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 Oral or parentral

Hospital Parentral

But to when?
 Switch Therapy

IV Shift Oral

Step-down 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 cover
morxella and H. influenza
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 Gram –ve

1st
2nd
3rd
4th
 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 its
nephrotoxicity
Pregnancy: better to be avoided
 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
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‫على ابن طالب‬