Appendix 16b : ADUP Summary of Pneumonia Guidelines

TOP (Adult)¹

CHR²

Ontario 2005³

Canada 2000

(Mandell et al)⁴

General

-Ensure adequate hydration. Many patients with pneumonia are dehydrated due to increased insensible water loss

- Adequate analgesics/ antipyretics for pain and fever

- Coughs suppressants are not routinely recommended

- For patients who may require admission, calculation of PSI score is recommended to guide determination of site of care

- Significant pleural effusion (>10 mm on lateral decubitus) should be drained

- Empyema should be drained

- Oxygen therapy is indicated for hypoxemia

- Due to morbidity and mortality of bacterial pneumonia and limitations of microbial diagnosis, empiric therapy is recommended for all patients with physical findings of pneumonia and new infiltrate on chest x-ray

- The choice of empiric therapy is based on severity of illness, patient age, comorbidities, treatment setting (outpatient or inpatient), local susceptibility patterns where available, and patient’s recent (3 month) antibiotic history

- Prudent to obtain patients antibiotic history. If there has been significant exposure to a particular class of agent, then consider selecting an alternate class of antibiotic

- Conflicting guidelines exist with respect to the use of the newer FQs in CAP. Some guidelines recommend their use as 1^st line agents (BTS 2004; Heffelfinger 2000). Others do not advocate their use as 1^st line agents due to their broad spectrum of activity and concerns over the rapid emergence of FQ resistance in pneumococci

- Physicians are encouraged to be aware of local antimicrobial susceptibility patterns to facilitate antibiotic selection

- Prudent to obtain a patient’s antibiotic history Review antibiotics prescribed for any type of infection in the previous 3 months. If there has been significant exposure to a particular class of agents, then consider selecting an alternate class of antibiotic agent

- Duration of therapy depends on various factors (e.g. clinical presentation, comorbidities, age, etc.) and varies from 10-14 days unless otherwise specified

- Unfortunately, there has never been an appropriately designed randomized controlled trial to specifically determine the duration of antibiotic therapy for CAP. Most physicians, including members of this committee, recommend treatment for 1-2 weeks, depending upon response of the patient

- General measures should be implemented. Adequate hydration will help clear secretions. Cough suppressants may be beneficial for patients with severe paroxysms or coughing that produce respiratory fatigue or pleuritic and chest wall pain

- Oxygen therapy may be indicated for hypoxemia

- Significant pleural effusion or pleural empyema should be drained

Outpatient

(no comorbid factors)

Azithromycin

500 mg PO x 1 day then 250 mg PO daily (5 days)

Or

Clarithromycin

250 to 500 mg PO BID (10 days)

Or

Erythromycin

500 mg PO QID (10 days)

Or

Doxycycline

200 mg PO x 1 day then 100 mg PO daily (10 days)

Macrolide (azithromycin, clarithromycin, or erythromycin)

OR

Doxycycline

Note: CHR outpatient prescription form includes:

Clarithromycin (500 mg po BID x 10 days)

Azithromycin (500 mg po x 1 day then 250 mg po QD x 4 days)

Levofloxacin (500 mg po QD x 10 days)

Doxycycline 200 mg po x 1 then 100 mg po x 9 days)

[Physician to tick off choice of antibiotic for patient]

First Line

Erythromycin

500 mg PO QID

Or

Clarithromycin

500 mg PO BID or

1000 mg (ER) QD

Or

Azithromycin

500 mg PO on first day then 250 mg PO QD x 4 days

Second Line

Doxycycline*

100 mg BID first day then 100 mg daily

Or

Telithromycin**

800 mg daily x 10 days

Note: A respiratory FQ alone or an advanced macrolide PLUS high dose amoxicillin or high dose amoxi-clav are options if the patient has had antibiotics within the past 3 months.

* Approximately 10% of pneumococci are resistant to tetracyclines

** Telithromycin may have a role in individuals with treatment failures or where drug-resistant pneumococci (penicillin or macrolide) are a problem or suspected.

First Choice

Macrolide (erythromycin, azithromycin, or clarithromycin)

Second choice

Doxycyline

Comments

- For outpatients who do not have modifying factors such as COPD or macroaspiration, treatment with a macrolide or doxycycline should suffice to cover pneumococci, Mycoplasma pneumonia, and Chlamydia pneumonia (the most likely pathogens in this setting)

- For the present, macrolides remain effective for patients with mild to moderately severe CAP on the basis of their pneumonia-specific severity of illness score.

Outpatient with comorbid factors

For CHR guidelines, recommend-ations are also for Failure of Therapy

Azithromycin

500 mg PO x 1 day then 250 mg PO daily (5 days)

Or

Clarithromycin

250 to 500 mg PO BID (10 days)

Or

Doxycycline

200 mg PO x 1 day then 100 mg PO daily (10 days)

Azithromycin

OR

Clarithromycin

OR

Doxycycline

OR

Respiratory FQ (gatifloxacin, levofloxacin, or moxifloxacin)

NO recent antibiotics within past 3 months

First Line

Clarithromycin

500 mg PO BID or

1000 mg (ER) PO QD

Or

Azithromycin

500 mg PO daily on first day then 250 mg daily x 4 days

Second Line

Telithromycin

800 mg daily x 10 days

Recent antibiotics within past 3 months

First Line

Amoxi/clavulanate

500 mg PO TID or 875 mg PO BID

Or

Cefuroxime

500 mg PO BID

OR

Cefprozil

500 mg PO BID

PLUS one of the following:

Clarithromycin

500 mg PO BID or

1000 mg (ER) PO QD

Or

Azithromycin

500 mg PO daily on first day then 250 mg daily x 4 days

OR

Telithromycin

800 mg PO QD x 10 days

OR any ONE of the following ALONE:

Gatifloxacin

400 mg PO QD

Or

Levofloxacin

500 mg PO QD (x 10 days) or 750 mg PO QD (x 5 days)

Or

Moxifloxacin

400 mg PO QD

NO recent antibiotics or PO steroids within past 3 months*

First Choice

Newer macrolide (azithromycin or clarithromycin)

Second Choice

Doxycycline

Recent antibiotics or PO steroids within past 3 months (H. influenzae and enteric gram –ve rods implicated)

First Choice

Respiratory FQ

(Levofloxacin**, gatifloxacin, or moxifloxacin)

Second Choice

Amoxi/clav + macrolide

Or

2-G cephalosporin + macrolide

* Treat the same as patients without modifying factors with the only caveat that the newer macrolides be used to insure adequate coverage of H. influenza

**Among the currently available respiratory FQs, levofloxacin has a record of safety and effectiveness for the treatment of CAP in a large number of patients and it has demonstrated substantial cost savings when included in a critical pathway for the treatment of CAP.

Failure of First Line Agents ^#

Gatifloxacin

400 mg PO daily (10 days)

Or

Levofloxacin

500 mg PO daily (10 days)

Or

Moxifloxacin

400 mg PO daily (10 days)

Or

Cefuroxime 500 mg PO BID PLUS Erythromycin 500 mg PO QID (10 days)