Pneumonias: 1. Morphologic Forms: A. Bronchopneumonia B. Lobar Pneumonia C. Interstitial Pneumonia 2. Pathology: Phases: Lobar Pneumonia A.

Congestion: Hyperemia, Heavy , Red, Boggy B. Red Hepatization: Liver Like Consistency; Alveolar Spaces With RBCs, PMNLs & Fibrin C. Gray Hepatization: Liver Dry, Gray & Firm; RBCs Lyse While Fibrinous Exudates Persists In The Alveoli D. Resolution 3. Consider Patients Age: A. Infants: Viral Pneumonia Common B. Young Adults: Mycoplsama Pneumonia Common C. Adults: Streptococcus Pneumonia Common D. Immunocompromised Patients: AIDS: Pneumocytis Carinii Pneumonia 4. Bacterial Pneumonias: A. Streptococcal Pneumonia : Commonest Community Acquired Pneumonia 1. Streptococcal Pneumonia Infections Occur With Increased Frequency in: 1. CHF, COPD, Diabetes Mellitus 2. Congenital Or Acquired Immunoglobulin Defects 3. Decreased Or Absent Splenic Function: SC Anemia, Post-Splenectomy 4. HIV 5. Alcoholism 2. Dx: 1. Gram Stain: Gram Positive Diplococci In Neutrophils 2. Blood Cultures

3. Clinical Findings: 1. High Fever 2. Shaking Chills 3. Pleuritic Chest Pain 4. Cough With Copious Purulent Sputum Production 4. Physical Findings: 1. Auscultation: A. Crackles B. Diminshed Breath Sounds 2. Percussion: A. Dullness To Percussion: 1. If Pleural Effusion Present 5. Rx: Outpatient Setting 1. Macrolides: A. Azithromycin Or Clarithomycin 2. Add: Cefotaxime + Beta-Lactam/Beta-Lactamase Inhibitor In Outpatient Setting With More Severe Presentation 5. Other Bacterial Pneumonias: A. Hemophilus Influenzae:
1. Individuals At Risk For H. Influenzae With

A. Chronic Pulmonary Disease: Cystic Fibrosis, Chronic Bronchitis, COPD, Bronchiectasis. 2. H. Influenzae: Most Common Bacterial Cause Of Acute Exacerbation Of COPD 3. H. Influenzae Type B: Epiglottitis In Children B. Moraxella Catarrhalis: 1. Second Most Common Bacterial Cause Of Acute Exacerbation Of COPD 2. S.Pneumoniae, H Influenzae and M Catarrhalis Are The Top Three Causes of Otitis Media in Children.

C. Staphylococcal Aureus: 1. Is An Important Cause : A. Secondary Bacterial Pneumonias In Children and Healthy Adults Following Viral Respiratory Illnesses ex. Measles in Children & Influenza in Children and Adults B. IVDA Right Sided Endocarditis C. Nosocomial Pneumonias 2. Associated With Complications : Lung Abscess & Empyema D. Klebsiella Pneumonia: 1. Most Frequent Cause Of Gram Negative Pneumonia. 2. Affects Debilitated, Malnourished Patients esp. Chronic Alcoholics 3. Thick Gelatinous Sputum E. Legionella Pneumophilia: 1. Cause Of Legionnaires Disease & Pontiac Fever. 2. Flourishes In Artificial Acquatic Environments Example: Water Cooling Towers & Within The Domestic Potable Water Supplies 3. Organ Transplant Recipients Are Particularly Vulnerable 4. Diagnostic Tests A. Positive Fluorescence Antibody Test On Sputum Samples Or Legionella Antigens in the Urine Are Helpful In Diagnosis. Cultures Remain The Gold Standard. 5. Clinical Findings: A. Fever B. Mild Cough C. Mental Status Changes D. Myalgias E. Diarrhea F. Respiratory Failure

6. Physical Findings: A. Auscultation: 1. Crackles 2. Diminished Breath Sounds B. Dullness to Percussion: 1. If Pleural Effusion Present F. E. Coli G. Pseudomonas 6. Atypical Pneumonias: A. Typical Syndrome included: 1. Pharyngitis & Systemic Flu-Like symptoms Evolved Into 2. Dry Cough 3. Modest Sputum Production 4. Moderately Elevated WBC Count 5. No Physical Findings Of Consolidation 6. Bacteria or Influenza A Virus Could Not Be Isolated. B. Causes Include: 1. Mycoplasma Pneumonia: Esp. Schools, Military Camps and Prisons 2. Chlamydia Psittaci: Psittacosis : Bird Handlers, Bird Fanciers 3. Chlamydia Trachomatis: Infants, Immunosuppressed Adults 4. Coxiella Burnetii: Q Fever: Farmers. Livestock Handlers 5. Chlamydia Pneumonia C. Diagnosis: 1. Cold Agglutinins For Mycoplasma: Effective 50% Of The Time 2. Polymerase Chain Reaction For Mycoplasma Organisms 3. Look For Rising Titers of Specific Antibodies D. Treatment: 1. Erythromycin: For Mycoplasma and Chlamydia Coverage

7. Mycoplasma Pneumonia: A. Incidence: 1. Estimated to Be 1 Case/ 1000 Persons/Year 2. Incidence Is Estimated To Triple Every 5 Years During An Epidemic 3. Probably Many Cases Resolve Without Coming To Medical Attention B. Peak Incidence: 1. Fall to Early Winter 2. Seems More Prevalent In Temperate Climates C. Prevalence: 1. 20% Of Hospitalized Patients For Pneumonia 2. Estimated To Cause 7% Of All Pneumonias 3. Half of Those Aged 5 To 29 Years Of Age D. Predominant Sex 1. Males= Females E. Predominant Age: 1. School Children & Young Adults (Ages 5-20 Years of Age) 2. Older Adults Especially With Exposure To Young Children 3. More Severe Infections In Elderly Patients F. Genetics: 1. May Be More Severe in Sickle Cell Anemia Patients 2. Neonatal Infections: Severe Respiratory Distress Sometimes Requires Intubation. G. Etiology: 1. Droplet Infection H. Clinical Findings: 1. Skin Rashes: A. Morbilliform B. Urticaria C. Erythema Nodosum (Unusual) D. Erythema Multiforme (Unusual) E. StevenJohnson Syndrome: Rare 2. Muscle Tenderness

3. Bullous Myringitis 4. Lymphadenopathy and Splenomegaly 5. Conjunctivitis I. Physical Findings: 1. Rhonchi or Rales Without Evidence Of Consolidation 2. Mononeuritis Or Polyneuritis 3. Transverse Myelitis 4. Cranial Nerve Palsies 5. Meningoencephalitis J. Work Up: 1. Chest X-Ray 2. Thorough History & Physical Examination 3. Laboratory Tests 4. Evaluation Guided By Symptoms K Imaging Studies: Chest X-Ray: 1. Predilection For Lower Lobe Involvement With X-Ray Abnormalities Frequently Out Of Proportion To Those On Physical Examination 2. 30%: Small Pleural Effusions 3. Large Effusions: Rare 4. Infiltrates: Patchy, Unilateral and Segmental Distribution : Multilobar Involvement May Be Seen 5. Hilar Adenopathy: 20-25% 6. Rare Cases Reported: A. Associated Lung Abscesses B. Residual Pneumatoceles C. Lobar Collapse D. Hyperlucent Lung Syndrome L. Laboratory Tests 1. WBC: WBC Count> 10,000/mm3: 25% Of Patients Differential: Non-Specific Leukopenia: Rare

2. Cold Agglutinins Positive A. Also Seen in: 1. Lymphoproliferative Disorders 2. Influenza 3. Mononucleosis 4. Adenovirus Infections 5. Legionnaires Disease: Occasionally B. Titers: >1:64 1. May Be Detectable With Bedside Testing 2. Appear Within Days 5-10 of Illness 3. Complement Fixation Testing Or Other Immunoassays Specific For Mycoplasma Antigens Of Paired Sera (Fourfold Rise) In Patients With Pneumonia A. Considered Diagnostic In Appropriate Clinical Setting 4. Cultures: A. Only True Specific Test For Infection B. Only Done By Few Laboratories & Technically Difficult C. May require Weeks For Results 5. Complications: Possible: A. Pancreatitis B. Glomerulitis C. DIC: Rare D. EKG Evidence Of Myocarditis Or Pericarditis M. Management: 10-14 Days Of Treatment A. Outpatient 1. Levofloxacin 2. Azithromycin 500 mg OD 3. Clarithromycin 500 mg BID 4. Erythromycin 500 mg QID B. Hospitalization: For Hospitalized Community Acquired Pneumonias: 1. Quinolones: Levofloxacin, Moxifloxacin, Gatifloxacin : As Effective As 2. Macrolide: Azithromycin IV +Third Generation Cephalosporin: Ceftriaxone , Ceftizoxime, Cefotaxime or Cefuroxime

8. Viral Pneumonia: A. Incidence: 1. Influenza Virus: A. 10-20% Of The Population In Temperate Zones Infected During 1-2 Month Epidemics Occurring Yearly During the Winter Months B. Up to 50 % Infected During Pandemics C. Pneumonia Develops in Small Percentage Of Infected Persons B. Peak Incidence: 1. Influenza A: Winter Months 2. Influenza B: Year Round 3. RSV & Parainfluenza: Winter and Spring 4. Adenovirus: Endemic (Military and Schools) 5. Varicella: Spring in Temperate Zones 6. Measles: Year Round 7. CMV: Year Round 8. Hantavirus 9. Herpes C. Prevalence: 1. Often Related To Immune Status Or Presence Of Epidemic 2. Normal Hosts: A. 89% of Cases Of Pnemonia Result In Hospitalization in USA B. 16% of Pediatric Pneumonias Managed As Outpatients C. 49% of Hospitalized Infants With Pneumonia 3. Important Problem In Immunocomprised Hosts D. Predominant Sex: 1. None Generally 2. Male Sex May Predispose To More Severe Respiratory Infection In RSV Infection

E. Predominant Ages: 1. Greatest Overall Incidence: Age 5 Years 2. The Most Serious Sequelae In Those With Chronic Medical Illnesses Especially Caridopulmonary Diseases 3. Hospitalizations Greatest In Infants & Adults > Age 64 Years 4. RSV and Parainfluenza: A. Major Cause Of Pneumonia In Young children B. Occurs Throughout Life 5. Adenovirus: A. Young Children B. Military Recruits 6. Varicella: A. 16% of Adults Not Previously Infected With Chickenpox B. Acute Varicella During Pregnancy More Likely To Be Complicated By Pneumonia A. 90% Of Reported Varicella Pneumonia Cases Are In Adults (Highest Incidence: 20-60 Years of Age) 7. Measles: A. Young Adults & Children Who Received A Single Vaccination ( 5% Failure Rate) B. Measles During Pregnancy Likely to Be Complicated By Pneumonia C Underlying Immunosuppression & Cardiopulmonary Disease Predispose To Penumonia D. Currently > 33% of US Patients > 14 Years of Age E. 3-50% of Measles Cases Are Complicated By Pneumonia 8. CMV: A. Neonatal Through Adult

F. Genetics: 1. Familial: Disposition: A. Congenital Anomalies & Immunosuppression Worsen RSV Infections 2. Congenital Infections: A. CMV : Most Common Intrauterine Infection In USA. 3. Neonatal Infections A. Severe RSV Pneumonia B. Adenovirus Pneumonia: 5-20% Fatality rate C. Varicella Neonatorum 1. Dsisseminated Visceral Disease Including Pneumonia C. May Develop in Neonates Whose Mothers Develop Peripartum Chickenpox D. CMV Pneumonia 1. Generally Fatal 2. Associated With Severe Cerebral Damage G. Clinical Findings & Physical Findings: 1. Influenza: A. Fever B. Lethargy C. Prominent Dry Cough D. Flushed Integument E. Erythematous Mucous Membranes F. Rales and Rhonchi 2. RSV & Parainfluenzae: A. Fever B. Tachypnea C. Prolonged Expiration D. Wheezes & Rales 3. Adenovirus A. Hoareseness B. Pharyngitis C. Tachypnea D. Cervical Adenitis

4. Measles: A. Conjunctivits B. Rhinorrhea C. Kopliks Spots D. Exanthem E. Pneumonias: 1. Complication in 3-4% Of Adolescents & Young Adults 2. Coincident With Rash 3. May Also Develop Following Recovery From Measles F. Fever G. Dry Cough 5. Varicella: A. Fever B. Maculopapular Or Vesicular Rash 1. Becomes Encrusted C. Pneumonia : 1. Typically 1-6 Days After Rash Appears 2. Accompanied By Cough & Occasionally Hemoptysis 6. CMV: A. Fever B. Paroxysmal Cough C. Occasional Hemoptysis D. Diffuse Adenopathy When Penumonia Occurs After Transfusion

H. Work Up 1. Cultures: From Respiratory Secretions During The Initial Few Days Of The Illness 2. Paired Sera Antibody Titers 3. Monoclonal Antibody Tests: Available For Influenza & Other Respiratory viruses 4. Clinical Diagnosis: For Measles and Adenovirus Pneumonia. 5. Polymerase Chain Reaction: A. May Identify Viral Nucleic Acid 6. Open Lung Biopsy: For CMV Pneumonia 7. Exudative : Parapneumonic Pleural Effusions May Occur. I. Laboratory Tests: 1. Sputum Gram Stains A. Few PMNLs & Few Bacteria 2. WBC Count: A. Lekopenia To Modest Elevation B. Without Leftward Shift 3. DIC: Complicates Adeovirus 7 Pneumonia 4. Tzanck Test: Mulinucleated Giant Cells: Varicella 5. Profound Hypoxemia Possible 6. Cultures : May Be Helpful If Superinfecting Bacterial Infection J. Imaging Studies 1. Chest X-Ray: Vary Fron: A. Ill-Defined Infiltrates B. Patchy Infiltrates C. Genralized Interstital Infiltrates D. Small Calcified Nodules: May Develop As Residulal of Varicella Pneumonia E. Localized Dense Alveolar Infiltrate: If Superimposed Bacterial Pneumonia

K. Management: 1. Non-Pharmacologic Therapy: A. Decrease Person to Person Transmission B. Modified Bed Rest C. Adequate Hydraation D. Ventilatory Support For Severe Pneumonia or ARDS 2. Influenza: A. Yearly Strain Specfic Vaccination 3. RSV: A. Isolation Techniques B. Immunoglobulins With High RSV Neutralizing Antibody Titers 4. Adenovirus: A. Vaccines Not Available For Civilian Population B. Intestinal Inoculation of Respiratory Adenovirus In Military Recruits. 5. Varicella: A. Live Attenauted Varicella Vaccine B. VaricellaZoster Immunoglobulin: Within 4 Days of Exposure 6. Measles; A. Measles Vaccine: 1. At 15 Months 2. Second Dose: At School Entry B. Live attenuated Vaccine or Gamma Globlin Can Prevent Measles In Unvaccinated Persons If Administered Early Following Exposure C. Vitamin A: PO: For 2 Days Reduces Morbidity And Mortality 7. SARS= Associated Coronaviruses A. No Vaccine Currrently Available B. Supportive Care: 1. Ribavirin: Ineffective 2. Use of Steroids Or InterferonAlpha: Unclear Value

2. General Rx: A. Influenza: 1. Amantadne & Rimantadine: Influenza A 2. Neuramindase Inhbitors: A. Oseltamivir & Zanamivir 1. During First 48 Hours Of Symptoms 3. Aerosilzed Riibavirn Or Amantadine: A. May Play A Role In Severe Influneza Pneumonia B. RSV &Parainfluenza: 1. Ribavirin Aerosol: For Severe RSV Pneumonia C. Adenovirus: 1. Adefovir : Some Reportted Case Usage D. Varicella Penumonia: 1. Acyclovir IV E. Measles: 1. No Effective Pharmacologic Treatment F. CMV: 1. Acyclovir: A. Can Prevent CMV Infection In Renal Transplant Patients 2. Ganciclovir & Foscarnet + CMV Hyperimmune Globulin A. Promise In Serious CMV Infection 1.Especially: CMV Pneumonia L. Differential Diagnosis 1. Bacterial Pneumonias 2. Atypical Pneumonias: A. Mycoplasma B. Chlamydia C. Coxiella D. Legionnaires Disease E. ARDS F. Pulmonary Embolism 1. Physical Findings & Associated Hypoxemia M. Comments; 1. Metapneumovirus: Newly Discovered Virus A. Upper Respiratory Infections Worldwide 2. Parainfluenza Virus Type 3: Most Common Cause Parainfluenza Viral Pneumonia

9. Community Acquired Aspiration Pneumonias: A. Causative Organisms: 1. Predominantly Anaerobic Mouth Bacteria: A. Anaerobic & Microaerophilic Streptococci B. Fusobacteria C. Anaerobic Gram Positive Non-Spore Forming Rods 2. Bacteroides Species 3. H. Influnzae 4. Streptococcus Pneumonia 5. Rarely: Eikenella Corrodens or Bacteroides Fragilis 8. Hospital Acquired Aspiration Pneumonia A. Which Patients: 1. Elderly Patients 2. Impaired Gag Reflex Patients 3. Nasogastric Tube Patients 4. Intestinal Obstruciton 5. Patients on Ventilatory Support B. High Risk Groups Of Patients: 1. Comatose Patients 2. Acidosis 3. Alcoholism 4. Uremia 5. Diabetes Mellitus 6. Nasogastric Intubation 7. Recent Antimicrobial Therapy With Colonized Aerobic Gram Negative Rods 8. Patients Undergoing Anesthesia 9. CVA Patients 10. Dementia Patients 11. Swallowing Disorders Especially In Elderly 12. Patients Taking Antacids Or H2 Blockers

C. Causative Organisms: 1. Gram Negative Anerobes: 60% 2. Gram Positive Aerobes: 20% 3. 66% of Cases: E. Coli, P.Aeuruginosa, Stap Aureus, Klebsiella, Enterobacter, Serratia, Proteus H Influenzae, Strep Pneumonia Legionella, Acinetobacter spp. 4. Fungal: <1% A. Including Candida Albicans D. Clinical Findings & Physical Findings: 1. Shortness of Breath 2. Tachypnea 3. Cough 4. Sputum 5. Fever After Vomiting 6. Diifculty Swallowing 7.Rales, Rhonchi E. Laboratory Tests: 1. CBC; Leukocytosis 2. Sputum Gram Stain 3. Cultures A. Sputum B. Blood 4. Tracheal Aspirate F. Imaging Studies 1. Chest X-Ray: A. Bilateral, Diffuse, Patchy Infiltrates Especially Posterior Segment Of Upper Lobes B. Necrosis C. Even Cavitation With Air/Fluid Levels

G. Management: 1. Non-Pharmacologic Therapy A. Airway Management: 1. Ventilatory Support 2. Community Acquired Anaerobic Aspiration Pneumonia: A. Levofloxicin 500 Mg qd Or B. Ceftriaxone 1-2 Grams/Day 3. Nursing Home Aspirations A. Levofloxacin 500 Mg qd or B. Piperacillin-Tazobactam 3.375 Grams q6H C. Ceftazidime 2 Grams q8H 4. Hospital Acquired Aspiration Pneumonia: A. Piperacillin-Tazobactam 3.375 IV q6H Or B. Clindamycin 450-900 mg IV q8H or C. Cefoxitin 2 Grams IV q8H D. Knowledge of Microflora Witihin Hospital Microenviornment E. For Pseudomonas Pneumonia: 1. Antipseudomonal Beta-Lactam + Aminoglycoside F. Do Not Use Metronidazole Alone For Anaerobes

10. Pneumocystis Carinii Pneumonia: A. Basic Science 1. Infects Most Patients Who Often Become Symptomatic In Immunosuppressed Patients Example: AIDS Patients 2. Unless Patients With CD4 Count < 200 Receive Prophylaxsis, The Majority Will Become Infected With P. Pneumonia. In This Population It Is the Major Cause Of Death & Often The First Presentation of HIV B. History: 1. Early Symptoms: Question About CD4 Count & Prophylactic Measures A. Non-Productive Cough B. Fever C. Dyspnea D. Fatigue E. Chest Pain F. Weight Loss 2. Late Symptoms: A. Febrile B. If Severs: Tachypnea & Use Acessory Muscles C. Laboratory Studies 1. CD4 Count <200 2. Elevated LDH

D. Diagnostic Studies: 1. Pulse Oximetry A. Deonstrates Hypoxia 2. ABG: Preferred 3. Sputum Analysis A. Giemsa Stain B. Silver 4. Bronchoscopy: A. Washings 1. Stain 5 Chest X-Ray Findings A. Diffuse Interstitial Pattern B. Less Common Presentations 1. Nodules 2. Cavitation 3. Cystic Changes 4. Pneumothorax E. Analysis of Severity Of Problem : 1. May Progress To Respiratory Distress 2. Hypoxia & Respiratory Require: A. Mechanical Ventilation 3. Severe Hypoxia (PaO2< 70 mm HG) Indication For Steroids F. Diagnostic Formulation: 1. Suggests PCP: A. Fever B. Dyspnea C. Non-Productive Cough D. Bilateral Interstitial Infiltrates On X-Ray G. Confirmation: Sputum Analysis Or Bronchoscopy

H. Patient Management: 1. Mild to Moderate PCP: A. TMP-SMZ or B. Atovaquone. 2. Severely Ill Patients: A. Hospitalization 1. IV TMP-SMZ: A. Timethoprim: 15-20 Mg/Kg B. Sulfamethoxazole: 75-100 Mg/Kg/Qd 2. Prednisone: 40 mg PO BID A. Taper Dose : : 20 Mg PO BID After 5 Days : 20 Mg PO OD After 10 Days 3. Pentamidine: 4 Mg/Kg IV Qd 4. Mechanical Ventilation & Intubaiton 5. Continue Therapy For 3 Weeks 6. Alternative Therapies: A. Dapsone/ Trimethorpim B. Clinidamycin/ Primaquine C. Atovaquone 3. If Discharge: A. PCP Prophylaxsis 1. TMP-SMZ : Single Strength : One Tablet PO Qd DS Three Times Weekly 2. If Intolerant: A. Dapsone 50 mg PO Qd + B. Pyrimethamine 50 mg PO Weekly + C. Leucovorin 25 mg Weekly B. Other Forms of Prophlyaxsis If Intolerant 1. Inhaled Pentamidine 300 mg Montlhly By Nebulizer A. Less Effective C. This Is The Same Approach For All HIV Patients With: CD4 Lymphocyte Counts <200 To 250/mm3 or <20% of Total Lymphocyte Count

11. Fungal Pneumonias: A. Histoplasmosis B. Coccidiomycosis C. Cryptococcus D. Aspergillus E. Blastomycosis 12. General Summary of Diagnostic Methods: A. CXR 1. Pneumococcal Pnumonia: Segmental or Lobar Infiltrate 2. Mycoplasma Pneumonia: Patchy Infiltrates 3. Viral Pneumonia: Hazy Infiltrates 4. Legionella, M.Pneumonia, Viral Pneumonia, P, Carinii, Hypersensitivity Pneumonitis, Diffuse Infiltrates Psittacosis, Q Fever,Aspiration Pneumonia, Miliary TB, ARDS: B. Blood Cultures C. Pulse Oximetry Hospital Admission: Partial Pressure Of Oxygen: < 60 mm HG On Room Air D. Serologic Tests: For HIV Patients E. Urinary Antigen for Legionella F. Bronchosocopy

13. Summary Management: A. Outpatient Therapy: Community Acquired Pneumonias 1. Macrolides: Azithromycin Or Clarithromycin or 2. Levofloxacin 3. Add: Beta-Lactam/Beta-Lactamase Inhibitor With More Severe Presentation Who Insist On Outpatient Therapy B. Mycoplasma Pneumonia: ( 10-14 Days): Outpatient Care: 1. Levofloxacin 2. Erythromycin 500 Mg QID PO or 3. Azithromycin 500 Mg Daily PO or 4. Clarithromycin 500 Mg BID PO C. Pneumocystis Carinii Pneumonia: 1. Trimethoprim-Sulfamethoxazole PO or IV 2. Pentamidine 3. Prednisone: 40 Mg BID PO: With Respiratory Distress 4. Alternatives: A. Dapsone/ Trimethoprim B. Clindamycin/Primaquine C. Atovaquone D. Viral Pneumonias: 1. Influenza: A. Amantadine and Rimantidine B. Neuraminidase Inhibitors: 1. During The First 48 Hours Of Symptoms C. Aerosolized Ribavirin or Amantadine 1. May Play A Role In Influneza Pneumonia 2. Varicella: Acyclovir IV 3. RSVand Parainfluenza: 1. Ribavrin Aerosol: For Severe RSV Pneumonia 4. CMV: 1. Prevention: Acylovir In Renal Transplant Patients 2. Ganciclovir + Foscarnet + Hyperimmune Globulin: Shows Promise 5. Adenovirus: No Effective Agent

E. MRSA Complications: 1. Vancomycin 2. Linezolid (Zyvox):Approved for Nosocomial and Community Acquired Pneumonias 3. Daptomycin (Cubicin) 4. Quinupristin/Dalfopristin 5. Telithromycin : Approved For Community Acquired Pneumonia F. Vancomycin Resistant Enterococci (VRE) Complications 1. Linezolid (Zyvox) 2. Daptomycin (Cubicin) 3. Quinupristin/Dalfopristin 4. Dalbavancin G. Hospital Setting: General Wards: 1. Second or Third Generation Cephalosporin ( Ceftriaxone, Ceftizoxime, Cefotaxime Or Cefuroxime) + Macrolide: Azithromycin , Clarithromycin Or Doxycycline May Substitute: Anti Pseudomonal Quinolone (Levofloxacin, Moxifloxacin, Gatifloxacin) In Place Of Macrolide Or Doxycycline May Substitute Cephalosporin In Penicillin Allergic Patients

H. Hospital Setting: Pseudomonal Infections 1. Empirical Treatment: Fourth Generation Cephalosporin (Cefipime) Or BetaLactam/Beta-Lactamase Inhibitor Ampiciliin/Sulbactam Or Ticarcillin/Clavulanate Or Piperacillin/Tazobactam + Antipseudomonal Quinolone (Levofloxacin, Moxifloxacin, Gatifloxicin) + Aminoglycoside (Gentamicin,Tobramycin) (Adjust for Renal Clearance) 2. Adjust Therapy According To Blood Cultures I. Aspiration Pneumonias A. Community Acquired Anaerobic Aspiration Pneumonia: 1. Levofloxacin 500 Mg QD Or 2. Clindamycin 450-900 Mg IV Q8H B Nursing Home Aspirations: 1. Levofloxacin 500 Mg QD or 2. Zosyn: Piperacillin-Tazobactam 3.375 Grams Q6H Or 3. Ceftazadime 2 Gr Q8H C. Hospital Acquired Aspiration Pneumonia: 1. Zosyn: Piperacillin-Tazobactam 3.375 IV Q6H Or 2. Clindamycin 450-900 IV Q8H or 3. Cefoxitin 2 Gr IV Q8H 4. Knowledge Of Resident Flora In The Microenviornment Within The Hospital Is Crucial To Intelligent Antibiotic Selection. Consult Infection Control Nurse Or Hospital Epidemiologist