The authors would like to acknowledge David A. Miller for his contributions that remain unchanged from the first edition.
Chronic obstructive pulmonary disease, 496
Pneumonia, community-acquired, 486
I. Defined as those pathogens found below the larynx
A. Note that pathogens in all parts of the lower respiratory tract are the same.
B. Recommended pharmacologic treatment may require revision after the results of sputum and blood cultures are obtained (Table 31-1).
| COPD, Chronic Obstructive Pulmonary Disease. | ||
| Lower respiratory tract infection | Organism | Recommended pharmacologic treatment |
|---|---|---|
| Acute tracheobronchitis | Viral | No therapy indicated |
| Mycoplasma pneumoniae | ||
| Chlamydia pneumoniae | ||
| Bordetella pertussis | ||
| Acute bacterial exacerbation of COPD | Viral, with secondary bacterial infection | Therapy may be unnecessary. |
| Streptococcus pneumoniae | Consider amoxicillin, trimethoprim-sulfamethoxazole, doxycycline, oral cephalosporin | |
| Haemophilus pneumoniae | ||
| Moraxella catarrhalis | For severe cases, consider amoxicillin-clavulanate, clarithromycin or azithromycin, oral cephalosporin, telithromycin, fluoroquinolone (with resistant S. pneumoniae coverage) | |
| Influenza | Influenza H and B (winter months) | Zanamivir (Relenza), 10 mg (two inhalations twice daily), or Oseltamivir (Tamiflu), 75 mg twice daily |
| Other viral | Supportive therapy. May check for respiratory syncytial virus in elderly or immuno-compromised patients, although ribavirin (Virazole) effectiveness in this setting is unknown | |
| Pneumonia: Community acquired | See TABLE 31-2TABLE 31-3TABLE 31-4TABLE 31-5TABLE 31-6TABLE 31-7TABLE 31-8 and TABLE 31-9. | |
II. Milder disease requires only narrow-spectrum antimicrobials, if any.
III. Severe disease requires a combination of antimicrobials while cultures are pending.
IV. The suggestions inTable 31-1apply to therapy that is chosen empirically while sputum and blood cultures are pending.
A. When culture data are available, antimicrobials used should be reviewed and changed if necessary.
B. The narrowest-spectrum antimicrobial that is reasonably expected to effectively treat the patient’s lower respiratory tract infection should be used.
V. Recall that antimicrobial therapy is intended to help clear pulmonary infection.
A. Other pharmacologic and nonpharmacologic therapies should be considered as well.
B. Examples:
1. Supplemental oxygen
2. Treatment of underlying chronic obstructive pulmonary disease
3. Nutritional support
| Typical bacterial pathogens (approximately 85%) | Streptococcus pneumoniae |
| Haemophilus influenzae | |
| Penicillin-sensitive S. pneumoniae | |
| Penicillin-resistant S. pneumoniae | |
| Ampicillin-sensitive H. influenzae | |
| Ampicillin-resistant H. influenzae | |
| Moraxella catarrhalis (all strains penicillin resistant) | |
| Atypical respiratory pathogens (approximately 15%) | Legionella species |
| Mycoplasma species | |
| Chlamydia pneumoniae | |
| Rare bacterial pathogens | Klebsiella pneumoniae (only in those with chronic alcoholism) |
| Staphylococcus aureus (postviral influenza setting) | |
| Pseudomonas aeruginosa (only in patients with cystic fibrosis or bronchiectasis) |
VII. Organism and treatment considerations for various pneumonias are depicted inTABLE 31-3TABLE 31-4TABLE 31-5TABLE 31-6TABLE 31-7TABLE 31-8 and TABLE 31-9.
| *Excludes patients at risk for HIV. | |
| †In roughly one third to one half of cases, no cause was identified. | |
| Organisms† | Streptococcus pneumoniae |
| Haemophilus influenzae | |
| Mycoplasma pneumoniae | |
| Chlamydia pneumoniae | |
| Miscellaneous | |
| Legionella species | |
| Staphylococcus aureus | |
| Aerobic gram-negative bacilli | |
| Therapy | First choice: macrolide (erythromycin, clarithromycin, or azithromycin) |
| Second choice: doxycycline | |
| *Excludes patients at risk for HIV. | ||
| †In roughly one third to one half of cases, no cause was identified. | ||
| Organisms† | Streptococcus pneumoniae Haemophilus influenzae Aerobic gram-negative bacilli Staphylococcus aureus Miscellaneous Moraxella catarrhalis Legionella species Mycoplasma | |
| Therapy | Chronic obstructive pulmonary disease (no recent antibiotics or oral steroids within past 3 months) | First choice: newer macrolides |
| Second choice: doxycycline | ||
| Chronic obstructive pulmonary disease (recent antibiotics or oral steroids in past 3 months) | First choice: respiratory fluoroquinolone* | |
| Second choice: amoxicillin/clavulanate plus macrolide or second-generation cephalosporin plus macrolide | ||
| Suspected microaspiration, oral anaerobes | First choice: amoxicillin/clavulanate and/or macrolide or fourth-generation fluoroquinolone (e.g., moxifloxacin) | |
| Second choice: third-generation fluoroquinolone (e.g., levofloxacin plus clindamycin or metronidazole) | ||
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