Empiric Treatment: Pneumonia

1. Empiric Treatment: Pneumonia

2. Overview of Pneumonia • http://www.virtualrespiratorycentre.com/diseases.asp?did=38 • Link • Link • Link • Link • LINK

3. What is pneumonia? • Pneumonia is an inflammatory illness of the lung.

4. 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.

6. 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.

8. Pneumonia • The alveoli are tiny air sacs within the lungs where the exchange of oxygen and carbon dioxide takes place.

9. 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.

10. Symptoms of Pneumonia • Fever • Chills • Cough • Pleurisy: inflamed membranes around the lungs • Dyspnea: Difficult or labored breathing; shortness of breath

11. 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.

12. 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.

14. Two Types of Pneumonia • Community-Acquired Pneumonia (CAP): individual residing in their homes • Hospital-Acquired Pneumonia (HAP): individuals residing in hospitals

15. 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

16. CAP: typical Streptococcus pneumoniae Gram + Usually susceptible to penicillin

17. Streptococcus pneumoniae

18. Treatment of Streptococcus pneumoniae • Penicillin G (high doses) • Aminopenicillins: Ampicillin (high doses) Ampicillin

19. Treatment of Penicillin-resistant Streptococcus pneumoniae • Second Generation Cephalosoporins: Cefuroxime • Third Generation Cephalosporins: Cefotaxime, Ceftriaxone • Quinolones: Moxifloxacin, Levofloxacin • Vancomycin • Macrolides/ketolines: Telithromycin

20. Haemophilus influenzae

21. Haemophilus influenzae • 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. • 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.

22. Haemophilus influenzae

23. Haemophilus influenzae

24. Treatment of Infections Caused by Haemophilus influenzae • Aminopenicillins + b-lactamase inhibitor: • Amoxicillin/clavulanate • Ampicillin/sulbactam • Second-generation cephalosporin • Cefuroxime • Third-generation cephalosporin • Ceftriaxone • Cefotaxime

25. 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%

26. Treatment of CAP

27. Treatment of CAP • Mild • Macrolide (azithromycin, clarithromycin) • Macrolide + -lactam • Doxycycline • Quinolone (moxifloxacin, levofloxacin, gemifloxacin) • Severe • -lactam + macrolide • -lactam + quinolone

28. Treatment of CAP • Severe • -lactam + macrolide • -lactam + quinolone

29. 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

30. Bacterial Causes ofEarly Onset HAP • Methicillin-sensitive Staphylococcus aureus 29-35% • Haemophilus influenzae 23-33% • Enterobacteriaceae 5-25% • Streptococcus pneumoniae 7-23%

31. Bacterial Causes of Late Onset HAP • Pseudomonas aeruginosa 39-64% • Acinetobacter spp. 6-26% • Enterobacteriaceae 16-31% • Methicillin-resistant S. aureus 0-2%

32. Treatment of Early Onset HAP Ceftriaxone = 3rd gen. cephalosporin

33. Treatment of Early Onset HAP • Ceftriaxone • Quinolone (Levofloxacin, Moxiflocacin, Ciprofloxacin) • Ampicillin/sulbactam • Ertapenem

34. Treatment of Late Onset HAP

35. Treatment of Late Onset HAP Use a combination regimen from the first and second categories below: • Antipseudomonal cephalosporin: ceftazidime, cefepime • Or Carbapenem: Imipenem, Meropenem • Or Extended spectrum penicillin/-lactamase inhibitor: piperacillin/tazobactam ++++ • Quinolone (ciprofloxacin, levofloxacin) • Or Aminoglycoside (gentamicin, tobramycin, amikacin) • If MRSA is suspected, add: Vancomycin or Linezolid

36. Urinary Tract Infections • http://www.virtualrenalcentre.com/diseases.asp?did=281

37. Urinary System

39. Mild and Severe UTI’s • Mild • Involve only the urethra and bladder • Referred to as “acute cystitis” • Symptoms include • dysuria (painful urination) • urinary frequency • hematuria (blood in urine)

40. Severe UTI’s • 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”

41. ‘Complicated’ and ‘Uncomplicated’ UTI’s • Uncomplicated: Less likely to recur. Occur in young, healthy, nonpregnant women • Complicated: All other UTI’s. More likely to recur.

42. Bacterial Causes of Uncomplicated UTI’s • Escherichia coli 53-79% • Proteus mirabilis 4-5% • Staphylococcus saprophyticus 3% • Klebsiella spp. 2-3% • Other Enterobacteriaceae 3%

43. Treatment of Uncomplicated Acute Cystitis

44. Treatment of Uncomplicated Acute Cystitis • Oral trimethoprim-sulfamethoxazole • Oral quinolones (ciprofloxacin, levofloxacin)

45. Treatment of Uncomplicated Acute Pyelonephritis Amoxicillin, an aminopenicillin Gentamycin, an aminoglycoside

46. Treatment of Uncomplicated Acute Pyelonephritis • Quinolones: Ciprofloxacin, levofloxacin • Third generation cephalosporins: Ceftriaxone, cefotaxime, ceftizoxime • If Gram positive organisms seen in urine: • Aminopenicillin (amoxicillin) • Aminopenicillin + -lactamase inhibitor: (amoxicillin + clavulanate) • Aminopenicillin + aminoglycoside (ampicillin + gentamicin)

47. Treatment of Complicated Urinary Tract Infections

48. Treatment of Complicated Urinary Tract Infections • Fourth generation cephalosporins (cefepime) • Quinolones: Ciprofloxacin, Levofloxacin • If Gram-positive bacteria seen in urine: • Aminopenicillin + aminoglycoside: Ampicillin + gentamicin

49. Pelvic Inflammatory Disease • Link

50. Female Reproductive Organs