The document discusses community acquired pneumonia (CAP), including common pathogens, goals of therapy, investigations, severity assessment tools like CURB-65, and treatment recommendations. It provides treatment guidelines for CAP that can be treated as an outpatient or requires hospitalization, including antibiotic options and dosing. Empiric treatment recommendations are provided for both adults and children with CAP. Prevention measures like smoking cessation, vaccines and proper swallowing technique are also mentioned.

1. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Pneumonia
Anas Bahnassi PhD
Pharmacotherapy of Infectious Diseases
Anas Bahnassi 2014
A Case-Based Approach

2. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Introduction
•Community Acquired Pneumonia (CAP)
–Common and serious disease.
–80% of cases can be treated at home.
–Mortality rate for patients requiring hospitalization is 8-10%, and can increase to 40% to those requiring ICU.
–Clinical presentation of CAP does not allow for and etiological diagnosis.
–Many organisms can be
Anas Bahnassi 2014

3. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Common pathogens in CAP:
Pneumonia treated on ambulatory basis
Streptococcus pneumoniae
Mycoplasm pneumoniae
Haemphilus Influenzae
Chlamydophila pneumoniae
Respiratory viruses
Moraxelia catarrhalis
Anas Bahnassi 2014
Pneumonia requiring hospital admission
Streptococcus pneumoniae
Chlamydophila pneumoniae
Haemphilus Influenzae
Lagionella supp.
Aspiration
G –ve. Bacilli
Mixed etiology
Respiratory viruses
Mycoplasm pneumoniae
Pneumonia requiring ICU admission
Streptococcus pneumoniae
Staphylococcus aureus
Lagionella supp.
G –ve. Bacilli
Haemphilus Influenzae

4. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Goals of Therapy
•Assess severity of pneumonia.
•Eradicate infecting pathogen.
•Relieve symptoms.
–Fever, cough, pleuritic chest pain, sputum, dyspnea.
•Promptly recognize and minimize complications.
–Metastatic infection, empyema, cavitation, pneumothorax, septic shock, respiratory failure, worsening of comorbid condition (IHD, DM).
•Provide end-of-life care if emerges.
Anas Bahnassi 2014
Empyema is a collection of pus in the space between the lung and the inner surface of the chest wall (pleural space). Pneumothorax: collapsed lung.

5. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Investigations
•History and PI with particular attention to:
–Symptoms:
•Cough, SOB, pleuritic chest pain, hemoptysis, sputum, fever, chills, headache, confusion, ….
–History of recent travel and other risk factors like:
•Smoking, alcohol, comorbid illnesses.
–Physical findings:
•Objective measurements:
–Vital signs: RR≥30 is the most sensitive and specific sign.
–Oxygenation status: If O2 saturation is ≤ 92% then perform arterial blood gas.
–Chest radiograph: consider a CT scan if radiograph is negative.
Anas Bahnassi 2014

6. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Investigations
•Laboratory testing:
–Electorlytes, Glu, BUN, Cr, CBC, differential WBC.
–Blood cultures.
–Sputum culture from the lower respiratory tract.
–Urine for Legionella antigens.
–Rapid test for flu.
–Serological studies.
–Nucleic acid amplification.
Anas Bahnassi 2014

7. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
CURB-65
Anas Bahnassi 2014

8. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Anas Bahnassi 2014

9. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Anas Bahnassi 2014

10. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Initial Management of CAP
Anas Bahnassi 2014
CAP diagnosed based on History, PE, Findings, chest X-ray
PSI is for guidance not to replace clinical judgment
< 90 and not hypo- oxynated
> 90 treat in hospital
Otherwise healthy, no use of antibiotics for 3 months, and no other risk factor use macrolide or doxycycline po
Co-morbidities , lung or kidney disease, risk factors then respiratory fluroquinolone *po, or Amox HD or Amox/Clav + Macrolide No Erythromycin alone
Treat at home
*moxifloxacin, levofloxacin. Gemifloxacin is not approved for CAP

11. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Initial Management of CAP
Anas Bahnassi 2014
CAP diagnosed based on History, PE, Findings, chest X-ray
PSI is for guidance not to replace clinical judgment
> 90 treat in hospital
(Respiratory Fluroquinolone po/iv or B- lactam po/iv )+ Macrolide po/iv
Antipnumococcal, antipsudomonal B- lactam*+ one of the followings:
•Ciprofloxacin
•Aminoglycoside + Macrolide
•Aminoglycoside + Ciprofloxaxin
Ward
B-lactam iv + (Macrolide iv or respiratory fluroquinolone iv)
ICU
ICU
S.aregunesa
* Cefepime or imipenem or meropenem or piperacillin/tazopactam

12. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class
Drug
Dose
ADR
Comments
Cost
Amino- glycosides
Gentamicin
Conventional:
1.5mg/kg DBW Q8H iv Extended:
4-6mg/kg DBW Once iv
Nephro/ Ototoxicity
Do not permeate pulmonary tissue very well.
Exhibit conc. dependent bacterial killing and postantibiotic effect
Co-administration with vancomycin or loop diuretics may increase the risk of nephro/ototoxicity
$
Tobramycin
Conventional:
1.5mg/kg DBW Q8H iv Extended:
4-6mg/kg DBW Once iv
$
In obese patients >30 of ideal body weight (IBW) use dosing body weight (DBW) instead of total body weight (TBW) to prevent overdosing. DBW=0.4 (TBW-IBW)
Ideal body weight in (kg) Males: IBW = 50 kg + 2.3 kg for each inch over 5 feet. Females: IBW = 45.5 kg + 2.3 kg for each inch over 5 feet.

13. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class
Drug
Dose
ADR
Comments
Cost
Fluro- quinolones
Cipro- floxacin
PO: 500- 750mg BID
IV: 400mg Q12H
GI upset, HA, dizziness, photo- sensitivity, hepatitis. Avoid in children: Cartridge toxicity.
Cipro is not a 1st line agent for CAP.
Cipro available in suspension.
Decreased absorption with antacids, metals, and sucrafate.
Cipro may decrease theophylline or cyclosporin elimination.
 Levo 750 BID X5d is equivalent to 500 BID X10d.
May increase warfarin effect.
Avoid in class Ia and III arrhythmia patients or prolonged QT intervals
Can switch from iv to po
$
Levo- floxacin
PO: 500mg Q24H X10 days. or 750mg Q12H X5 days.
IV: 500mg Q24H
$
Moxi- floxacin
400mg Q24H po/iv`

14. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class
Drug
Dose
ADR
Comments
Cost
Glyco- peptides
Vanco- mycin
1g Q12H iv
Nephro/ ototoxicity
Infusion related ADRs may increase with shorter infusion times
For MRSA pneumonia.
Increase risk of nephrotoxicity when co- administered with aminoglycosides.
$$$$
Ketolides
Telithro-mycin
800mg daily X7-10 days
Diarrhea, nausea, vomiting, elevated liver enzymes, hepatotoxicity.
Can not be considered as a first line.
Hepatotoxicity can be fatal.
Telithromycin: Atorvastatin, Lovastatin, Simvastatin, Itraconazole, Ketoconazole.
Digoxin levels.
Contraindicated with ergot, pimozide and disopyramide.

15. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class
Drug
Dose
ADR
Comments
Cost
Linco- semides
Clindamycin
300-450mg Q6H po
600mg Q8H iv
Diarrhea
C.Difficile
For suspected aspiration provide anareobic coverage
$
Macro- lides
Azithromycin
Adults
500mg on day 1 then 250 on days 2-5
Lower GI effects than Eryth.
Azi QD X5days = Ery QID X10days.
More effective than clarithro-mycin for H.influenzae.
$$
Clarithromycin
500mg BID X10d
Or
1g ER QD X10d
Contraindicated with pimozide.
Rifampin  Conc.
Warfarin levels.
Conc. of CYP3A4 susbtrates (statins/digoxin)
$$
Erythromycin
500mg QID po
GI upset
$

16. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class
Drug
Dose
ADR
Comments
Cost
Nitro- imidazole
Metronidazole
500mg po/iv Q12H
Vertigo, HA, Ataxia, GI, taste change
Avoid alcohol until 48h after the last dose
(disulfram-like reaction)
$
Oxazolidi- none
Linezolide
600mg po/iv Q12H
GI, HA, dose and time dependent bone marrow suppression, peripheral neuropathy.
Preferred agent for MSRA –pneumonia.
 Risk of serotonin toxicity with concurrent use of serotonergic drugs.
$$

17. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class
Drug
Dose
ADR
Comments
Cost
Carba- penems
Ertapenam
1g daily iv
Anaphylaxis, diarrhea, HA, increased seizure risk.
Indicated for S.pneumonia (penicillin- susceptible), H.influenzae. M. Catarrhalis.
$$$
Impenem
500 mg Q6H iv
Hypotension, nausea with rapid infusion, seizure activity with high levels.
Antipseudomonal for patients with high risk for P. aeruginosa.
$$$$
Meropenam
1g Q8H iv
Less than Impenem.
$$$$

18. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class
Drug
Dose
ADR
Comments
Cost
Carba- penems
Ertapenam
1g daily iv
Anaphylaxis, diarrhea, HA, increased seizure risk.
Indicated for S.pneumonia (penicillin- susceptible), H.influenzae. M. Catarrhalis.
$$$
Impenem
500 mg Q6H iv
Hypotension, nausea with rapid infusion, seizure activity with high levels.
Antipseudomonal for patients with high risk for P. aeruginosa.
$$$$
Meropenam
1g Q8H iv
Less than Impenem.
$$$$

19. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class
Drug
Dose
ADR
Comments
Cost
Cephalo- sporins
Cefazolin
1st generation
1-2g Q8H iv
Hyper- sensitivity
$-$$
Cefaclor
2nd generation
250mg TID po
$
Cefprozil
2nd generation
500mg BID po
$
Cefotaxime
3rd generation
1-2g Q8H iv
Can be used hepatobilliary disease.
$$- $$$
Cefepim
4th generatrion
1-2g Q12H
Antipseudomonal for patients with high risk for P. aeruginosa.
$$$$

20. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class
Drug
Dose
ADR
Comments
Cost
Penicillins
Penicillin V K
300mg TID- QID po
Anaphylaxis
GI distress
Diarrhea.
$
Penicillin G
2MU Q4H iv
$
Amoxicillin
500mg TID po
GI distress
Diarrhea.
Consider HD if patient is with drug resistant S.pneumoniae risk factors
$
Amox/Clav
500/125 TID po
or
875/125 BID po
$$
Rifamycin
Rifampin
300mg BID po
Rash, orange discoloration of body fluids, GI upset, liver toxicity, hematologic effects
Never use as a single agent for CAP
CYP inducer.

21. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class
Drug
Dose
ADR
Comments
Cost
Sulfo- namides
SMX/TMP
800/160mg BID po
GI, rash, Stevenson- Johnson’s syndrome
May  effects of sulfonylurea and warfarin.
Caution with G6PD deficiency and impaired renal and hepatic function.
$
Tetracyclins
Doxycycline
100mg BID on 1st day then 100mg once
GI, photosensitivity
Fe/antacids  absorption.
Alcohol. Barbiturates, phenytoin, rifampin, carbamazepin  levels.
$

22. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Empiric Treatments for Adults
Anas Bahnassi 2014

23. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Empiric Treatments for Adults
Anas Bahnassi 2014

24. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Empiric Treatment in Children
Anas Bahnassi 2014

25. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Prevention Measures
•Smoking cessation.
•Influenza vaccine.
•Pneumococcal vaccine.
•Chin down posture reduce the chance of aspiration both before and during the swallow.
•Follow-up chest radiographs for smokers.
Anas Bahnassi 2014

26. Pharmacotherapy of Infectious Diseases
A Case-Based Approach
Pharmacotherapy: Infectious Diseases: Anas Bahnassi PhD
abahnassi@gmail.com
http://www.twitter.com/abpharm
http://www.facebook.com/pharmaprof
http://www.linkedin.com/in/abahnassi
Anas Bahnassi 2014