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Pharmacology of Pneumonia


Principles of Antibiotic Therapy for Hospital-Acquired Pneumonia

Prompt empiric therapy: Initiate when there is clinical suspicion of infection
Obtain a lower respiratory tract culture (sputum, tracheal aspirate, protected brush, BAL) prior to
initiation of antibiotic
therapy. Samples can be obtained bronchoscopically or nonbronchoscopically, culured quantitatively
Use a narrow spectrum agent for patients only at risk for infection with core pathogens, and with
no risk factors for MDR
Options include: ceftriaxone, ampicillin/sulbactam, ertapenem, levofloxacin, or moxifloxacin. For
penicillin allergiy, use a
quinolone or the combination of clindamycin and aztreonam.
Use combination therapy with a broad spectrum regimen, containing at least two antimicrobials in
patients with risk factors
for MDR pathogens. Specific choices should be guided by a knowledge of local microbiology patterns.
Use an aminoglycoside or an antipneumococcal quinolone (ciprofloxacin or high dose levofloxacin),
anti-Pseudomonal -lactam such as: cefepime, ceftazidime, imipenem, meropenem or piperacillintazobactam. If there
is concern about MRSA, add either linezolid or vancomycin
Use the correct therapy in recommended doses (see text).

Choose an empiric therapy that uses agents from a different class of

antibiotics than the patient has received in the past 2
Try to de-escalate to monotherapy after initial combination therapy, after
reviewing culture data and clinical response.
If Pseudomonas aeruginosa, consider stopping the aminoglycoside after 5
days and finish with a single agent to which the
organism is sensitive.
If a non-Pseudomonal infection, switch to a single agent that the organism is
sensitive to, using: imipenem, meropenem,
cefepime, piperacillin/tazobactam, ciprofloxacin, or high-dose levofloxacin.
The drug of choice for Acinetobacter is a carbapenem, but colistin should be
oonsidered if there is carbapenem resistance.
Consider linezolid as an alternative to vancomycin in patients with proven
MRSA VAP, those with renal insufficiency, and
those receiving other nephrotoxic medications (e.g., an aminoglycoside).
Consider adjunctive aerosolized aminoglycosides in patients with highly
resistant gram-negative pathogens

Initial Empiric Antimicrobial Therapy for CAP

Previously healthy
No recent antibiotic therapy: a macrolide, doxycycline telithromycin now known to
cause hepatic necrosis.
Recent antibiotic therapy (within past 3 months). In general choose from a class of
agents that the patient has not
received within the past 3 months: a respiratory fluoroquinolone alone, an advanced
macrolide (clarithromycin or
azithromycin) plus high-dose amoxicillin, an advanced macrolide plus amoxicillinclavulanate.
Co-morbidities such as congestive heart failure, chronic obstructive pulmonary
disease, diabetes, or malignancy
No recent antibiotic therapy: an advanced macrolide or respiratory fluoroquinolone
Recent antibiotic therapy: Choose from a class of agents that the patient has not
received within the past 3 months.
Suspected aspiration with infection: amoxicillin-calvulanate or clindamycin
Influenza with bacterial superinfection: a vancomycin or linezolid or respiratory

No recent antibiotic therapy: a respiratory fluoroquinolone, or an advanced macrolide plus beta lactam,
ceftriaxone ampicillin ertapenem for selected patients.
Recent antibiotic therapy: An advanced macrolide plus a beta lactam, or respiratory fluoroquinolone alone. (The
regimen selected depends on the nature of the recent antibiotic therapy. Choose from a class of agents that the
has not received within the past 3 months.
Pseudomonas infection is not an issue: a beta lactam plus an advanced macrolide or respiratory fluoroquinolone
Pseudomonas infection is not an issue but patient has a beta lactam allergy: a respiratory fluoroquinolone with or
without clindamycin
Pseudomonas infection is an issue: an antipseudomonal agent plus ciprofloxacin or antispseudomonal agent plus
aminoglycoside plus respiratory fluoroquinolone or macrolide
Pseudomonas infection is an issue and patient has a beta lactam allergy: aztreonam plus levofloxacin or
aztreonam plus
moxifloxacin or gatifloxacin with or without aminoglycoside
Nursing home
Treatment in the nursing home: a respiratory fluoroquinolone or advanced macrolide plus amoxicillin-clavulanate
Hospitalized: same as ward or intensive care unit

ConsiderationsWhen Pneumonia Fails to

Resolve orWorsens During Therapy
Reconsider the pneumonia diagnosis: Could this be
pulmonary infarction, malignancy, vasculitis, drug
reaction, or eosinophilic pneumonia?
Reconsider the etiologic diagnosis: Are you treating the
appropriate microorganism(s)?
Remember that 10% of cases of community-acquired
pneumonia are polymicrobial.
Tuberculosis can mimic pyogenic pneumonia. Also
consider unusual organisms such as Actinomyces or
Nocardia species.
Are you dealing with a resistant microorganism?
Streptococcus pneumoniae resistant to penicillin,
erythromycin, and tetracycline is common in several
European countries and the United States.

Has your patient developed nosocomial pneumonia?

Such an event is common, particularly in patients who
require endotracheal intubation and assisted
ventilation. Is your hospitals potable water supply
contaminated by Legionella spp.? If so, consider
nosocomial Legionnaires disease. Nosocomial
legionnaires disease should be a consideration anytime
a patient with CAP is improving and develops
nosocomial pneumonia.
Could this be postobstructive pneumonia (i.e., is
endobronchial obstruction present)?
Have you considered empyema? Pus in the pleural space
will continue to cause fever until it is drained.
Has metastatic infection occurred? Occasionally, patients
who are bacteremic as a result of their pneumonia
develop endocarditis, meningitis, septic arthritis, or a
deep abscess such as splenic or renal abscess.
Always consider drug fever.