Sir William Osler called pneumonia “the captain of the men of death.” Over a century later, pneumonia remains the leading cause of infectious death in the developed world.
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Evidence that tracheal aspirates are helpful? I noted that this wasn’t explicitly referenced. I’m concerned that tracheal bugs may misguide the microbiological dx?
PS This electronic handbook is a great idea, thank you!
There is pretty reasonable evidence to support tracheal aspirates. There are a lot of studies out there comparing tracheal aspirates versus bronchoscopy (which is the gold standard), and this literature essentially shows no difference in clinical outcomes. Most of these studies were performed in patients with ventilator-associated pneumonia but similiar test characteristics should generally apply.
That said, both tracheal aspirates and bronchoscopy are potentially imperfect. Both can be contaminated in various ways. One study of bronchoscopy compared lavaging different parts of the lungs and found less than perfect agreement between the different samples. So nothing is perfect.
Hi Josh
Does it matter which macrolide is used?
You mention azothromycin being a good choice. Would clarithromycin/erythromycin be reasonable choices too?
I think clarithromycin would be fine, although I don’t know a ton about it because I rarely use it. QTc issues might be more of a problem with clarithromycin (whereas they really aren’t with azithromycin).
Clarithromycin also lacks an IV form (for when that’s relevant), has to be dosed every 12 hours instead of daily, and has more drug interactions due to CYP3A4 and P-glycoprotein inhibition.
Erythromycin does have an IV form, but needs to be given every 6 hours, has the same drug interaction issues as clarithromycin, and overall is tolerated less well (PO form causes lots of GI issues, IV administration is reportedly very irritating with high risk of phlebitis).
Here in Brazil we use a lot Clarithomycin… that´s ok for us…
But the question is… do we really need macrolide for treating CAP?
Hello,
Why do you consider ceftriaxone contra-indicated in case of reported penicillin anaphylaxis ?
Nice review, thanks
Great question!! We will eventually have a whole chapter on penicillin allergy. Honestly I think you would probably be fine, but most references seem to shy away from cephalosporins in patients with PCN anaphylaxis (even 3rd-4th generation cephalosporins). Meropenem is definitively safe based on a deep dive into the literature on that. Will look into this question further when we do the chapter on PCN allergy.
Great job, Josh.
A few words about steroids in CAP:
The Torres study in JAMA 2015; 313(7): 677-86 – doi:10.1001/jama.2015.88 showed that in patients with severe community-acquired pneumonia and a high inflammatory response, defined as CRP > 150 mg/L at admission, iv methylprednisolone @ 0.5 mg/kg q 12 hours for 5 days may decrease the “treatment failure”
Hello,
here is Bernardo from Portugal.
Why do you recommend Ceftriaxone as the first beta-lactam choice instead of Amoxicillin? Is it because we’re talking about COP in a ICU environment?
Hi ,
Need ur opinion on diffrent steroid .
Won’t dexamethasone cause critical illness associated weakness more than hydrocortisone . And methylpred has more lung penetrance than other two
So won’t it be better to choose
Hydrocortisone > Methylprednisolone > dexamethasone as last resort .
Thank u
Procalcitonin is not significantly impacted by renal function, at least not to the point of obviating it when used in practice in the ICU where large changes and cutoffs are utilized within the clinical context to make antibiotic de-escalation or discontinuation decisions. Lot of studies out there looking at this, whether CKD, AKI, on/off CRRT, measuring levels in urine and plasma etc. Procal is elevated in ESRD/PD pts at baseline and will be impacted to some degree by IHD pre/post so this does need to be taken into account. But studies like this one (SAPS 26947523) didn’t exclude these patients,… Read more »