Dr. Grock presents today’s Morning Report!
Pulmonary Infections
CAP
- If no abx in last 3 mo and healthy: A Macrolide (2nd line Doxy)
- If chronic heart, lung, liver, renal disease, DM, ETOH, Ca, Asplenia, Immunosuppressed, or abx use in last 3 months: Resp fluoroquinolone, B-lactam + Macrolide
- If inpt: Resp Fluoroquinolone, B-lactam + Macrolide
- If ICU: B-lactam + azithro/resp fluoroquinolone. If Pen allergic: aztreonam/fluoro.
- If CA-MRSA concern: add vanco/linezolid
- If Pseudomonas concern: zosyn/cefepime/imipenem/meropenum + cipro/levo OR aminoglycoside and azithro OR aminoglycoside and antipneumococcal fluoro.
- Blood cultures?
- Admit? Curb-65, PSI, clinical judgement
HCAP
- (hosp for >2 days in last 90 days, NH, home infusion therapy, HD, home wound care)
- Cefepime/ceftazadime OR imipenem/meropenem OR zosyn AND cipro/levo OR gent AND vanco/linezolid
- Azithro?
- Admit All? (risk factors: Abx < 90 days, recent hosp >5 days, poor functional status, immunosuppressive dx and/or therapy. If > 2 “high risk”. If < 2 “low risk”. Low risk group = 50% of patients, 93% fine with CAP guidelines.)
PNA in AIDS
- AIDS: add Bactrim/azithro. ABG: PaO2<70, hypoxia on O2 sat, or A-a gradient >35 give steroids
Lung Abscess
- Clinda (2 studies show better than pens) with vanco/linezolid. Usually polymicrobial. Per Tintinalli’s add a cephalosporin/clinda. Flagyl sucks. Abx 80-90% effective.
References
- Lionel A. Mandell, et al. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. IDSA/ATS Guidelines for CAP in Adults • CID 2007:44 (Suppl 2)
- Maruyama T, et al. A new strategy for healthcare-associated pneumonia: a 2-year prospective multicenter cohort study using risk factors for multidrug-resistant pathogens to select initial empiric therapy. Clin Infect Dis. 2013 Nov; 57(10):1373-83. doi: 10.1093/cid/cit571. Epub 2013 Sep 2.
- Emily Heil, PharmD, BCPS, AAHIVPThe Not-So-Sick Health-Care Associated Pneumonia Patient: New Treatment Strategy. ALiEM. November 26th, 2013 Retrieved from http://www.aliem.com/new-treatment-strategy-not-so-sick-health-care-associated-pneumonia/
- Uptodate.com
- Emedicine
- Tintinalli’s 7th ed.
The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.
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Jay Khadpe MD
Editor in Chief of "The Original Kings of County"
Assistant Professor of Emergency Medicine
Assistant Residency Director
SUNY Downstate / Kings County Hospital
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A chart would be a nice way to present all of this Grock. Here is a more current review:
N Engl J Med 2014;371:1619-28. DOI: 10.1056/NEJMra1312885
For uncomplicated CAP, ID specialists have been discouraging the use of azithromycin due to its unnecessarily broad coverage and overuse and development of pneumococcal resistance in some populations. One should strongly consider doxycycline.