Pulmonary / Critical Care Md Mansoura University

PULMONARY / CRITICAL CARE MDPULMONARY / CRITICAL CARE MD

Mansoura UniversityMansoura University

Where to treat pneumonia?Where to treat pneumonia?

How we treat pneumonia?How we treat pneumonia?

Challenges in treatment of pneumonia:Challenges in treatment of pneumonia:

Pneumonia in hepatic patientPneumonia in hepatic patient

Pneumonia in renal patientPneumonia in renal patient

Pneumonia In HF patientsPneumonia In HF patients

In pregnantIn pregnant

Objectives

O . P . CO . P . C

WardWard

I C UI C U

Fully conscious

Hemodynamically stable

Non cavitating or < lobar pneumonia

Financially affordable

O.P.C TreatmentO.P.C Treatment

Disturbed level of consciousness

RR > 30 & HR > 130

Temp < 35 or > 40

BP: Systole < 90 & Diastole < 60

CXR: Bilateral – Cavitating – Doubling

within 48 h – Associated effusion

Hospital AdmissionHospital Admission

CBC: Hb < 9gm WBC < 4000 or > 30000

Neutrophil < 1000

ABGs: PaO2 < 60mmhg

Creatinine > 2 mg (acute)

Presence of co-morbidity or immunocompromization

Hospital AdmissionHospital Admission

Disturbed level of consciousness

RR > 30 & HR > 130

Temp < 35 or > 40

BP systole < 90 & diastole < 60

CXR: Bilateral – Cavitating – Doubling

within 48 h – Associated effusion

ICU AdmissionICU Admission

Disturbed level of consciousness

BP systole < 90 & diastole < 60

CBC: Hb < 9gm WBC < 4000 or >

30000

Neutrophil < 1000

ABGs: PaO2 < 60

Creatinin > 2 mg (acute)

Presence of co-morbidity

Immunocompromization

ICU AdmissionICU Admission

Presence of co-morbidity

Immunocompromization

Aetiological treatment:

Antibiotics.

Biological ttt.

How We Treat?How We Treat?

Supportive treatment:

Fluids.

Inotropics.

Oxygen.

Mechanical ventilation.

Route of administration

Antibiotics in PneumoniaAntibiotics in Pneumonia

But to when?

O.P.CO.P.C Oral or parentralOral or parentral

HospitalHospital ParentralParentral

Switch TherapySwitch Therapy

Step-downStep-down

IVIV OralOralShiftShift

SequentialSequential

Timing: 3 – 4 days.

Switch Therapy Switch Therapy (Cont.)(Cont.)

Candidate for switch:Intact GIT.

Improving respiratory symptoms.

Improving leukocytosis.

Hemodynamically stable.

Value of switch

Time dependent antibiotics:

Frequent 3 & 4 times / day.

Has No PAE

e.g. pencillins.

Interval of AdministrationInterval of Administration

Concentration dependent antibiotics:

2 or once / day

has PAE & PALE

e.g. quinolone – cefotriaxon

Empirically why ?

Antibiotic SelectionAntibiotic Selection

Because according to role of 40:

40% can’t expectorate.

40% received antibiotic prior to

hospitalization or consultation.

40% does not diagnosed bacteriologically.

40% of infections are polymicrobial.

Antibiotic characteristics:

Pharmacodynamic & Pharmacokinetics

& Spectrum of antibiotic

Possible offending organism:

Based on clinical and radiological data

Patient status:

Co-morbidity and Severity of illness

Suspect:

G–ve bacilli + pseudomonas

Antibiotic:

3rd cephalosporin and/or

quinolones

Don’t forget to assay creatinine

in this case

Pneumonia with Shock

Pneumonia with history of aspiration

Suspect:

Polymicrobial

Antibiotic:

Cover all the spectrum

Don’t forget antifungal in near

drowning aspiration

O.P.C pneumoniaWithout co-morbidity

Possible organism Strep + atypical.

Antibiotic: penicillin combination +

Macrolide

With controlled morbidityPossible organism DRSP

Antibiotic Antipneumococal quinolone

Suspect:

G–ve bacilli

Staph

Anaerobe

Legionella

Fungal (in immunocompromized)

Antibiotic:

Cover all spectrum

Cavitating Pneumonia

Suspect:

Klebseila

Antibiotic:

3rd cephalosporine + aminoglycoside

Pneumonia Upper Lobar With Bowing Fissure

PCPPCP

Suspect:

Atypical organism but don’t forget

Viral & PCP in immunocompromized

Antibiotic:

Macrolide is very important + ………

Bilateral Pneumonia

Challenges in TreatmentChallenges in Treatment

Renal patientRenal patient

Not under dialysis

Reduce dose & increase interval

Cefoperazon is safe

Cefotriaxon may be used

Under dialysis

Give usual drugs but in the day of dialysis

give the antibiotic after the session

Pneumonia in pregnancy:

Avoid:

Quinolones.

Metronidazol.

But:

Penicillins & Cephalosporin & Erythromycn

& Clindamycin are safe

Pneumonia in Hepatic:

Avoid:

Cefoperazon

Macrolide except clarithromycin

metronidazol

But:

In both hepatic and renal diseases dose

modification

Action: interfer with bacterial cell wall, so it is not active against bacteria that loss cell wall as atypical organisms.

Safe during pregnancy.

Excretion: mainly renal.

Draw backs:Leucopenia – Thrombocytopenia – rash

Amoxicillin + clavulenic or ampicillin sulbactam extending the spectrum into –ve & some anaerobes.

PenicillinesPenicillines

PenicillinesPenicillines

Anti staph Penicillins :Cloxacillin – flucoloxacillin - methicillin

Anti pseudomonas Penicillins:Carboxypencillin – ticarcillin (Na Load)

Ureidopenicillin – pipracillin

Also these group has antianaerobic, so it is valuable in mixed aspiration pneumonia

Pipracillin + tazobactam = Tazocin is a good combination

Dose 4.5 gm/6h

Excretion mainly renal.

Safe in pregnancy.

High dose or prolonged use

Hemorrhagic tendency.

CephalosporinCephalosporin

1st generation:

Active against +ve.

It has no effect against H. influenza

or morexlla

2nd generation:

Extending spectrum to cover

morxella and H. influenza

CephalosporinCephalosporin

3rd generation:Mainly for g–ve enteric bacilli

Defective anti g+ve

Cefotriaxon:

Prolonged action

No dose modification unless both hepatic and renal are coexist

Cefoperazon:

Excretion Is mainly hepatic

Cefpodixim (oral 3rd generation):

Loss its g+ve efficacy as a price for improving g–ve

Can be used in sequential therapy

4th generation (cefepim):Active against g+ve and g–ve

Can be used as monotherapy

Antipseudomonal

cephalosporin:Ceftazidim.

Cefepim.

Gram +veGram –ve

1st

2nd

3rd

4th

Cephalosporin SpectrumCephalosporin Spectrum

Astronam – azactam

Only active against g–ve

Not avilable alone

Renal excretion

MonobactamMonobactam

Impinem / cilastatin (tinam)

+ve & -ve & anaerobes

Renal excretion

Contraindicated in epilepsy

Meropenem (meronem):

Less neurogenic effect

Needs no cilastatin

CarbonemesCarbonemes

QuinolonesQuinolones

Action:Inhibit DNA gyrase therby inhibition DNA synthesis

Spectrum:G–ve mainly

No anti-anaerobe effect

Anti-atypical effect is less than macroleds

Some have antistrept

Should not be given for children & pregnant & lactating

QuinolonesQuinolones

Drawbacks:

Epileptogenic especially with

theophyllin or steroids

Interaction:

Ciprofloxacin increase theophyllin

and warafarin level

QuinolonesQuinolones

Levofloxacin:

It is optical isomer of ofloxacin

It has additional g+ve effect

Sparfloxacin:

400 mg loading then 200 mg/daily

Photo-sensitivity

QuinolonesQuinolones

Moxifloxacin:

It covers atypical organisms

Beside its potent G–ve effect .

Only 20% is renal excretion, so no renal

modification

400 mg daily

N.B: Ciprofloxacin is the only quinolone

that has antipseudomonal effect

Action: Inhibit RNA dependent protein synthesis.

Spectrum: Strept & staph g+veG–ve (except pseudomonas)Atypical organism

Excretion: Mainly hepatobiliary Clarithromycin: renal

Interaction:Food & antiacid decrease its absorptionIncrease serum level of theophyllin – digoxin – warfarin

Pregnancy: Erythromycin is safe.

MacrolidesMacrolides

Action: Inhibit microbial protein synthesis by binding to RNA subunit.

Spectrum: G–veStaph aureus

Excretion:Renal

Interaction:It has neuromuscular blockade effectFuresmid & clindamycin increase its nephrotoxicity

Pregnancy: better to be avoided

AminoglycosiedAminoglycosied

Anti-anaerobesAnti-anaerobes

Metronidazol.

Clindamycin.

Excresion is hepatic

MRSA antibioticMRSA antibiotic

Vancomycin

Ticoplanin

Fucidic acid

New AntibioticsNew Antibiotics

Ketolid

Linzolid

Oxazolidinone

Non Antibiotic TreatmentNon Antibiotic Treatment

Vaccination as prophylaxis

Monoclonal antibodies

G-CSF & M-CSF

Interferon gamma

Neutrophil replacement therapy

Antifungal – antiviral

This trend mainly for immunocompromized patient

Confusion

Shock

Fatigue

Mechanical VentilationMechanical Ventilation

عبد) يرجون إال ااال واليخافن ربه، إالأن – - يعلم لم إذا يستحى وال ذنبه،ال - عما سئل إذا يستحى وال يتعلم،

أن – واعلموا أعلم، ال يقول ان يعلمالرأسمن بمنزلة االيمان من الصبر

رأسله ( ال فىجسد والخير الجسد،

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