Identifying optimal drugs pt specific factors

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Identifying Optimal Drugs Pt specific factors (allergies, comorbidities) Antimicrobial properties Spectrum of activity Dose PKs AE profile Cost Streptococcus Pneumoniae Aerobic, encapsulated, GP diplococci Most common form of CAP Older patients, those without significant underlying disease Mortality ~5% DOC Penicillin or ampicillin Macrolides resistance 35% in US FQ Resistance rare, recent FQ Treatment Options 3rd generation cephalosporin ß-lactam/ß-lactamase inhibitor Respiratory FQ Haemophilus Influenzae Aerobic, encapsulated, GN coccobacilli Group B and non-typeable strains Elderly individuals, smokers with COPD Treatment Options 3rd gen Cephalosporin Respiratory viruses: influenzae A and B, respiratory syncytial virus, parainfluenza
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ß-lactam/ß-lactamase inhibitor Newer macrolide FQ What’s atypical about atypicals Mycoplasma pneumoniae Chlamydophilia pneumoniae Legionella pneumophilia Not detectable on a gram stain or cultivatable on standard bacteriologic media Common causes of CAP, especially outpatients Subacute onset Not often identified in clinical practice Mycoplasma pneumoniae “Walking pneumonia” < 40-50 y.o. w/o significant comorbidities Hacking cough, worse at night Seasonal- late summer, early fall Treatment options Macrolide FQ Tetracycline Chlamidophylia pneumoniae Obligate intracellular bacterium 5-15% cases Mild symptoms (similar to M. Pneumoniae) Treatment options Macrolide FQ Tetracycline Legionella pneumophilia “Pontiac fever” Gram-negative bacilli Ubiquitous in aqueous environments Standing water, soil Aerosolized by cooling towers, shower heads Peaks in summer and fall Treatment options Macrolide FQ Tetracycline Macrolides In vitro activity against gram pos and some gram neg Increased rates of S. Pneumoniae resistance Active vs atypicals Azithromycin, clarithromycin > erythromycin Better PO Absorption
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Broader spectrum of activity ADEs: NVD, QTc prolongation DDIs: clarithro > azithro FQ In vitro activity against gram pos and negative 2nd generation (ciprofloxacin) GN organisms (P. Aeruginosa) Some GP Some atypical coverage 3rd/4th generation (levo and moxi) Similar spectrum as 2nd gen Increased GP coverage Increased atypical coverage Moxi: anaerobic coverage ADE Nausea, anorexia, QTc prolongation, arthropathy, tendonitis DDI Chelation with cations, variety of drugs Respiratory FQ: moxi, gemi, levo Outpatient Tx options Previous healthy, no antibiotic therapy 3 months Macrolide Azithromycin 500 mg PO x 1, 250 mg x 4d Clarithromycin 500 mg PO q12h x 5d Doxycycline 100 mg PO q12h Presence of comorbidities* or antimicrobial use within 3 months OR high rate (>25% of high level macrolide resistant S. Pneumoniae
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  • Fall '19
  • Tetracycline, UTI, Ceftriaxone

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