University of Pennsylvania Medical Center Guidelines for Antibiotic Use
PULMONARY INFECTIONS
|
Clinical Setting |
Empiric Treatment |
Likely Pathogens |
Definitive Treatment |
Dosage Regimen |
Duration |
Community Acquired Pneumonia |
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|
Single lobe involvement, without comorbidities1 |
azithromycin + penicillin G2 |
S. pneumoniae |
penicillin G3 |
3.0 mu IV q 4 hr |
7-14 days4 |
|
Mycoplasma spp. or Legionella spp.7 |
azithromycin |
500 mg qd x 3 days |
3 days4 |
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|
Chlamydia pneumoniae |
doxycycline |
100 mg q 12 hr |
10-14 days4 |
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|
With comorbidity1, multilobar involvement, or gram negative bacilli on sputum Gram stain |
levofloxacin5 -OR- 750 mg q 24h x 5 d |
as above |
as above |
as above |
as above |
|
H. influenzae |
TMP/SMX |
8-10mg/kg/d TMP in 3-4 divided doses |
10-14 days4 | ||
|
Legionella spp.7 |
azithromycin |
500 mg qd x3 days |
3 days4 |
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|
Transplant recipient (on cyclosporin A or tacrolimus) |
levofloxacin5 -OR- 750 mg q 24h x 5d |
S. pneumoniae |
penicillin G2,3 |
3.0 mu IV q 4 hr |
14-21 days4 |
|
H. influenzae |
levofloxacin |
500 mg q 24 hr |
10-14 days4 |
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|
Mycoplasma spp. |
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|
Chlamydia pneumoniae |
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|
Legionella spp.7 |
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|
Long term care facility |
see Nosocomial pneumonia below |
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|
Intensive Care Unit |
azithromycin or levofloxacin6 +penicillin G2 |
S. pneumoniae |
penicillin G3 |
3.0 mu IV q 4 hr |
7-14 days4 |
|
H. influenzae |
TMP/SMX |
8-10mg/kg/d TMP in 3-4 divided doses |
10-14 days4 |
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|
Mycoplasma spp. or Legionella spp.7 |
azithromycin |
500 mg qd x 3 days |
3 days4 |
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|
Chlamydia pneumoniae |
doxycycline |
100 mg q 12 hr |
10-14 days4 |
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1Comorbidities: COPD, ESRD, liver disease, RR>30/min, SBP<90mmHg, DBP<60mmHg, PaO2<60mmHg or PaCO2>50mmHg
2If beta-lactam allergy: use ceftriaxone 1g IV q 24 hr for rash, vancomycin for hives and more severe reactions
3Review susceptibilities-S. pneumoniae resistance is about 2-5% (NCCLS and CDC criteria)
4Should switch to oral therapy once clinical improvement occurs: for penicillin G, switch patient to amoxicillin 1 gm po tid.
5If P. aeruginosa a consideration (ANC<500/mcg/l), add tobramycin
6If gram negative pneumonia suspected, use levofloxacin
7 If patient has Legionnaires' disease and is immunosuppressed, give azithromycin 500 mg qd for 7 to 10 days
|
Clinical Setting |
Empiric Treatment |
Likely Pathogens |
Definitive Treatment |
Dosage Regimen |
Duration |
Aspiration Pneumonia |
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|
Outpatient acquired |
penicillin G1 + metronidazole |
oral flora |
penicillin G + metronidazole |
3.0 mu IV q 4 hr 500mg IV/PO q 12 hr |
10-14 days3 |
|
Nosocomial (includes nursing home2) |
cefepime OR piperacillin/tazobactam4 |
oral flora |
cefepime
|
1 gm IV q 12 hr |
10-14 days3 |
|
Enterobacteriaceae |
TMP/SMX + metronidazole |
8-10mg/kg/d TMP in 3-4 divided doses 500mg IV/PO q 12 hr |
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|
P. aeruginosa |
review susceptibility data |
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|
S. aureus |
nafcillin5 or cefazolin5 |
2gm IV q 4-6 hr 500mg IV q 8 hr |
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|
A. baumanii |
review susceptibility data |
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|
Tracheobronchitis |
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|
Acute |
TMP/SMX |
S. pneumoniae |
amoxicillin6 |
1gm PO q 12 hr |
10-14 days |
|
H. influenzae M. catarrhalis |
TMP/SMX |
160mg/800mg (1 double strength tablet) PO BID |
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|
Mycoplasma spp. |
erythromycin base |
500mg PO q 6 hr |
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|
Chlamydia pneumoniae |
doxycycline OR erythromycin base |
100mg PO q 12 hr 500mg PO q 6 hr |
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|
viral |
no treatment |
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|
Intubation/Tracheostomy |
TMP/SMX7 |
S. aureus |
nafcillin5 OR cefazolin5 |
2 gm IV q 4-6 hr 500mg IV q 8 hr |
14 days |
|
Enterobacteriaceae |
TMP/SMX |
8-10mg/kg/d TMP IV in 3-4 divided doses |
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|
P. aeruginosa |
cefepime8 |
2gm IV q 12 hr |
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|
A. baumanii |
review susceptibility data8 |
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1If penicillin allergy use clindamycin
2If community-acquired pneumonia is a possibility add azithromycin to regimen
3Can switch to oral therapy once clinical improvement occurs: for penicillin G - use amoxicillin 1 gm poTID
4For piperacillin/tazobactam dosing, please refer to the renal dosing guidelines for recommendations.
5If penicillin allergy use clindamycin or trimethoprim/sulfamethoxazole; if MRSA-use vancomycin
6Review susceptibilities-S. pneumoniae resistance ranges from 4-7% (NCCLS criteria)
7Substitute levofloxacin if gram negative bacilli are seen on Gram stain or if P. aeruginosa suspected.
8If multiresistant microorganism, consider aerosolized tobramycin
updated 9/28/04 by Lori LaRosa