where the exchange of oxygen
and carbon dioxide takes place.
Bronchiole: A tiny tube in the air conduit system
within the lungs that is a continuation of the
bronchi and connects to the alveoli (the air sacs)
where oxygen exchange occurs.
Bronchiole is the diminutive of bronchus, from
the word bronchos by which the Greeks referred
to the conduits to the lungs.
Symptoms of
Pneumonia
Fever
Chills
Cough
Pleurisy: inflamed membranes around
the lungs
Dyspnea: Difficult or labored breathing;
shortness of breath
Diagnosis of Pneumonia
Pneumonia usually produces distinctive
sounds; these abnormal sounds are
caused by narrowing of airways or filling
of the normally air-filled parts of the lung
with inflammatory cells and fluid, a
process called consolidation.
Diagnosis of Pneumonia
In most cases, the diagnosis of pneumonia is
confirmed with a chest x-ray.
For most bacterial pneumonias, the involved
tissue of the lung appears on the x-ray as a dense
white patch (because the x-ray beam does not get
through), compared with nearby healthy lung
tissue that appears black (because the x-rays get
through easily, exposing the film).
Viral pneumonias typically produce faint, widely
scattered white streaks or patches.
Two Types of Pneumonia
Community-Acquired Pneumonia
(CAP): individual residing in their homes

Hospital-Acquired Pneumonia (HAP):
individuals residing in hospitals
Community-Acquired
Pneumonia
Typical: Sudden onset of fever, chills,
pleuritic chest pain, productive cough
Streptococcus pneumoniae
Haemophilus influenzae
Atypical: often preceded by mild respiratory
illness
Legionella spp.
Mycoplasma pneumoniae
Chlamydophila pneumoniae
CAP: typical
Streptococcus pneumoniae
Gram +
Usually susceptible to penicillin
Streptococcus pneumoniae
Treatment of Streptococcus
pneumoniae
Penicillin G (high doses)
Aminopenicillins: Ampicillin (high doses)

Ampicillin
Treatment of Penicillin-resistant
Streptococcus pneumoniae
Second Generation Cephalosoporins:
Cefuroxime
Third Generation Cephalosporins:
Cefotaxime, Ceftriaxone
Quinolones: Moxifloxacin, Levofloxacin
Vancomycin
Macrolides/ketolines: Telithromycin
Haemophilus influenzae
Haemophilus influenzae
Since the organism was
frequently isolated from
the lungs of patients
during the 1890 and 1918
influenza pandemics,
scientists incorrectly
concluded that the
bacterium was the
causative agent.
Haemophilic means blood loving. The organism
requires a blood-containing medium for growth
Influenzae: The bacterium often attacks the lungs
of a patient with viral influenza.
Haemophilus influenzae
Haemophilus influenzae
Treatment of Infections Caused
by Haemophilus influenzae
Aminopenicillins + b-lactamase inhibitor:
Amoxicillin/clavulanate
Ampicillin/sulbactam
Second-generation cephalosporin
Cefuroxime
Third-generation cephalosporin
Ceftriaxone
Cefotaxime







Bacterial Causes of CAP
Streptococcus pneumoniae 16-60%
Haemophilus influenzae 3-38%
Legionella spp 2-30%
Mycoplasma pneumoniae 1-20%
Other aerobic Gram-neg 7-18%
Chlamydophila pneumoniae 6-12%
Staphylococcus aureus 2-5%
Treatment of CAP
Treatment of CAP
Mild
Macrolide (azithromycin, clarithromycin)
Macrolide + b-lactam
Doxycycline
Quinolone (moxifloxacin, levofloxacin,
gemifloxacin)

Severe
b-lactam + macrolide
b-lactam + quinolone
Treatment of CAP
Severe
b-lactam + macrolide
b-lactam + quinolone

HAP is also divided into two
classes:
Early onset HAP: occurs within first five
days of hospitalization

Late onset HAP: occurs after 5 days of
hospitalization
Bacterial Causes of
Early Onset HAP
Methicillin-sensitive Staphylococcus aureus 29-35%
Haemophilus influenzae 23-33%
Enterobacteriaceae 5-25%
Streptococcus pneumoniae 7-23%
Bacterial Causes of Late
Onset HAP
Pseudomonas aeruginosa 39-64%
Acinetobacter spp. 6-26%
Enterobacteriaceae 16-31%
Methicillin-resistant S. aureus 0-2%
Treatment of Early Onset HAP
Ceftriaxone = 3rd gen. cephalosporin
Treatment of Early Onset HAP
Ceftriaxone
Quinolone (Levofloxacin, Moxiflocacin,
Ciprofloxacin)
Ampicillin/sulbactam
Ertapenem
Treatment of Late Onset HAP
Treatment of Late Onset HAP
Antipseudomonal cephalosporin: ceftazidime,
cefepime
Or Carbapenem: Imipenem, Meropenem
Or Extended spectrum penicillin/b-lactamase
inhibitor: piperacillin/tazobactam
++++
Quinolone (ciprofloxacin, levofloxacin)
Or Aminoglycoside (gentamicin, tobramycin,
amikacin)
If MRSA is suspected, add: Vancomycin or
Linezolid
Use a combination regimen from the first and second
categories below:
Urinary Tract Infections
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Urinary System
Mild and Severe UTIs
Mild
Involve only the urethra and bladder
Referred to as acute cystitis
Symptoms include
dysuria (painful urination)
urinary frequency
hematuria (blood in urine)

Severe UTIs
Severe
Infection of the upper urinary tract involves the
spread of bacteria to the kidney
Symptoms include fever, chills, nausea,
vomiting and flank pain
Called pyelonephritis
Complicated and
Uncomplicated UTIs
Uncomplicated: Less likely to recur.
Occur in young, healthy, nonpregnant
women

Complicated: All other UTIs. More likely
to recur.
Bacterial Causes of
Uncomplicated UTIs
Escherichia coli 53-79%
Proteus mirabilis 4-5%
Staphylococcus saprophyticus 3%
Klebsiella spp. 2-3%
Other Enterobacteriaceae 3%
Treatment of Uncomplicated Acute Cystitis
Treatment of Uncomplicated
Acute Cystitis
Oral trimethoprim-sulfamethoxazole
Oral quinolones (ciprofloxacin, levofloxacin)
Treatment of Uncomplicated Acute Pyelonephritis
Gentamycin, an aminoglycoside
Amoxicillin, an aminopenicillin
Treatment of Uncomplicated Acute Pyelonephritis
Quinolones: Ciprofloxacin, levofloxacin
Third generation cephalosporins: Ceftriaxone,
cefotaxime, ceftizoxime

If Gram positive organisms seen in urine:
Aminopenicillin (amoxicillin)
Aminopenicillin + b-lactamase inhibitor: (amoxicillin +
clavulanate)
Aminopenicillin + aminoglycoside (ampicillin +
gentamicin)
Treatment of Complicated
Urinary Tract Infections
Treatment of Complicated
Urinary Tract Infections
Fourth generation cephalosporins
(cefepime)
Quinolones: Ciprofloxacin, Levofloxacin

If Gram-positive bacteria seen in urine:
Aminopenicillin + aminoglycoside:
Ampicillin + gentamicin
Pelvic Inflammatory Disease
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Female Reproductive Organs
PID is the general term for an infection that
has traveled through the vagina, to the
uterus, and then to other parts of the pelvis
Symptoms of
PID
Abnormal bleeding
Dyspareunia (pain during sexual intercourse)
Vaginal discharge
Lower abdominal pain
Fever
chills
Bacterial Causes of PID
Neisseria gonorrhoeae 27-56%
Chlamydia trachomatis 22-31%
Anaerobic and facultative bacteria
(Bacteria that can live under aerobic or
anaerobic conditions) 20-78%
Treatment of PID
Treatment of PID
Mild to Moderate Disease
Oral quinolone: Levofloxacin, ofloxacin
+ oral metronidazole
Single IM dose of cephalosporin
+ oral doxycycline
+ oral metronidazole
Treatment of PID
Severe Disease (regimen 1)
Cephalosporin with anaerobic activity (cefotetan,
cefoxitin)
+ doxycycline (active against atypical C. trachomatis)

Severe Disease (regimen 2)
Clindamycin (active against C. trachomatis and against
many anaerobes)
+ Gentamicin (effective against Gram-negative N. gonorrhoeae)

Those that are severely ill should be admitted to the
hospital and treated initially with intravenous agents.
Meningitis
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Meningitis
Meningitis is the inflammation of the
protective membranes covering the central
nervous system, known collectively as the
meninges.
Meningitis may develop in response to a
number of causes, most prominently
bacteria, viruses and other infectious
agents, but also physical injury, cancer, or
certain drugs.

Meninges: the membranes that envelope
the brain and the spinal cord.

Symptoms of Meningitis
Headache
Fever
Neck stiffness
Altered mental status
Photophobia
Nausea
Vomiting
Seizures
The most important test used to diagnose meningitis
is the lumbar puncture (commonly called a spinal
tap).
Lumbar puncture (LP) involves the insertion of a thin
needle into a space between the vertebrae in the
lower back and the withdrawal of a small amount of
CSF.
Lumbar puncture

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Diagnosis of Meningitis
The CSF is then examined under a microscope to
look for bacteria or fungi.
Normal CSF contains set percentages of glucose
and protein.
These percentages will vary with bacterial, viral, or other
causes of meningitis.
For example, bacterial meningitis causes a greatly lower
than normal percentage of glucose to be present in CSF, as
the bacteria are essentially "eating" the host's glucose, and
using it for their own nutrition and energy production.
Diagnosis of Meningitis
Normal CSF should contain no infection-fighting
cells (white blood cells), so the presence of white
blood cells in CSF is another indication of
meningitis.

Some of the withdrawn CSF is also put into
special lab dishes to allow growth of the
infecting organism, which can then be
identified more easily.
Special immunologic and serologic tests may
also be used to help identify the infectious
agent.
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Bacterial Causes of Acute
Bacterial Meningitis
0 - 3 months:
Streptococcus agalactiae
Escherichia coli
Listeria monocytogenes
Bacterial Causes of Acute
Bacterial Meningitis
3 month - 6 yrs:
Neisseria meningitidis
Streptococcus pneumoniae
Haemophilus influenzae

Bacterial Causes of Acute
Bacterial Meningitis
16 yrs - 50 yrs
Streptococcus
pneumoniae
Neisseria
meningitidis
Bacterial Causes of Acute
Bacterial Meningitis
> 50 yrs
Streptococcus pneumoniae
Listeria monocytogenes
Aerobic Gram-negative bacilli

Treatment of Bacterial Meningitis
Treatment of Bacterial Meningitis
Third-generation cephalosporins: cefotaxime,
ceftriaxone
+ Vancomycin (coverage against resistant Streptococcus
pneumoniae)

If patient < 3 months or > 50 years
Same as above, but also
Add ampicillin to provide coverage of L.
monocytogenes and S. agalactiae.

Cellulitis
Cellulitis is an inflammation of the connective tissue
underlying the skin, that can be caused by a bacterial
infection.
Cellulitis
Bacterial Causes of Cellulitis
Staphylococcus aureus 13-37%
Streptococcus pyogenes 4-17%
Other streptococci 1-18%
Treatment of Cellulitis
Treatment of Cellulitis
Mild Disease (oral formulations)
Antistaphylococcal penicillins (Dicloxacillin)
First Generation Cephalosporins
(Cephalexin, Cefadroxil)
Clindamycin



Macrolides (Erythromycin, azithromycin,
clarithromycin)

Treatment of Cellulitis
Severe Disease (intravenous formulations)
Antistaphylococcal penicillins (Nafcillin, oxacillin)
First-generation cephalosporins (cefazolin)
Clindamycin

Treatment of Cellulitis
If MRSA is suspected
Vancomycin
Linezolid
Daptomycin
Tetracyclines (Tigecycline, doxycycline)
Sulfa drugs (Trimethoprim-
sulfamethoxazole)
Clindamycin
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Symptoms of Otitis Media
Otalgia (ear pain)
Hearing Loss
Irritability
Anorexia
Apathy
Fever
Swelling around the ear
Otorrhea (discharge from the affected ear)
Bacterial Causes of Acute
Otitis Media
Streptococcus pneumoniae 25-50%
Haemophilus influenzae 15-30%
Moraxella catarrhalis 3-20%
Treatment of Acute Otitis Media
Treatment of Acute Otitis
Media
First Line Therapy
High Dose Amoxicillin
If Mild Allergy to Penicillin
Cefdinir, Cefpodoxime, Cefuroxime axetil
If Type 1 Hypersensitivity Allergic
Reaction
Macrolide (Azithromycin, Clarithromycin,
Erythromycin with sulfisoxazole)
Sulfisoxazole
Used in combination
with Erythromycin
Sulfmethoxazole
Used in combination with
Trimethoprim
(co-trimoxazole)
Infective Endocarditis
Causes of
Endocarditis
There are many ways that bacteria can
enter the bloodstream and cause
endocarditis. Even a small cut can
enable bacteria that normally live on the
skin to enter the bloodstream.
In some cases, this occurs during a dental
or surgical procedure. In many cases,
however, it is not clear how the bacteria
first got into the bloodstream.

Symptoms of Endocarditis
Symptoms are non-specific, making
endocarditis difficult to diagnose:
Fatigue
Malaise
Weakness
Weight loss
Fever
Chills
Dyspnea on exertion (shortness of breath)
Bacterial
Causes of
Endocarditis
Viridans group streptococci 18-48%
Staphylococcus aureus 22-32%
Enterococci 7-11%
Coagulase-negative staphylococci 7-11%
HACEK organisms 2-7%
Viridans Group streptococci
Viridans streptococcus are alpha-hemolytic,
normal flora of the oral, respiratory tract, and
GI mucosa.
They are the major cause of bacterial
endocarditis in people with damaged
heart valves. They may enter the blood
stream after dental procedures.

HACEK Organisms
A HACEK organism is one of a set of slow-growing
Gram negative bacteria that form a normal part of
the human flora. They are a frequent cause of
endocarditis in children.
The name is formed from their initials:
Haemophilus aphrophilus, Haemophilus
parainfluenzae and Haemophilus paraphrophilus
Actinobacillus actinomycetemcomitans
Cardiobacterium hominis
Eikenella corrodens
Kingella kingae
Empiric Therapy for Infective
Endocarditis
Vancomycin + Gentamicin
Vancomycin is effective against S. aureus and
viridans group streptococci
When used in combination with Gentamicin,
activity is extended to the majority of enterococcal
strains





Even intensive therapy may not be
sufficient, and surgical intervention is
often required
Despite intensive antibiotic therapy,
mortality remains high: 20-25%.

Prosthetic Valve Endocarditis
Many cases of endocarditis are associated
with prosthetic valves in the heart
Sometimes these infections occur within two
months after the valve is installed and are
thus thought to be hospital acquired
Sometimes they occur 6-20 month after
surgery and are thus thought to be
community acquired

Treatment of Prosthetic Valve
Endocarditis
Vancomycin + Gentamicin + Rifampin
With or without cefepime or ceftriaxone
Intravascular-Related
Catheter Infections
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200,000 catheter-related infections
occur each year in the U.S.
Should be suspected in anyone with an
intravascular catheter and a fever of
unclear etiology.

Diagnosis may involve:
Removal and culture of the catheter
Growth of bacteria from blood cultures

What type of bacteria cause
catheter-related infections?
Skin flora, including:
Staphylococcus epidermidis 32-41%
Staphylococcus aureus 5-14%
Enteric Gram-negative bacilli 5-11%
Psuedomonas aeruginosa 4-7%
Treatment of Intravascular
Catheter-related Infections
Treatment of Catheter Related
Infections
Hospital setting where MRSA is uncommon
Antistaphylocccal penicillin: Nafcillin, Oxacillin
Hospital setting where MRSA is common
Vancomycin
Immunocompromised or severely ill patient
Add cephalosporin to initial antibiotic regimen
Ceftazidime, cefepime
Intra-Abdominal Infections
Causes of Intra-abdominal
infections
Usually caused by contamination of the
usually sterile abdomen with microbial
flora of the bowel
Can be quite severe, leading to sepsis
and death
Bacterial Causes of Intra-
abdominal Infections
Gram-negative bacilli
Escherichia coli 32-61%
Enterobacter spp. 8-26%
Klebsiella spp. 6-26%
Proteus spp.4-23%
Bacterial Causes of Intra-
abdominal Infections
Gram-positive cocci
Enterococci 18-24%
Streptococci 6-55%
Staphylococci 6-16%


Bacterial Causes of Intra-
abdominal Infections
Anaerobic bacteria
Bacteroides spp.
Clostridium spp.
Treatment of Intra-abdominal
Infections
Due to their polymicrobial nature, the
antibiotic regimen must be very broad
spectrum, including Gram-negative
bacilli, Gram-positive cocci, and
anaerobic bacteria
Treatment of Intra-Abdominal
Infections
b-Lactam/b-lactamase inhibitor
combinations (piperacillin/tazobactam)
Carbapenems (imipenem, meropenem)
Aminoglycoside (gentamicin,
tobramycin, amikacin)
+ metronidazole

Ciprofloxacin + metronidazole

Treatment of Intra-abdominal
Infections