Pulmonary / Critical Care Md Mansoura University

PULMONARY / CRITICAL CARE MD Mansoura University

Objectives Where to treat pneumonia? How we treat pneumonia? Challenges in treatment of pneumonia: Pneumonia in hepatic patient Pneumonia in renal patient Pneumonia In HF patients In pregnant

O.P.C Ward ICU

O.P.C Treatment

Fully conscious Hemodynamically stable Non cavitating or < lobar pneumonia Financially affordable

Hospital 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

Hospital Admission

CBC: Hb < 9gm

WBC < 4000 or > 30000

Neutrophil < 1000 ABGs: PaO2 < 60mmhg Creatinine > 2 mg (acute) Presence of co-morbidity or immunocompromization

ICU 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 Admission CBC: Hb < 9gm

WBC < 4000 or > 30000

Neutrophil < 1000 ABGs: PaO2 < 60 Creatinin > 2 mg (acute) Presence of co-morbidity Immunocompromization Immunocompromization

How We Treat? Aetiological treatment: Antibiotics. Biological ttt. Supportive treatment: Fluids. Inotropics. Oxygen. Mechanical ventilation.

Antibiotics in Pneumonia

Route of administration O.P.C Hospital

Oral or parentral Parentral

But to when?

Switch Therapy IV

Shift

Step-down

Oral

Sequential

Switch Therapy (Cont.) Timing: 3 – 4 days.

Candidate for switch: Intact GIT. Improving respiratory symptoms. Improving leukocytosis. Hemodynamically stable.

Value of switch

Interval of Administration Time dependent antibiotics: Frequent 3 & 4 times / day. Has No PAE e.g. pencillins.

Concentration dependent antibiotics: 2 or once / day has PAE & PALE e.g. quinolone – cefotriaxon

Antibiotic Selection Empirically why ? 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

Pneumonia with Shock Suspect: G–ve bacilli + pseudomonas

Antibiotic: 3rd cephalosporin and/or quinolones

Don’t forget to assay creatinine in this case

Pneumonia with history of aspiration Suspect: Polymicrobial

Antibiotic: Cover all the spectrum

Don’t forget antifungal in near drowning aspiration

O.P.C pneumonia Without co-morbidity Possible organism  Strep + atypical. Antibiotic: penicillin combination + Macrolide

With controlled morbidity Possible organism  DRSP Antibiotic  Antipneumococal quinolone

Cavitating Pneumonia Suspect: G–ve bacilli Staph Anaerobe Legionella Fungal (in immunocompromized)

Antibiotic: Cover all spectrum

Pneumonia Upper Lobar With Bowing Fissure Suspect: Klebseila

Antibiotic: 3rd cephalosporine + aminoglycoside

PCP

Bilateral Pneumonia Suspect: Atypical organism but don’t forget Viral & PCP in immunocompromized

Antibiotic: Macrolide is very important + ………

Challenges in Treatment

Renal 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

Penicillines 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.

Penicillines 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

Cephalosporin Excretion mainly renal. Safe in pregnancy. High dose or prolonged use  Hemorrhagic tendency.

Cephalosporin 1st generation: Active against +ve. It has no effect against H. influenza or morexlla

2nd generation: Extending spectrum to morxella and H. influenza

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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.

Cephalosporin Spectrum Gram +ve 1st 2nd 3rd 4th

Gram –ve

Monobactam Astronam – azactam Only active against g–ve Not avilable alone Renal excretion

Carbonemes Impinem / cilastatin (tinam) +ve & -ve & anaerobes Renal excretion Contraindicated in epilepsy

Meropenem (meronem): Less neurogenic effect Needs no cilastatin

Quinolones 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

Quinolones Drawbacks: Epileptogenic especially with theophyllin or steroids

Interaction: Ciprofloxacin increase theophyllin and warafarin level

Quinolones Levofloxacin: It is optical isomer of ofloxacin It has additional g+ve effect

Sparfloxacin: 400 mg loading then 200 mg/daily Photo-sensitivity

Quinolones 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:

Macrolides

Inhibit RNA dependent protein synthesis.

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

Excretion: Mainly hepatobiliary Clarithromycin: renal

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

Pregnancy: Erythromycin is safe.

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

Spectrum: G–ve Staph aureus

Excretion: Renal Interaction: It has neuromuscular blockade effect Furesmid & clindamycin increase nephrotoxicity

Pregnancy: better to be avoided

its

Anti-anaerobes

Metronidazol. Clindamycin. Excresion is hepatic

MRSA antibiotic

Vancomycin Ticoplanin Fucidic acid

New Antibiotics

Ketolid Linzolid Oxazolidinone

Non Antibiotic Treatment Vaccination as prophylaxis Monoclonal antibodies G-CSF & M-CSF Interferon gamma Neutrophil replacement therapy Antifungal – antiviral This trend mainly for immunocompromized patient

Mechanical Ventilation

Confusion Shock Fatigue

‫) ل يرجون عبدااإل ربه‪ ،‬وليخافن إل ذنبه‪ ،‬ول‬ ‫يستحى – إذا لم يعلم ‪ -‬أن يتعلم‪ ،‬ول يستحى إذا ‪-‬‬ ‫سئل عما ل يعلم – ان يقول ل أعلم‪ ،‬واعلموا أن‬ ‫الصبر من اليمان بمنزلة الرأس من الجسد‪،‬‬ ‫ولخير فى جسد ل رأس له (‬ ‫على ابن طالب‬