Sandbox ID Lower Respiratory Tract

Jump to navigation Jump to search

Acute bacterial exacerbations of chronic bronchitis

  • Chronic bronchitis with Acute bacterial Exacerbation [1]
  • Preferred Regimen

Bronchiectasis

  • Bronchiectasis

Bronchiolitis

Bronchitis

Cystic fibrosis

  • Pathogen directed antimicrobial therapy [2]
  • Bacterial
  • Pseudomonas aeruginosa
  • Preferred Regimen: Tobramycin 3.3 mg/kg q8h or 12 mg/kg IV q24h AND (Piperacillin 100 mg/kg q6h OR Ticarcillin 100 mg/kg q6h OR Ceftazidime 50 mg/kg IV q8h (to maximum of 6 gm/day))
  • Alternative Regimen: Tobramycin (3.3 mg/kg q8h or 12 mg/kg IV q24h) AND (Aztreonam 50 mg/kg IV q8h OR Tobramycin 3.3 mg/kg q8h or 12 mg/kg IV q24h) AND Imipenem 15-25 mg/kg IV q6. If Tobramycin resistant add Ciprofloxacin Oral : 500-750 mg twice daily for 7-14 days-IV 400 mg every 12 hours for 7-14 days OR Levofloxacin 750 mg every 24 hours for 7-14 days
  • Only in children: Ciprofloxacin Oral :500-750 mg twice daily for 7-14 days-IV 400 mg every 12 hours for 7-14 days AND Ceftazidime IV 500 mg to 1 g every 8 hours.
  • Staphylococcus aureus
  • Preferred Regimen (Adult)
  • IF methicillin sensitive staphylococcus aureus: Nafcillin 2 gm IV q4hs OR Oxacillin 2 gm IV q4hs
  • If methicillin resistant staphylococcus aureus: Vancomycin 15-20 mg/kg IV q8-12h OR Linezolid 600 mg po/IV q12h
  • Preferred regimen (Pediatric)
  • IF methicillin sensitive staphylococcus aureus: Nafcillin 5 mg/kg q6h (Age >28 days) OR Oxacillin 75 mg/kg q6h (Age >28 days)]]
  • If methicillin resistant staphylococcus aureus: Vancomycin 40 mg/kg divided q6-8h (Age >28 days) OR Linezolid 10 mg/kg po/IV q8h (up to age 12)
  • Burkholderia cepacia

Empyema

Influenza

Inhalational anthrax, Prophylaxis

  • Oral postexposure prophylaxis for infection with Bacillus anthracis (for adults)[3]
  • (1) For all strains, regardless of penicillin susceptibility or if susceptibility is unknown: Ciprofloxacin, 500 mg q12h OR Doxycycline, 100 mg q12h OR Levofloxacin, 750 mg q24h OR Moxifloxacin, 400 mg q24h OR Clindamycin, 600 mg q8h OR
  • (2) Alternatives for penicillin-susceptible strain Amoxicillin, 1 g q8h OR Penicillin VK, 500 mg q6h
Note (1): Preferred drugs are indicated in boldface.
Note (2): Alternative drugs are listed in order of preference for treatment for patients who cannot take first-line treatment or if first-line treatment is unavailable.
  • Postexposure Prophylaxis for Bacillus anthracis (for Children 1 Month of Age and Older)[4]
  • (1). For penicillin-resistant strains or prior to susceptibility testing: Ciprofloxacin, 30 mg/kg/day, by mouth (PO), divided q12h (not to exceed 500 mg/dose) OR Doxycycline, <45 kg: 4.4 mg/kg/day, PO, divided q12h (not to exceed 100 mg/dose) >45 kg: 100 mg/dose, PO, given q12h OR Clindamycin, 30 mg/kg/day, PO, divided q8h (not to exceed 900 mg/dose) OR Levofloxacin, <50 kg: 16 mg/kg/day, PO, divided q12h (not to exceed 250 mg/dose) >50 kg: 500 mg, PO, given q24h OR
  • (2). For penicillin-susceptible strains: Amoxicillin, 75 mg/kg/day, PO, divided every q8h (not to exceed 1 g/dose) OR Penicillin VK, 50-75 mg/kg/day, PO, divided q6h to q8h
Note (1) : Duration of Therapy is 60 days after exposure
Note (2) : Bold font are preferred antimicrobial agent (when 2 bolded antimicrobial agents are present, both are considered equivalent in overall safety and efficacy).
Note (3) : Normal font are alternative selections are listed in order of preference for therapy for patients who cannot take first-line therapy or if first-line therapy is unavailable.
Note (4) : Doses are provided for children with normal renal and hepatic function. Doses may vary for those with some degree of organ failure.
Note (5) : Italicized font: indicates FDA approval for the indication in the pediatric population.
Note (6) : A single 14-day course of doxycycline is not routinely associated with tooth staining, but some degree of staining is likely for a prolonged treatment course of up to 60 days.
Note (7) : Safety data for Levofloxacin in the pediatric population are limited to 14 days for duration therapy.
Note (8) : Be aware of the possibility of emergence of penicillin-resistance during monotherapy with Amoxicillin or Penicillin.

Inhalational anthrax, Treatment

  • Treatment for anthrax in adults [3]
  • Pathogen-directed antimicrobial therapy
  • Intravenous therapy for systemic anthrax with possible/confirmed meningitis
  • Preferred regimen
Note (1): Duration of treatment: ≥2-3 weeks until clinical criteria for stability are met.(Preferred drugs are indicated in boldface)
Note (2): Patients exposed to aerosolized spores will require prophylaxis to complete an antimicrobial drug course of 60 days from onset of illness.
Note (3): Systemic anthrax includes anthrax meningitis; inhalation, injection, and gastrointestinal anthrax; and cutaneous anthrax with systemic involvement, extensive edema, or lesions of the head or neck. Preferred drugs are indicated in boldface.
Note (4): Alternative drugs are listed in order of preference for treatment for patients who cannot take first-line treatment, or if first-line treatment is unavailable.
Note (5):Increased risk for seizures associated with Imipenem/Cilastatin treatment.
Note (6): Linezolid should be used with caution in patients with thrombocytopenia because it might exacerbate it. Linezolid use for >14 days has additional hematopoietic toxicity.
Note (7): Rifampin is not a protein synthesis inhibitor. However, it may be used in combination with other antimicrobial drugs on the basis of its in vitro synergy.
Note (8): ChloramphenicolShould only be used if other options are not available because of toxicity concerns.
  • Intravenous therapy for systemic anthrax when meningitis has been excluded
  • Preferred regimen:
  • Bactericidal drug
Note (1): Duration of treatment: for 2 weeks until clinical criteria for stability are met. (Preferred drugs are indicated in boldface).
Note (2):Patients exposed to aerosolized spores will require prophylaxis to complete an antimicrobial drug course of 60 days from onset of illness.
Note (3):Systemic anthrax includes anthrax meningitis; inhalation, injection, and gastrointestinal anthrax and cutaneous anthrax with systemic involvement, extensive edema, or lesions of the head or neck.
Note (4):Alternative drugs are listed in order of preference for treatment for patients who cannot take first-line treatment, or if first-line treatment is unavailable.
Note (5):Increased risk for seizures associated with imipenem/cilastatin treatment.
Note (6):Linezolid should be used with caution in patients with thrombocytopenia because it might exacerbate it.Linezolid use for >14 d has additional hematopoietic toxicity.
Note (7):A single 10-14 days course of Doxycycline is not routinely associated with tooth staining.
Note (8):Rifampin is not a protein synthesis inhibitor. However, it may be used in combination with other antimicrobials drugs on the basis of its in vitro synergy.
  • Oral treatment for cutaneous anthrax without systemic involvement
Note (1): Alternative drugs are listed in order of preference for treatment for patients who cannot take first-line treatment, or if first-line treatment is unavailable. (Preferred drugs are indicated in boldface).
Note (2): Duration of treatment is 60 days for bioterrorism-related cases and 7-10 days for naturally acquired cases.
  • Treatment for anthrax in childern
  • 2. Treatment of cutaneous anthrax without systemic involvement (for children 1 month of age and older)

3. Combination therapy for systemic anthrax when meningitis can be ruled out (for children 1 month of age and older) 4. Triple therapy for systemic anthrax (anthrax meningitis or disseminated infection and meningitis cannot be ruled out) for Children 1 Month of Age and Older 5. Oral follow-up combination therapy for severe anthrax (for Children 1 Month of Age and Older) 6. Dosing in preterm and term neonates 32 to 44 Weeks postmenstrual Age (Gestational Age Plus Chronologic Age)

Pertussis

  • Pertussis (whooping cough)
  • Preferred Regimen
  • Alternate Regimen
Note: Clarithromycin and Trimethoprim-Sulfamethoxazole are contraindicated in children below 6 mths and 2 mths respectively

Pneumonia, Acinetobacter

  • Acinetobacter species (atypical bacterial pneumonia) [5]

Pneumonia, Actinomycosis

Pneumonia, Anaerobes

Anaerobe (aspiration) pneumonia [5]

Pneumonia, Aspiration pneumonia

  • Aspiration (anaerobe) pneumonia

Pneumonia, Chlamydophila

  • Chlamydophila pneumoniae (atypical bacterial pneumonia) [5]

Pneumonia, community-acquired

  • Community acquired pneumonia
  • Empiric therapy in adults
  • (A) Outpatient treatment
  • (1) Previously healthy and no use of antimicrobials within the previous 3 months.
  • Preferred regimen : Azithromycin 500 mg PO on day 1 followed by 250 mg q24h on days 2-5 OR Azithromycin 500 mg IV as a single dose OR Clarithromycin 250 mg q12h for 7-14 days OR 1000 mg q24h for 7 days OR Erythromycin 250-500 mg q6-12h (max: 4 g/day)
  • Alternative regimen : Doxycycline 100 mg PO/IV q12h (Weak recommendation).
  • (2) Presence of comorbidities such as chronic heart, lung, liver or renal disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing conditions or use of immunosuppressing drugs; or use of antimicrobials within the previous 3 months (in this case an alternative from a different class should be selected)
  • (B) Inpatient Therapy (in regions with a high rate (125%) of infection with high-level (minimum inhibitory concentration 16 mg/mL) macrolide-resistant Streptococcus pneumoniae)
  • (1) Non-ICU treatment
  • (2) ICU treatment
  • (C) Special Concerns
  • (1) Pseudomonas
Note : For penicillin-allergic patients, substitute the B-lactam for Aztreonam 2 g IV q6-8h (maximum 8 g/day)
  • (2) Methicillin resistant staphylococcus aureus ,Add the following to the selected regimen
  • Preferred regimen: Vancomycin 45-60 mg/kg/day divided q8-12h OR Linezolid 600 mg PO/IV q12h for 10-14 days.
  • Empiric therapy in neonates ( Age < 1 month)
  • Preferred regimen: Ampicillin 500 mg/day for 7-14 days or 750 mg/day for 5 days OR Gentamicin 400 mg/day PO/IV for 7-14 days With or without Cefotaxime 320 mg PO q24h for 5 or 7 days
Note (1) : If methicillin resistant staphylococcus aureus is suspected, add the following Vancomycin 10 mg/kg q8h
Note (2) : If Chlamydia trachomatis is suspected, add the following Erythromycin 12.5 mg/kg PO or IV qid for 14 days OR Azithromycin 10 mg/kg PO/IV on day one then 5 mg/kg PO/IV q24h for 4 days.
  • Alternate Regimen (If methicillin resistant staphylococcus aureus is suspected): Vancomycin 10 mg/kg q8h OR Linezolid 10 mg/kg q8h
  • Empiric therapy,Children (> 3 months) Outpatient Therapy
  • pathogen directed antimicrobial therapy
  • Bacterial
  • (A) Streptococcus pneumoniae
  • (1) Penicillin nonresistant; minimum inhibitory concentration < 2 mg / mL
  • (2) Penicillin resistant; minimum inhibitory concentration > 2 mg / mL
  • Preferred Regimen (Agents chosen on the basis of susceptibililty) : Cefotaxime 1 g IM/IV q12h OR Ceftriaxone 1 g IV q24h, 2 g daily for patients at risk OR levofloxacin 750 mg IV q24h OR moxifloxacin 400 mg IV q24h
  • Alternative Regimen: Vancomycin 45-60 mg/kg/day divided q8-12h (maximum: 2000 mg/dose) for 7-21 days depending on severity OR Linezolid 600 mg PO/IV q12h for 10-14 days OR Amoxicillin 875 mg PO q12h or 500 mg q8 ( 3 g/day with penicillin ,minimum inhibitory concentration 4 ≤ microgram / mL)
  • (B)Haemophilus influenzae
  • (1) Non-beta lactamase producing
  • (2) Beta lactamase producing
  • (C) Bacillus anthracis (inhalation)
  • (D) Enterobacteriaceae
  • (E)Pseudomonas aeruginosa
  • (F)Staphylococcus aureus
  • (1) Methicillin susceptible
  • (2) Methicillin resistant
  • Preferred Regimen : Vancomycin 45-60 mg/kg/day divided q8-12h (max: 2000 mg/dose) for 7-21 days OR Linezolid 600 mg PO/IV q12h for 10-14 days
  • Alternative Regimen: Trimethoprim-sulfamethoxazole 1-2 double-strength tablets (800/160 mg) q12-24h
  • (G)Bordetella pertussis
  • (H) Anaerobe (aspiration)
  • (I) Mycobacterium tuberculosis
  • Preferred Regimen:
  • Intensive phase: Isoniazid 5 mg/kg/day q24h daily for 2 months (usual dose: 300 mg/day) AND Rifampin 10 mg/kg/day daily for 2 months (maximum: 600 mg / day) AND Ethambutol 5-25 mg/kg daily for 2 months (maximum dose: 1.6 g) AND Pyrazinamide 1000 - 2000 mg / day daily for 2 months.
  • Continuation phase: Isoniazid 300 mg/day PO daily for 4 months (5 mg/kg/day) AND Rifampicin 600 mg/day PO daily for 4 months (10 mg/kg/day).
  • Alternate regimen (1):
  • Intensive phase: Isoniazid 5 mg/kg/day q24h daily for 2 months (usual dose: 300 mg/day) AND Rifampin 10 mg/kg/day daily for 2 months (maximum: 600 mg / day) AND Ethambutol 5-25 mg/kg daily for 2 months (maximum dose: 1.6 g) AND Pyrazinamide 1000 - 2000 mg / day daily for 2 months.
  • Continuation phase: Isoniazid 300 mg/day PO 3 times per week for 4 months (5 mg/kg/day) AND Rifampicin 600 mg/day PO 3 times per week for 4 months (10 mg/kg/day).
Note : Acceptable alternative for any new TB patient receiving directly observed therapy
  • Alternate regimen (2)
  • Intensive phase:Isoniazid 5 mg/kg/day q24h 3 times per week for 2 months (usual dose: 300 mg/day) AND Rifampin 10 mg/kg/day 3 times per week for 2 months (maximum: 600 mg / day) s AND Ethambutol 5-25 mg/kg (maximum dose: 1.6 g) 3 times per week for 2 months AND Pyrazinamide 1000 - 2000 mg / day 3 times per week for 2 months.
  • Continuation phase: Isoniazid 300 mg/day PO 3 times per week for 4 months (5 mg/kg/day) AND Rifampicin 600 mg/day PO 3 times per week for 4 months (10 mg/kg/day).
Note : Acceptable alternative provided that the patient is receiving directly observed therapy and is not living with HIV or living in an HIV prevalent setting.
  • (J) Yersinisa pestis
  • Atypical bacteria
  • (A) Mycoplasma pneumoniae
  • (B) Chlamydophila pneumoniae
  • (C) Legionella species
  • (D)Chlamydophila psittaci
  • Preferred Regimen: Tetracycline 250-500 mg PO q6h
  • Alternate Regimen: Azithromycin 500 mg PO on day 1 followed by 250 mg q24h
  • (E) Coxiella burnetii
  • Preferred Regimen: Tetracycline 250-500 mg PO q6h
  • Alternate Regimen: Azithromycin 500 mg PO on day 1 followed by 250 mg q24h
  • (F) Francisella tularensis
  • (G) Burkholderia pseudomallei
  • (H) Acinetobacter species
  • Viral
  • Influenza virus
  • Preferred Regimen: Oseltamivir 75 mg PO q12h for 5 days (initiated within 48 hours of onset of symptoms) OR Zanamivir Two inhalations (10 mg total) q12h for 5 days (Doses on first day should be separated by at least 2 hours; on subsequent days, doses should be spaced by ~12 hours)
  • Fungal
  • (A) Coccidioides species
Note: No therapy is indicated for uncomplicated infection, treat only if complicated infection
  • (B) Histoplasmosis
  • (C) Blastomycosis

Pneumonia, concomitant influenza

  • Influenza virus pneumonia [5]
  • Preferred Regimen: Oseltamivir 75 mg PO q12h for 5 days (initiated within 48 hours of onset of symptoms) OR Zanamivir Two inhalations (10 mg total) q12h for 5 days (Doses on first day should be separated by at least 2 hours; on subsequent days, doses should be spaced by ~12 hours)

Pneumonia, Cytomegalovirus

  • Preferred regimen (1): Ganciclovir Induction therapy 5 mg/ kg IV every 12 h for normal GFR; maintenance therapy 5 mg/kg IV daily; 1 g orally every 8 h with food.
  • Preferred regimen (2): Valganciclovir Induction therapy 900 mg orally every 12 h; maintenance therapy 900 mg daily.
  • Alternate regimen (1): Foscarnet Induction therapy 60 mg/ kg every 8 h for 14–21 days or 90 mg/kg every 12 h for 14–21 days; maintenance therapy 90–120 mg/kg per day as a single infusion.
  • Alternate regimen (2): Cidofovir Induction therapy 5 mg/ kg per week for 2 weeks, followed by maintenance therapy every 2 weeks.
  • Prophylaxis

Pneumonia, Haemophilus Influenza

  • Haemophilus influenzae pneumonia [5]
  • (1) Non-beta lactamase producing
  • (2) Beta lactamase producing

Pneumonia, health care-associated

Pneumonia, hospital-acquired

  • No Risk Factors for multi drug resistance
  • Presence of Risk Factors for multi drug resistance
Note (1) : Trough levels for gentamicin and tobramycin should be less than 1 g/ml, and for amikacin they should be less than 4-5 g/ml.
Note (2) : Trough levels for vancomycin should be 15-20 g/ml

Pneumonia, Klebsiella

Pneumonia, Legionella

  • Legionella pneumonia (atypical bacterial pneumonia) [5]

Pneumonia, Lung abscess

Pneumonia, Meliodosis

Pneumonia, Moraxella catarrhalis

Pneumonia, Mycoplasma

  • Mycoplasma pneumoniae (atypical bacterial pneumonia) [5]

Pneumonia, neutropenic patient

Pneumonia, Nocardia

Pneumonia, post-influenza

Pneumonia, Pseuodomonas

  • Pseudomonas aeruginosa pneumonia [5]

Pneumonia, Staphylococcus aureus

  • Staphylococcus aureus pneumonia [5]
  • (1) Methicillin susceptible
  • (2) Methicillin resistant
  • Preferred Regimen : Vancomycin 45-60 mg/kg/day divided q8-12h (max: 2000 mg/dose) for 7-21 days OR Linezolid 600 mg PO/IV q12h for 10-14 days
  • Alternative Regimen: Trimethoprim-sulfamethoxazole 1-2 double-strength tablets (800/160 mg) q12-24h

Pneumonia, Stenotrophomonas

Pneumonia, Streptococcus pneumoniae

  • Streptococcus pneumoniae [5]
  • (1) Penicillin nonresistant; minimum inhibitory concentration < 2 mg / mL
  • (2) Penicillin resistant; minimum inhibitory concentration > 2 mg / mL
  • Preferred Regimen (Agents chosen on the basis of susceptibililty) : Cefotaxime 1 g IM/IV q12h OR Ceftriaxone 1 g IV q24h, 2 g daily for patients at risk OR levofloxacin 750 mg IV q24h OR moxifloxacin 400 mg IV q24h
  • Alternative Regimen: Vancomycin 45-60 mg/kg/day divided q8-12h (maximum: 2000 mg/dose) for 7-21 days depending on severity OR Linezolid 600 mg PO/IV q12h for 10-14 days OR Amoxicillin 875 mg PO q12h or 500 mg q8 ( 3 g/day with penicillin ,minimum inhibitory concentration 4 ≤ microgram / mL)

Pneumonia, Tularemia

  • Francisella tularensis pneumonia [5]

Pneumonia, Yersinia pestis

  • Yersinisa pestis pneumonia [5]

References

  1. Rabbat A, Guetta A, Lorut C, Lefebvre A, Roche N, Huchon G (2010). "[Management of acute exacerbations of COPD]". Rev Mal Respir. 27 (8): 939–53. doi:10.1016/j.rmr.2010.08.003. PMID 20965408.
  2. Mogayzel PJ, Naureckas ET, Robinson KA, Mueller G, Hadjiliadis D, Hoag JB; et al. (2013). "Cystic fibrosis pulmonary guidelines. Chronic medications for maintenance of lung health". Am J Respir Crit Care Med. 187 (7): 680–9. PMID 23540878.
  3. 3.0 3.1 Hendricks KA, Wright ME, Shadomy SV, Bradley JS, Morrow MG, Pavia AT; et al. (2014). "Centers for disease control and prevention expert panel meetings on prevention and treatment of anthrax in adults". Emerg Infect Dis. 20 (2). doi:10.3201/eid2002.130687. PMC 3901462. PMID 24447897.
  4. Bradley JS, Peacock G, Krug SE, Bower WA, Cohn AC, Meaney-Delman D; et al. (2014). "Pediatric anthrax clinical management". Pediatrics. 133 (5): e1411–36. doi:10.1542/peds.2014-0563. PMID 24777226.
  5. 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC; et al. (2007). "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults". Clin Infect Dis. 44 Suppl 2: S27–72. doi:10.1086/511159. PMID 17278083.
  6. Torres-Madriz G, Boucher HW (2008). "Immunocompromised hosts: perspectives in the treatment and prophylaxis of cytomegalovirus disease in solid-organ transplant recipients". Clin Infect Dis. 47 (5): 702–11. doi:10.1086/590934. PMID 18652557.