Treatment of Hospital-Acquired Pneumonia

TREATMENT OF HOSPITAL-ACQUIRED PNEUMONIA

· RESPONSE:

· The American Thoracic Society treatment guidelines for severe hospital-acquired pneumonia are as follows (Nelson, 1998): ======

EARLY ONSET PNEUMONIA

- Start with a second- or nonpseudomonal third-generation

cephalosporin or a beta-lactam/b-lactamase inhibitor

combination

- If allergic to penicillin, a fluoroquinolone or a

combination of clindamycin and aztreonam is recommended

PNEUMONIA WITH RISK FACTORS* OR

LATE-ONSET INFECTION

- Aminoglycoside or ciprofloxacin plus one of the

following:

An antipseudomonal penicillin

Beta-lactam/beta-lactamase inhibitor combination

An antipseudomonal third-generation cephalosporin

(eg, ceftazidime or cefoperazone)

Imipenem

Aztreonam

- Add vancomycin if methicillin-resistant Staphylococcus

aureus is suspected

======

key:

* Risk factors include recent abdominal surgery, witnesses

aspiration, coma, head trauma, diabetes mellitus, renal

failure, high-dose steroids, prolonged intensive care

unit stay, prior antibiotic therapy, or structural lung

disease.

· REFERENCES:

· 1. Nelson S: Ciprofloxacin in the treatment of severe pneumonia. Infect Dis Clin Amer 1998; 7(3 suppl):211-216.

· AUTHOR INFORMATION:

Original publication: 09/98

List of contributors:

1. DRUGDEX(R) Editorial Staff

For further information on contributing authors,

see editorial board listings.

TREATMENT OF COMMUNITY-ACQUIRED PNEUMONIA

· RESPONSE:

· The Drug-Resistant Streptococcus pneumoniae Therapeutic Working Group developed guidelines for the treatment of community-acquired pneumonia (Heffelfinger et al, 2000). Treatment for community-acquired pneumonia should target Streptococcus pneumoniae because 9% to 55% of community- acquired pneumonia requiring hospitalization is caused by Streptococcus pneumoniae. Another consideration when treating is the increased prevalence of drug-resistant Streptococcus pneumoniae. The Working Group determined the susceptibility breakpoints of the penicillin minimum inhibitory concentration (MIC) as susceptible if the MIC is no greater than 1 microgram/milliliter (mcg/mL), intermediate if the MIC is 2 mcg/mL, and resistant if the MIC is no less than 4 mcg/mL. Antimicrobial agents, with poor activity against Streptococcus pneumoniae, including penicillin V potassium, all of the first- generation cephalosporins, cefaclor, cefixime, ceftibuten, and loracarbef should be avoided. The following table provides empiric regimens for treating community-acquired pneumonia:

EMPIRIC ANTIMICROBIALS FOR

TREATING COMMUNITY-ACQUIRED PNEUMONIA

OUTPATIENTS

------

Macrolide *

Erythromycin, clarithromycin, or azithromycin

Tetracycline ** (contraindicated in children younger

than 8 years)

Doxycycline or tetracycline

Beta-lactams, Oral ***

Cefuroxime, amoxicillin,

or amoxicillin-clavulanate

Fluoroquinolones (restricted use)

levofloxacin or sparfloxacin

INPATIENTS

------

Beta-lactam, Parenteral

Cefuroxime, cefotaxime, ceftriaxone, or

ampicillin-sulbactam PLUS a macrolide

(erythromycin, clarithromycin, or azithromycin)

Fluoroquinolones (restricted use)

levofloxacin, sparfloxacin, or

trovafloxacin

INTUBATED OR INTENSIVE CARE UNIT PATIENTS

------

FIRST-LINE ANTIMICROBIALS

Beta-lactam, Parenteral (intravenous)

Ceftriaxone or cefotaxime PLUS an intravenous

macrolide (erythromycin or azithromycin)

SECOND-LINE ANTIMICROBIALS

Beta-lactam, Parenteral (intravenous)

Ceftriaxone or cefotaxime PLUS a

fluoroquinolone (levofloxacin,

sparfloxacin, or trovafloxacin)

Fluoroquinolones (restricted use; not as monotherapy,

use in combination)

levofloxacin, sparfloxacin, or

trovafloxacin)

· * American Thoracic Society and Infectious Disease Society of America (IDSA) recommend macrolides for uncomplicated pneumonia in adults without comorbid conditions. However, macrolides are not the first line recommended agents for children younger than 5 years (coverage for atypical microorganisms are not necessary). ** IDSA also recommend doxycycline as a first line agent. *** Beta-lactams are the preferred agents for children younger than 5 years.

· REFERENCES:

· 1. Heffelfinger JD, Dowell SF, Jorgensen JH et al: Management of community-acquired pneumonia in the era of pneumococcal resistance. Arch Intern Med 2000; 160:1399-1408.

· AUTHOR INFORMATION:

Original publication: 12/2000

List of contributors:

1. DRUGDEX(R) Editorial Staff

For further information on contributing authors,

see editorial board listings.

PNEUMOCYSTIS CARINII PNEUMONIA - DRUG OF CHOICE

· RESPONSE:

· The recommended drug of choice for PNEUMOCYSTIS CARINII PNEUMONIA (PCP) or extrapulmonary P carinii infection in patients with AIDS is COTRIMOXAZOLE (trimethoprim-sulfamethoxazole). The recommended treatment dose, based on trimethoprim, is 15 milligrams/kilogram/day orally or intravenously (IV) in 3 to 4 divided doses for 14 to 21 days in children and adults.

· Oral PREDNISONE in a tapering schedule of 40 milligrams twice daily for the first 5 days, 20 milligrams twice daily from day 6 through 10, then 20 milligrams daily through day 21 should be used in moderate to severe PCP complicated by moderate to severe hypoxia (room air PO2 of 70 mmHg or less or Aa gradient of 35 mmHg or more) to reduce the incidence of pulmonary deterioration or death.

· A number of alternative drug treatment regimens can be recommended; PENTAMIDINE 3 to 4 milligrams/kilogram IV daily for 14 to 21 days; TRIMETREXATE (45 milligrams/square meter IV daily for 21 days) plus leucovorin (folinic acid) rescue (20 milligrams/square meter orally or IV every 6 hours for 21 days); or a combination of DAPSONE (100 milligrams orally daily for 21 days) plus TRIMETHOPRIM (5 milligrams/kilogram orally 4 times daily for 21 days); ATOVAQUONE (750 milligrams orally 2 times daily for 21 days); or PRIMAQUINE (30 milligrams base orally daily for 21 days) plus CLINDAMYCIN (600 milligrams IV or 300 to 450 milligrams orally 4 times daily for 21 days) may be effective in treating PCP in AIDS patients who develop hypersensitivity or resistance (Anon, 1998).

· In ADULTS, for both primary and secondary prophylaxis of PCP, oral cotrimoxazole (1 single- or double-strength tablet daily or 1 double-strength tablet 3 times weekly) is preferred. Children should be dosed with trimethoprim 150 milligrams/square meter or sulfamethoxazole 750 milligrams/square meter in 2 doses orally for 3 consecutive days weekly. Alternative therapies include dapsone (50 milligrams orally twice daily or 100 milligrams orally once daily) alone or dapsone (50 milligrams daily or 200 milligrams each week) with PYRIMETHAMINE 50 to 75 milligrams weekly; or aerosolized pentamidine (300 milligrams monthly via Respirgard II nebulizer); or ATOVAQUONE 750 milligrams twice daily. In CHILDREN, alternative regimens include either dapsone 2 milligrams/kilogram daily (maximum 100 milligrams) or (for children over 5-years-old) aerosolized pentamidine as 300 milligrams monthly via Respirgard II nebulizer (Anon, 1998).

· REFERENCES:

· 1. Anon: Drugs for parasitic infections. Med Lett Drugs Ther 1998; 40(1017):1-12.

· AUTHOR INFORMATION:

Original publication: 07/84

Most recent revision: 09/98

List of contributors:

1. DRUGDEX(R) Editorial Staff

For further information on contributing authors,

see editorial board listings.