Download 11.02 Community Acquired Pneumonia

HKCEM College Tutorial
Communityacquired
Pneumonia
Author
Dr. Shek Kam Chuen
Oct 2013
History
▪ M/39
▪ Good past health
▪ Fever one day, 38.8oC
▪ Cough with yellowish sputum
▪ Right pleuritic chest pain
Any other important history?
▪ FTOCC
▪ Travel: Middle East, Avian flu
▪ Occupation: virus laboratory worker, poultry worker, work in wet
market
▪ Contact: Poultry contact or index case
▪ Cluster: any, ?Amoy Garden in 2003 March
Case one: CAP Out-patient Tx
▪ FTOCC –ve
▪ What is clinical diagnosis?
▪ CAP, clinically stable
▪ What antibiotics shall we give?
▪ What are the common pathogens
in HK?
What are possible pathogens?
▪Bacterial
▪Atypical
▪Viral
Community Acquired Pneumonia
▪ Local pathogens in order of commonest:
▪ Haemophilus influenzae (13.7%-60%)
▪ Streptococcus pneumoniae
Big 3
▪ Moraxella catarrhalis
▪ Chlamydia pneumoniae
▪ Legionella
▪ Mycoplasma
Atypical
▪ Not to forget TB (esp elderly) or viral agents
▪ Local A&E sputum culture (QEH & PMH) data suggests H. influenzae is much more
common than S. pneumoniae.
Subsequent treatment
Augmentin 1g BD 1/52
+Azithromycin 500mg daily for 3/7
Sputum CST + AFB CST saved
Follow up in 5/7
What are components of Augmentin?
▪ β-lactam/β-lactamase inhibitors
combinations
▪ Amoxicillin-clavulanate
▪ 1. Augmentin 375mg tds
=(amoxil250 + clavulanate125)x3
=amoxil750 + clavunanate375/D
(Augmentin)
▪
▪
▪
▪
▪
MSSA,
S. pneumoniae,
H. influenzae,
M. catarrhalis,
some E-coli, anaerobes
▪ 2. Augmentin 375+ amoxil250 tid
=amoxil1500 +clavunanate 375 /D
▪ 3. Augmentin 1 gm bd
=(amoxil 875+caluvulanate 125)x2
=amoxil1750+calvunanate250/D
Why Azithromycin added?
▪ Macrolides are good at CAP atypical agents and
campylobacter(GE).
▪ Newer macrolides (clarithromycin, azithromycin) have a better
coverage of H. influenzae. But there are wide spread resistance
among the common Gram-positive bacteria including MSSA,
Pneumococcus, Group A Streptococcus.
▪ not be used as single empirical treatment of CAP and soft tissue
infections to substitute penicillin in penicillin-allergy patients
At Follow-Up, Afebrile for 3 days, Feel better but still cough, CXR:
more or less the same
Sputum grew:
 Streptococcus Pneumoniae
▪Levofloxacin: S
▪Penicillin (CNS): R
▪Penicillin (non CNS): S
▪Vancomycin : S
What is subsequent MX?
A. levofloxacin 500mg daily x 7 days
B. iv vancomycin
C. Change Klacid 500mg BD 1/52
D. Continue high dose Augmentin
E. Consult microbiologist whether the S. Pneumoniae is S to
Augmentin
Ans D
First line Antibiotics for CAP
▪ Higher dose Augmentin or Unasyn
in view of drug resistant S. Pneumoniae
DRSP infection
Augmentin 1gm BD or
(Augmentin 375mg tds + amoxycillin 250mg tds)
+
Azithromycin(Zithromax)
is preferred in view of no major drug interaction 9
Clarithromycin (Klacid) is P-450 cytochrome inhibitor with multiple drug interactions
What is the role Fluoroquinolones?
▪ Fluoroquinolone inhibit DNA gyrase and useful in G+ve and G-ve
bacteria. But the resistance is increasing.
▪ Not for 1st line for CAP in HK
▪ Which quinolones?
▪ Levofloxacin is more potent than ciproxin against S. Pneumoniae
Fluoroquinolones are used as second line for
CAP
▪ for adults when the first line regime is failed
▪ Allergic to alternative agents
▪ Documented infection due to pneumococci with high level
penicillin resistance (Penicillin MIC >=4UG /mL.)
▪ (it is not used as first line since it
resistance in future.)
may mask TB and may cause drug
▪ levofloxacin 750mg QD for 5/7
Impact
because it is concentration dependent.
CID 2007;44 (Suppl 2) S27-S72
Thank You