Antimicrobial treatment of hospital-acquired pneumonia in adults
Pon the footsteps of Russian national guidelines in 2009
Allocate empirical and targeted antimicrobial treatment of nosocomial pneumonia (NP0. Most ABT begin in the empirical mode, and after the identification of the causative agent of its optimized taking into account the sensitivity to antimicrobial agents.
Identified two important conditions of treatment of patients with NP: providing timely and appropriate antimicrobial therapy and reduce waste and excessive use of antimicrobial agents.
Determining the outcome of treatment is the immediate appointment of an adequate empirical antimicrobial therapy.
In extremely severe cases ABT correction after the data sensitivity of flora due to inadequate selection of home ABT is not able to reduce mortality.
To implement the second rule of antimicrobial therapy provides a number of approaches: improving the quality of diagnosis of NP, refusal to carry out at ABT questionable diagnosis of NP and the rejection of unjustified antibiotic NP in patients on mechanical ventilation, antibiotic administrative restrictions (can reduce unnecessarily frequent use of some high-performance products) tactics de-escalation (change mode of antibiotic therapy for a wide range narrower on the results of bacteriological tests) reduction in the duration of the course of ABT based on regular monitoring of the patient's condition and results of microbiological studies.
The main criteria for the selection of adequate empirical therapy:
1) A wide range of activity against most relevant pathogens in view of the sensitivity of the local flora;
2) length of hospital stay before the occurrence of the NP (early and late);
3) risk management multiresistant pathogens.
So, at the risk of Pseudomonas infection modes of AMT should include products with pseudomonas activity, taking into account the local features of the sensitivity of P.aeruginosa; when an infection caused by staphylococcus, especially resistant to methicillin / oxacillin (MRSA),? treatment regimen is necessary to attach drugs active against resistant Gram-positive pathogens (linezolid, vancomycin).
Alternative drugs (rifampicin, ciprofloxacin, levofloxacin) are recommended only for documented sensitivity to the local monitoring. Preferably their combined use.
Original and generic drugs
All data on the efficacy and safety of ABT NP obtained in the study of original drugs.
Data on the relative effectiveness of original and generic drugs at the NP is not enough. Therefore, the treatment of life-threatening infections of the cost factor of the drug can not prevail over the factors of efficiency and safety.
Monotherapy and combination therapy
There are no reliable clinical evidence of the superiority of combination therapy versus monotherapy.
There are experimental data synergism beta-lactams and aminoglycosides against P.aeruginosa and Acinetobacter spp. Monotherapy NP beta-lactams (carbapenems, cephalosporins, penicillins, or pseudomonas) was compared to the combination therapy (beta-lactam + AH), 16 randomized clinical trials. None of them has been detected benefits of combination therapy with inclusion of hypertension before monotherapy beta-lactams.
Moreover, the use of hypertension increased the frequency of adverse drug reactions.
Therefore, routine use of combination regimens ABT unjustified.
Such combinations are suitable only when one of the possible causative agents definitely not be sensitive to the recommended treatment regimen (e.g., MRSA to beta-lactams and fluoroquinolones)? in this case it is advisable to add linezolid or vancomycin. Combinations of antibiotics are also grounded in the allocation panrezistentnyh strains of gram-negative bacteria (P.aeruginosa, Acinetobacter spp.). In patients with immunological disorders appropriate to discuss the issue of combination therapy with antifungal agents.
Antifungal therapy
Mushrooms are not usually considered as the etiological causes of the NP. Isolated lesions of the lungs, which can be conventionally regarded as fungal NP, due to Aspergillus spp. Other fungi are (Mucor spp., Rhizopus spp., Fusarium spp., Pneumocystis jiroveci, etc.) are much rarer.
Candida spp. NP caused very rarely. Lung damage is possible with hematogenous dissemination or aspiration of gastric contents.
The drug of choice for the treatment of pulmonary aspergillosis is voriconazole. After stabilization, a transition to oral, but it is always important to continue the use of voriconazole to a complete cure. With the ineffectiveness of voriconazole second-line drugs is caspofungin.
The use of amphotericin B limit the inefficiency and high toxicity and use it mostly for economic reasons.
Fluconazole is inactive against most pathogens including Aspergillus spp., Where it should not be used.
If confirmed fungal lung infection antifungal therapy is carried out to relieve persistent clinical, laboratory and instrumental signs of infection. An important condition for successful treatment is to eliminate or reduce the severity of risk factors, particularly neutropenia and the use of steroids.
The route of administration and dosage of antimicrobial
Choosing the route of administration is determined by the severity of the patient's condition, the pharmacodynamic and pharmacokinetic characteristics of drugs. In most patients beginning treatment with NP require intravenous antibiotics. In the future, the clinical efficacy of therapy and no dysfunction of the gastrointestinal tract can move to the ingestion, but drugs with bioavailability (fluoroquinolones and linezolid)? the so-called sequential therapy.
Some antibacterials well into the lung tissue, achieving therapeutic concentrations (linezolid, fluoroquinolones), others (vancomycin)? bad.
The effectiveness of beta-lactam is dependent on the duration of the outbreak of infection in a concentration greater than the minimum inhibitory concentration of agent that requires frequent administration. Promising is the purpose of beta-lactams by prolonged or continuous infusion.
The effectiveness of other antibacterial drugs (fluoroquinolones, aminoglycosides) depends on the concentration in the infection. Single dose correctly calculated daily doses of aminoglycosides (with proper body weight and kidney function) increases not only their performance, but also safety.
In recent years, there are also data on aerosol routes of administration, in particular aminoglycosides and polymyxin B.
Despite the theoretical advantages of the approach (with higher concentrations in the lung tissue), and anecdotal reports of efficacy against multi-drug resistant P.aeruginosa (for polymyxin), is required to obtain reliable evidence to determine whether widespread clinical use of this route of administration.
Duration of therapy
Normally the ABT TM is 14-21 days.
Considered proven ability to reduce treatment time to 7-8 days without compromising the clinical efficacy, except NPivl caused by non-fermenting microorganisms (P.aeruginosa and Acinetobacter spp.), Or detection of suppurative complications (empyema, abscess formation) that require longer courses of ABT .
pneumonia symptoms in adults
Doctor Sapkota tells his patients about symptoms of pneumonia in adults. Read more here: http://bitly.com/zapiYj.
Video transcript:
Today I will be talking about how pneumonia symptoms develop in adult patients. In this video, I am not talking to my fellow health care providers but I am talking directly to you- the patient. You may be a patient concerned about symptoms or pneumonia or you may have a friend or family member who you think may have symptoms of pneumonia. This video is for you. You do not need any medical background to understand what I am going to explain. I will not be using any medical terms.###First off, let me tell you there are no universal symptoms of pneumonia that can apply to all patients. Symptoms of pneumonia depend on the specific situation of the individual patient having pneumonia. That is why instead of listing a set of symptoms just like other medical websites do, I will tell you how pneumonia symptoms develop in our body. Once you understand that, you can predict which patient may have what kind of symptoms.You have to learn a little about how we breathe to understand pneumonia.
When we breathe air in, it goes down from our nose into our throat down into our air pipes. The air pipes divide and take the air down into our 2 lungs. Each lung is like a bag of small air bubbles. Each bubble is connected by small pipes and these small pipes are connected to larger pipes. Eventually the lager pipes connect to the two branches of the air pipe. When we take air in, all these bubbles expand. When we breathe the air out, these bubbles partially collapse. This is how air moves in and out of the lungs as we breathe. In these bubbles, there are blood vessels with very thin walls. They capture the oxygen in the blood and give out carbon-dioxide. Then the blood carries oxygen to all over our body.
Now you understand what lungs are how how we breathe with them. Pneumonia is simply an infection of the lungs. When bugs get into the lungs, they settle down deep inside. They cause irritation of the nerves in these small air tubes. They cause inflammation or swelling of the lungs and they produce pus like gunky liquid that can fill up these delicate small air bubbles. This irritation can cause cough and pain with breathing. The swelling can cause difficulty breathing. The fluid in the bubbles can prevent the blood vessels from being able to pick up oxygen from the bubble.This can cause low levels of oxygen in the blood. These bugs can also produce toxins that can travel into the blood and cause fevers, chills, weakness and sometimes confusion.
Having said that, do not think that all patients with pneumonia have all of those symptoms I just mentioned. The exact symptom in an patient depends on the unique situation. If someone has a very healthy and elastic lungs their nerves are very sensitive. They may have bad cough as soon as the bug gets there and start coughing those up. The only symptoms they may have could be cough and pain in the chest with cough. If someone has damaged and scarred lungs, the nerves may not be that sensitive and they may not have much cough to start with. They probably have the pneumonia spread to a larger area of the lungs even before they start to have any symptoms. Their symptoms may be more from swelling of lungs than from irritation. They may only have symptoms of shortness of breath. Again, in patients with years of smoking, they may have saggy big lungs. In those patients the first symptom may be from low oxygen in the blood as they do not have much lung capacity or lung reserve.
This way, when you understand the basic mechanism of how pneumonia causes symptoms, you can put the unique symptoms of a patient together and see it it fits the pattern. This is the correct way to learn about pneumonia symptoms in adults. If you have any questions, leave a comment and I will talk about those in my future videos. Thanks for listening.
Thank you.
