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HKCEM College Tutorial. Community-acquired Pneumonia. Author Dr. Shek Kam Chuen Oct 2013. History. M/39 Good past health Fever one day, 38.8 o C Cough with yellowish sputum Right pleuritic chest pain. Any other important history?. FTOCC Travel: Middle East, Avian flu
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HKCEM College Tutorial Community-acquired 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?
Bacterial Atypical Viral What are possible pathogens?
Community Acquired Pneumonia • Local pathogens in order of commonest: • Haemophilus influenzae(13.7%-60%) • Streptococcus pneumoniae • Moraxella catarrhalis • Chlamydia pneumoniae • Legionella • Mycoplasma • 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. Big 3 Atypical
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 (Augmentin) • MSSA, • S. pneumoniae, • H. influenzae, • M. catarrhalis, • some E-coli, anaerobes • 1. Augmentin 375mg tds =(amoxil250 +clavulanate125)x3 =amoxil750 + clavunanate375/D • 2. Augmentin 375+ amoxil250 tid =amoxil1500 +clavunanate375 /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
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 What is subsequent MX? 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 may mask TB and may cause drug resistance in future.) • levofloxacin 750mg QD for 5/7 because it is concentration dependent. Impact CID 2007;44 (Suppl 2) S27-S72