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5 first-line drugs for tx TB
5. rifabutin, rifapentine
CAP: tx outpatient with no risk factors
azithromycin, clarithromycin, or antipneumococcal fluoroquinolone (levofloxacin or moxifloxacin)
Empirical tx if severity score > 90 and neg gram stain/no sputum
2nd or 3rd gen ceph + macrolide (e.g. clarithromycin, clindamycin, erythromycin, or azithromycin) or antipneumococcal fluoroquinolone (e.g. levofloxacin or moxifloxacin)
3 classes of drugs used for drug-resistant S. pneumoniae
1. anti-pneumococcal fluoroquinolones (e.g. levofloxacin)
2. oral beta-lactam (e.g. amoxicillin-clavulanate/augmentin)
3. oral macrolide (e.g. azithromycin)
Two reasons why oral cephs aren't be used for CAP
1. pneumococcal resistance
2. lack of activity against atypical organisms
2 options for normal CAP requiring hospitalization
1. IV/PO anti-pneumococcal fluoroquinolone (e.g. levofloxacin)
2. IV beta-lactam (e.g. 3rd gen ceph--ceftriaxone) + IV macrolide (e.g. azithromycin)
What drug can be added for suspected aspiration pneumonia if patient requires hospitalization?
Tx for severely ill, ICU patients with CAP
IV beta lactam (e.g. ceftriaxone) + IV anti-pneumococcal fluoroquinolone (e.g. levofloxacin)
In general, to improve gram negative coverage when treating CAP, what options are there?
ticarcillin/clavulanate (e.g. Timentin) or piperacillin/tazobactam (e.g. Zosyn) PLUS macrolide or fluroquinolone to cover atypicals (e.g. Mycoplasma or Chlamydia)
Tx for intermediate resistant strain of pneumococcal pneumonia
ceftriaxone, high dose of pen G IV, or levofloxacin IV
Tx for highly resistant strain of pneumococcal pneumonia
add vancomycin or linezolid; or an IV fluoroquinolone
HAP: three options for initial treatment
ticarcillin/clavulanate (e.g. Timentin), piperacillin/tazobactam (e.g. Zosyn), or carbapenem (e.g. imipenem)
HAP with multi-drug resistant P. aeroginosa
cefepime (4th gen ceph) or carbapenems (e.g. imipenem or meropenem) PLUS an aminoglycoside (e.g. gentamicin)
Tx for atypical pneumonia (M. pneumoniae or C. pneumoniae)
macrolide (e.g. azithromycin, clarithromycin, or erythromycin) or tetracycline (e.g. doxycycline)
OR i thought could also use fluoroquinolone???
Two options for tx H. influenzae pnuemonia
2nd or 3rd gen ceph (e.g. cefuroxime)
Augmentin (amoxicillin + clavulanate)
3 options for tx Legionella pneumonia
azithromycin +/- rifampin
fluoroquinolone +/- rifampin
erythromycin +/- rifampin
Tx for Klebsiella spp. pneumonia (or other gram neg bacilli e.g E.coli, Proteus, or Enterobacter); also, what to add in severely ill patients
3rd or 4th gen ceph
add aminoglycoside (e.g. gentamicin or tobramicin)
Tx for methicillin-sensitive S. aureus
penicillinase-resistant penicillin (e.g. PO cloxacilin or IV nafcillin/oxacillin)
Tx for anaerobic mouth flora pneumonia (e.g. Bacteroides, Fusobacterium, Peptostreptococcus)
clindamycin or metronidazole
3 mechanisms of resistance to penicillin
decreased permeability (e.g. decreased porins in g- bacteria)
altered PBP (e.g. MRSA, PRSP)
Mnemonic for activity of extended spectrum penicillins
ampicillin and amoxicillin HELPS kill enterococci
Haemophilus, E. coli, Listeria, Proteus, Salmonella, and enterococci
MOA for vancomycin
tricyclic glycopeptide that inhibits cell wall mucopeptide formation, bactericidal, but not penicillin or lactam.
2 mechanisms of resistance against fluoroquinolones
mutated DNA gyrase
decreased permeability through porins
Fluoroquinolones contraindicated in what two groups of patients
1. preg and nursing mothers
2. pts over 60 yo due to increased risk of tendonitis
3 mechanisms of resistance against aminoglycosides
producing deactivating enzyme
impaired entry (mutant porins or pH, o2)
mutant 30S subunit
What is unique about clinical action of gentamicin?
Postantibiotic effect: antibacterial activity continues beyond the time that measurable drug is present
TB: latent infection by positive PPD
INH x 9 months single dose or daily rifampin alone for 4 months
Timeline of therapy for susceptible TB
2 month initial-phase, with a continuation phase for 4-7 months depending on sputum results at 2 months
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