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Infection

Pneumonia
Duration of treatment:  Community acquired-mild: 7-10days. //  Gram negative (usually nosocomial): 3 to 6 weeks. // Staphylococcal: 3 to 4 weeks //   Legionella, mycoplasma, chlamydia: 14 to 21 days. // Lung abscess: 4 to 6 weeks.
Possible therapeutic alternatives

Community-acquired Pneumonia (CAP):   (outpatient therapy)   Adult patient

Pneumonia: Community acquired. (outpatient therapy) Adult patient Common pathogens
OUTPATIENT
No co-morbidities:
Azithromycin 500 mg x1, then 250 mg once daily OR   azithromycin 2 gm (XR) x 1 dose   (OR)
Clarithromycin 500mg orally twice daily or 1gram (XR) orally once daily x 7 days   (OR)
Doxycycline 100mg orally twice daily
Co-morbidities present:
Levofloxacin 750 mg once daily x 5 days (OR)
moxifloxacin 400mg po qd x 7-10days (OR)
Azithromycin 500 mg x1, then 250 mg once daily PLUS  [ Augmentin XR* 1000/62.5 mg 2 tablets orally twice daily or  Cefdinir 300 mg orally twice daily or Cefpodoxime 200 mg orally twice daily or
Cefprozil 500 mg orally twice daily] x  7 days

*AUGMENTIN XR is contraindicated in patients with a creatinine clearance of < 30 mL/min. and in hemodialysis patients

Community acquired PNEUMONIA –  Adult (any age) Common pathogens
Hospitalized patient:
Azithromycin 500mg  IV once daily PLUS Ceftriaxone 1 gram q24h   (OR)

Azithromycin 500mg  IV once daily PLUS
Ertapenem 1 gram q24h   (OR)

Monotherapy:
Levofloxacin 750 mg IV/PO once daily (OR)
Moxifloxacin 400mg IV qd.

ICU patient (CAP):
[Ceftriaxone 1-2 grams IV q24h  OR
Ampicillin-sulbactam (Unasyn) 1.5-3.0 grams ivpb q6h]

PLUS
[Azithromycin 500mg  IV once daily OR Levofloxacin 750 mg IV/PO once daily (OR)
Moxifloxacin 400mg IV qd.]

PLUS
Vancomycin – (patient-specific regimen – trough goal 15-20 mcg/ml)

Hospital-acquired PNEUMONIA (HAP)

Hospital-acquired PNEUMONIA (HAP) (nosocomial) Common pathogens
Multi-drug resistance unlikely
Ceftriaxone 1-2 grams IV q24h  OR
Ampicillin-sulbactam (Unasyn) 3.0 grams ivpb q6h  OR
Levofloxacin 750 mg IV/PO once daily
Multi-drug resistance LIKELY
Piperacillin-tazobactam 3.375g ivpb q6h OR
Cefepime 2 grams IV every 12 hours OR
Meropenem 1 gm IV q8h

PLUS (If MRSA suspected)
Vancomycin – (patient-specific regimen – trough goal 15-20 mcg/ml)

Aspiration pneumonia

Common pathogens
Community acquired:
Clindamycin 600mg ivpb every 6 to 8 hours or
Augmentin 875mg PO bid or 500mg tid x 10 days
Hospital acquired:
Piperacillin-tazobactam 3.375g ivpb q6h OR
Ampicillin-sulbactam (Unasyn) 1.5-3.0 grams ivpb q6h. OR
Cefoxitin 2 grams ivpb q6-8h or  Cefotetan 1-2 grams IV q12h.  OR
[Cefotaxime 2g ivpb q8h or Ceftriaxone 2 grams ivpb q24h] + Clindamycin 600mg IV q6-8h. OR
Clindamycin 600mg IV q6-8h + [Ciprofloxacin 400mg IV q12h  or  Levofloxacin 500 – 750mg IV qd. ]
Hospital acquired: (Cover most common pathogens + possibility of aspiration) Common pathogens
 Piperacillin-tazobactam 3.375 grams IV every 6 hours + Ciprofloxacin 400mg IV q12h  or
Cefepime 2 grams IV every 12 hours + Clindamycin 600mg IV every 6 hours.

Ventilator-associated pneumonia (VAP)

(Mild to moderate infection AND multi-drug resistance unlikely): Common pathogens
Ceftriaxone 1-2 grams IV q24h  OR
Ampicillin-sulbactam (Unasyn) 3.0 grams ivpb q6h  OR
Levofloxacin 750 mg IV/PO once daily OR
Ertapenem 1 gm IV q24h

PLUS (If MRSA suspected)
Vancomycin – (patient-specific regimen – trough goal 15-20 mcg/ml)

(Severe infection OR multi-drug resistance LIKELY): Common pathogens
Cefepime 2 grams IV every 12 hours OR
Piperacillin-tazobactam 4.5 grams IV Q6H OR
Meropenem 1 gm IV q8h

PLUS
Vancomycin – (patient-specific regimen – trough goal 15-20 mcg/ml)

PLUS
Ciprofloxacin 400mg IV q8h  OR
Levofloxacin 750 mg IV/PO once daily OR
Aminoglycoside (Tobra) – patient-specific regimen.

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