Empiric Treatment: Pneumonia - PowerPoint PPT Presentation

About This Presentation
Title:

Empiric Treatment: Pneumonia

Description:

Empiric Treatment: Pneumonia Overview of Pneumonia http://www.virtualrespiratorycentre.com/diseases.asp?did=38 Link Link Link Link What is pneumonia? – PowerPoint PPT presentation

Number of Views:281
Avg rating:3.0/5.0
Slides: 110
Provided by: facultySm
Learn more at: https://s2.smu.edu
Category:

less

Transcript and Presenter's Notes

Title: Empiric Treatment: Pneumonia


1
Empiric Treatment Pneumonia
2
Overview of Pneumonia
  • http//www.virtualrespiratorycentre.com/diseases.a
    sp?did38
  • Link
  • Link
  • Link
  • Link

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

4
(No Transcript)
5
(No Transcript)
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.

7
(No Transcript)
8
Pneumonia
  • The alveoli are tiny air sacs within the lungs
    where the exchange of oxygen and carbon dioxide
    takes place.

9
Bronchiole
  • 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.

13
(No Transcript)
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
Ampicillin
  • Penicillin G (high doses)
  • Aminopenicillins Ampicillin (high doses)

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
38
(No Transcript)
39
Mild and Severe UTIs
  • Mild
  • Involve only the urethra and bladder
  • Referred to as acute cystitis
  • Symptoms include
  • dysuria (painful urination)
  • urinary frequency
  • hematuria (blood in urine)

40
Mild and Severe UTIs
  • 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 UTIs
  • Uncomplicated occur in young, healthy,
    nonpregnant women
  • Complicated All other UTIs

42
Bacterial Causes of Uncomplicated UTIs
  • 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
  • http//www.virtualendocrinecentre.com/diseases.asp
    ?did791

50
Female Reproductive Organs
51
PID is the general term for an infection that has
traveled through the vagina, to the uterus, and
then to other parts of the pelvis
52
(No Transcript)
53
Symptoms of PID
  • Abnormal bleeding
  • Dyspareunia (pain during sexual intercourse)
  • Vaginal discharge
  • Lower abdominal pain
  • Fever
  • chills

54
Bacterial Causes of PID
  • Neisseria gonorrhoeae 27-56
  • Chlamydia trachomatis 22-31
  • Anaerobic and facultative bacteria (Bacteria that
    can live under aerobic or anaerobic
    conditions) 20-78

55
Treatment of PID
56
Treatment of PID
  • Mild to Moderate Disease
  • Oral quinolone Levofloxacin, ofloxacin
  • oral metronidazole
  • Single IM dose of cephalosporin
  • oral doxycycline
  • oral metronidazole

57
Treatment of PID
Those that are severely ill should be admitted to
the hospital and treated initially with
intravenous agents.
  • Severe Disease (regimen 1)
  • Cephalosporin with anaerobic activity (cefotetan,
    cefoxitin)
  • doxycycline (active against atypical C.
    trachomatis)
  • Severe Disease (regimen 2)
  • Clindamycin (active against C. trachomatis and
    against many anaerobes)
  • Gentamicin (effective against Gram-negative N.
    gonorrhoeae)

58
Meningitis
  • Link
  • Link
  • Link

59
Meningitis
  • Meningitis is the inflammation of the protective
    membranes covering the central nervous system,
    known collectively as the meninges. Meningitis
    may develop in response to a number of causes,
    most prominently bacteria, viruses and other
    infectious agents, but also physical injury,
    cancer, or certain drugs.

60
  • Meninges the membranes that envelope the
    brain and the spinal cord.

61
(No Transcript)
62
Symptoms of Meningitis
  • Headache
  • Fever
  • Neck stiffness
  • Altered mental status
  • Photophobia
  • Nausea
  • Vomiting
  • Seizures

63
Diagnosis of Meningitis
  • The most important test used to diagnose
    meningitis is the lumbar puncture (commonly
    called a spinal tap). Lumbar puncture (LP)
    involves the insertion of a thin needle into a
    space between the vertebrae in the lower back and
    the withdrawal of a small amount of CSF.

64
Lumbar puncture
  • http//antbits.net/first_consult/lumbar_puncture.s
    wf?random0.8897603
  • http//www.virtualcancercentre.com/investigations.
    asp?sid13

65
Diagnosis of Meningitis
  • The CSF is then examined under a microscope to
    look for bacteria or fungi. Normal CSF contains
    set percentages of glucose and protein. These
    percentages will vary with bacterial, viral, or
    other causes of meningitis. For example,
    bacterial meningitis causes a greatly lower than
    normal percentage of glucose to be present in
    CSF, as the bacteria are essentially "eating" the
    host's glucose, and using it for their own
    nutrition and energy production.

66
Diagnosis of Meningitis
  • Normal CSF should contain no infection-fighting
    cells (white blood cells), so the presence of
    white blood cells in CSF is another indication of
    meningitis. Some of the withdrawn CSF is also put
    into special lab dishes to allow growth of the
    infecting organism, which can then be identified
    more easily. Special immunologic and serologic
    tests may also be used to help identify the
    infectious agent.

67
Bacterial Causes of Acute Bacterial Meningitis
  • 0 - 3 months
  • Streptococcus agalactiae
  • Escherichia coli
  • Listeria monocytogenes

68
Bacterial Causes of Acute Bacterial Meningitis
  • 3 month - 6 yrs
  • Neisseria meningitidis
  • Streptococcus pneumoniae
  • Haemophilus influenzae

69
Bacterial Causes of Acute Bacterial Meningitis
  • 16 yrs - 50 yrs
  • Streptococcus pneumoniae
  • Neisseria meningitidis

70
Bacterial Causes of Acute Bacterial Meningitis
  • gt 50 yrs
  • Streptococcus pneumoniae
  • Listeria monocytogenes
  • Aerobic Gram-negative bacilli

71
Treatment of Bacterial Meningitis
72
Treatment of Bacterial Meningitis
  • Third-generation cephalosporins cefotaxime,
    ceftriaxone
  • Vancomycin (coverage against resistant
    Streptococcus pneumoniae)
  • If patient lt 3 months or gt 50 years
  • Same as above, but also
  • Add ampicillin to provide coverage of L.
    monocytogenes and S. agalactiae.

73
Cellulitis
Cellulitis is an inflammation of the connective
tissue underlying the skin, that can be caused by
a bacterial infection.
74
Cellulitis
75
Bacterial Causes of Cellulitis
  • Staphylococcus aureus 13-37
  • Streptococcus pyogenes 4-17
  • Other streptococci 1-18

76
Treatment of Cellulitis
77
Treatment of Cellulitis
  • Mild Disease (oral formulations)
  • Antistaphylococcal penicillins (Dicloxacillin)
  • First Generation Cephalosporins (Cephalexin,
    Cefadroxil)
  • Clindamycin
  • Macrolides (Erythromycin, azithromycin,
    clarithromycin)

78
Treatment of Cellulitis
  • Severe Disease (intravenous formulations)
  • Antistaphylococcal penicillins (Nafcillin,
    oxacillin)
  • First-generation cephalosporins (cefazolin)
  • Clindamycin

79
Treatment of Cellulitis
  • If MRSA is suspected
  • Vancomycin
  • Linezolid
  • Daptomycin
  • Tetracyclines (Tigecycline, doxycycline)
  • Sulfa drugs (Trimethoprim-sulfamethoxazole)
  • Clindamycin

80
Otitis Media
  • http//www.virtualrespiratorycentre.com/diseases.a
    sp?did879

81
Symptoms of Otitis Media
  • Otalgia (ear pain)
  • Hearing Loss
  • Irritability
  • Anorexia
  • Apathy
  • Fever
  • Swelling around the ear
  • Otorrhea (discharge from the affected ear)

82
Bacterial Causes of Acute Otitis Media
  • Streptococcus pneumoniae 25-50
  • Haemophilus influenzae 15-30
  • Moraxella catarrhalis 3-20

83
Treatment of Acute Otitis Media
84
Treatment of Acute Otitis Media
  • First Line Therapy
  • High Dose Amoxicillin
  • If Mild Allergy to Penicillin
  • Cefdinir, Cefpodoxime, Cefuroxime axetil
  • If Type 1 Hypersensitivity Allergic Reaction
  • Macrolide (Azithromycin, Clarithromycin,
    Erythromycin with sulfisoxazole)

85
Sulfmethoxazole Used in combination with
Trimethoprim (co-trimoxazole)
Sulfisoxazole Used in combination with
Erythromycin
86
Infective Endocarditis
87
(No Transcript)
88
(No Transcript)
89
Causes of Endocarditis
  • There are many ways that bacteria can enter the
    bloodstream and cause endocarditis. Even a small
    cut can enable bacteria that normally live on the
    skin to enter the bloodstream. In some cases,
    this occurs during a dental or surgical
    procedure. In many cases, however, it is not
    clear how the bacteria first got into the
    bloodstream.

90
Symptoms of Endocarditis
  • Symptoms are non-specific, making endocarditis
    difficult to diagnose
  • Fatigue
  • Malaise
  • Weakness
  • Weight loss
  • Fever
  • Chills
  • Dyspnea on exertion (shortness of breath)

91
Bacterial Causes of Endocarditis
  • Viridans group streptococci 18-48
  • Staphylococcus aureus 22-32
  • Enterococci 7-11
  • Coagulase-negative staphylococci 7-11
  • HACEK organisms 2-7

92
Viridans Group streptococci
  • Viridans streptococcus are alpha-hemolytic,
    normal flora of the oral, respiratory tract, and
    GI mucosa. They are the major cause of bacterial
    endocarditis in people with damaged heart valves.
    They may enter the blood stream after dental
    procedures.

93
HACEK Organisms
  • A HACEK organism is one of a set of slow-growing
    Gram negative bacteria that form a normal part of
    the human flora. They are a frequent cause of
    endocarditis in children.
  • The name is formed from their initials
  • Haemophilus aphrophilus, Haemophilus
    parainfluenzae and Haemophilus paraphrophilus
  • Actinobacillus actinomycetemcomitans
  • Cardiobacterium hominis
  • Eikenella corrodens
  • Kingella kingae

94
Empiric Therapy for Infective Endocarditis
  • Vancomycin Gentamicin
  • Vancomycin is effective against S. aureus and
    viridans group streptococci
  • When used in combination with Gentamicin,
    activity is extended to the majority of
    enterococcal strains
  • Even intensive therapy may not be sufficient, and
    surgical intervention is often required
  • Despite intensive antibiotic therapy, mortality
    remains high 20-25.

95
Prosthetic Valve Endocarditis
  • Many cases of endocarditis are associated with
    prosthetic valves in the heart
  • Sometimes these infections occur within two
    months after the valve is installed and are thus
    thought to be hospital acquired
  • Sometimes they occur 6-20 month after surgery and
    are thus thought to be community acquired

96
Treatment of Prosthetic Valve Endocarditis
  • Vancomycin Gentamicin Rifampin
  • With or without cefepime or ceftriaxone

97
Intravascular-Related Catheter Infections
  • http//www.skinisthesource.org/

98
  • 200,000 catheter-related infections occur each
    year in the U.S.
  • Should be suspected in anyone with an
    intravascular catheter and a fever of unclear
    etiology.
  • Diagnosis may involve
  • Removal and culture of the catheter
  • Growth of bacteria from blood cultures

99
What type of bacteria cause catheter-related
infections?
  • Skin flora, including
  • Staphylococcus epidermidis 32-41
  • Staphylococcus aureus 5-14
  • Enteric Gram-negative bacilli 5-11
  • Psuedomonas aeruginosa 4-7

100
Treatment of Intravascular Catheter-related
Infections
101
Treatment of Catheter Related Infections
  • Hospital setting where MRSA is uncommon
  • Antistaphylocccal penicillin Nafcillin,
    Oxacillin
  • Hospital setting where MRSA is common
  • Vancomycin
  • Immunocompromised or severely ill patient
  • Add cephalosporin to initial antibiotic regimen
  • Ceftazidime, cefepime

102
Intra-Abdominal Infections
103
Causes of Intra-abdominal infections
  • Usually caused by contamination of the usually
    sterile abdomen with microbial flora of the bowel
  • Can be quite severe, leading to sepsis and death

104
Bacterial Causes of Intra-abdominal Infections
  • Gram-negative bacilli
  • Escherichia coli 32-61
  • Enterobacter spp. 8-26
  • Klebsiella spp. 6-26
  • Proteus spp. 4-23

105
Bacterial Causes of Intra-abdominal Infections
  • Gram-positive cocci
  • Enterococci 18-24
  • Streptococci 6-55
  • Staphylococci 6-16

106
Bacterial Causes of Intra-abdominal Infections
  • Anaerobic bacteria
  • Bacteroides spp.
  • Clostridium spp.

107
Treatment of Intra-abdominal Infections
  • Due to their polymicrobial nature, the antibiotic
    regimen must be very broad spectrum, including
    Gram-negative bacilli, Gram-positive cocci, and
    anaerobic bacteria

108
Treatment of Intra-Abdominal Infections
  • B-Lactam/b-lactamase inhibitor combinations
    (piperacillin/tazobactam)
  • Carbapenems (imipenem, meropenem)
  • Aminoglycoside (gentamicin, tobramycin, amikacin)
  • metronidazole
  • Ciprofloxacin metronidazole

109
Treatment of Intra-abdominal Infections
Write a Comment
User Comments (0)
About PowerShow.com