Stat Consult Other management • Deep vein thrombosis prophylaxis Follow-up
• ATS/IDSA recommendations — After 48 to 72 hours, assess clinical response with serial evaluations. — Make changes to empiric therapy based on clinical and microbiologic data. — Narrow therapy to most focused regimen possible using culture data. — In nonresponding patients, evaluate for ■ Noninfectious mimics of pneumonia ■ Unsuspected or drug-resistant organisms ■ Extrapulmonary sites of infection ■ Complications of pneumonia (empyema, abscess) Prognosis
• Better prognosis if onset is fewer than four days after admission. • Increased morbidity and mortality if onset five or more days after admission. • Decrease in procalcitonin or C-reactive protein (CRP) level over four days is associated with increased survival. • Elevated interleukin levels predicted development of septic shock Screening
• Daily CRP measurements might be effective in detection. • Daily routine CXRs appear to have low yield in intensive care unit. ■
72 THE CLINICAL ADVISOR • APRIL 2013 • www.ClinicalAdvisor.com
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— If recent antibiotic therapy, use drug from different antibiotic class when possible — If MDR risk low/absent ■ Cover for » S. pneumoniae » H. influenzae » Methicillin-sensitive S. aureus » Antibiotic-sensitive enteric gram-negative bacteria, including − Escherichia coli − K. pneumoniae − Enterobacter species − Proteus species − Serratia marcescens ■ Empiric mono-antibiotic therapy may be as effective as combination antibiotic therapy for suspected ventilator-associated pneumonia ■ Monotherapy options − Ceftriaxone (Rocephin) − Levofloxacin (Levaquin) − Moxifloxacin (Avelox) − Ciprofloxacin (Cipro, Proquin) − Ampicillin/sulbactam (Unasyn) − Ertapenem (Invanz) — If MDR risk high ■ Cover for » P. aeruginosa » K. pneumoniae » Acinetobacter species » Methicillin-resistant S. aureus (MRSA) » L. pneumophila » Local nosocomial pathogens ■ Dual or triple therapy recommended » One of − Cefepime (Maxipime) − Ceftazidime − Imipenem − Meropenem (Merrem) − Piperacillin-tazobactam (Zosyn) » Plus one of − Ciprofloxacin − Levofloxacin − Amikacin (Amikin) − Gentamicin (Garamycin) − Tobramycin » If MRSA risk or high incidence locally, add one of − Linezolid (Zyvox) − Vancomycin (Vancocin)