pulmonary / critical care md mansoura university
TRANSCRIPT
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
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