AIIMS releases antibiotic guidance for Community acquired pneumonia

All India Institute of Medical Sciences, Delhi has released AIIMS Antibiotics Policy which has been prepared by the Department of Medicine with Multidisciplinary collaboration. The antibiotic guidance for respiratory Infections includes Community-acquired pneumonia the salient features of which are hereunder.

When to suspect

Community-acquired pneumonia should be suspected in a patient presenting with fever, cough with expectoration, shortness of breath and bronchial breath sounds or crepitations on auscultation.

Note: No pathogen is identified in majority of the cases.

How to confirm

• 
  

  Chest X-Ray- presence of lobar consolidation/ interstitial infiltrates and/or cavitations.

  
  


• 
  

  Confirmation of diagnosis- gram staining and culture of sputum sample.

  
  


• 
  

  Serology for atypical pathogens may be required on a case to case basis.

  
  


• 
  

  Blood cultures may be helpful prior to the initiation of antibiotic therapy.

  
  

Treatment

The severity of CAP and requirement of in-patient care can be ascertained by simple scores such as CURB-65 score. One point each is awarded if the patient has Confusion, BUN> 20mg/dl, Respiratory rate>30/min, SBP<90mm of Hg or DBP <60 mm of Hg and Age >65 years. A CURB-65 score of ≥ 2 requires inpatient care.

Early initiation of empirical antibiotics is the key to the treatment of CAP as it prevents complications and decreases morbidity & mortality. Pathogen directed therapy should be started as soon as microbiological diagnosis is available to decrease antimicrobial resistance.

Etiology: Streptococcus pneumoniae, Haemophilus influenza, Moraxella catarrhalis, aerobic gram-negative bacteria, Mycoplasma pneumoniae, Chlamydia pneumoniae

Empirical Treatment:

Inpatient (CURB-65 ≥ 2)

[Inj. Ceftriaxone 1 g IV BD or Inj. Amoxicillin-clavulanic acid 1.2 g IV TDS] PLUS Azithromycin 500 mg (IV/PO) OD for 5 days

Outpatient (CURB-65 ≤ 1)

Tab Amoxicillin-clavulanic acid 625 mg TDS PLUS Tab Azithromycin 500 mg OD for 5 days

When risk factors of Pseudomonas are present: (COPD, bronchiectasis, broad-spectrum antibiotics for at least 7 days in the past month, corticosteroid therapy & malnutrition)

Replace Ceftriaxone with any of the following:

Piperacillin/Tazobactam 4.5 gm iv QID or Cefoperazone/Sulbactam 2- 3 gm iv BD (upto TDS in severe infections) or Cefepime 2gm iv TDS or Imipenem 500 mg QID or Meropenem 1g TDS

Remarks:

1. Once the aetiology of CAP has been identified on the basis of reliable microbiological methods, antimicrobial therapy should be directed at that pathogen.

2. Duration of antibiotic therapy may be extended if indicated clinically.

3. Fluoroquinolones should be avoided in the treatment of community-acquired pneumonia due to high burden of tuberculosis in India.

4. Macrolide (erythromycin) resistance noted in Streptococcus pneumoniae is between 9% - 20% in India.

5. Addition of empirical vancomycin: History of IV drug usage, post influenza pneumonia, severe CAP, associated skin and soft tissue infection.

The following criteria can be used for diagnosing severe pneumonia: (either major criterion or 3 or more minor criteria)

Major criteria:

• 
  

  Invasive mechanical ventilation

  
  


• 
  

  Septic shock with the need for vasopressors

  
  

Minor criteria:

• 
  

  Respiratory rate ≥ 30/min

  
  


• 
  

  P/F ratio < 250

  
  


• 
  

  Multilobar infiltrates

  
  


• 
  

  Confusion/disorientation

  
  


• 
  

  BUN ≥ 20mg/dl

  
  


• 
  

  WBC < 4000/mm3

  
  


• 
  

  Thrombocytopenia

  
  


• 
  

  Core temperature < 360C

  
  


• 
  

  Hypotension requiring aggressive fluid resuscitation