MEDICINA INTERNA NEUMOLOGÍA
Dr.. Christ Dr Christiam iam Oc Ochoa hoa
BACILO DE KOCH Mycobacte Mycobacterium rium tuberculosis tuberculosis Envoltura Ac. Micolico 1-4x0.3-0.6 micras Inmóvil No esporulado Aerobio estricto Desarrollo 35-37°C No es cromogeno Tincion: • Ziehl-Neelsen/Kinyoun • Auramina Auramina (+ sensible, pero pero no distingue de los M. no tubercul..) • Cultivo: Middlebrook 7H10 o 7H11 7H11 • Middlebrook • Lowenstein-Jensen • Pruebas Bioquimicas • Niacina (+) Nitrato reduct reductasa asa (+) • Nitrato Catalasa Catalasa (debil +) • • • • • • • • •
Define el genero Resiste a la decolorac ión
DEFINICIONES OPERACIONALES SINTOMATICO RESPIRATORIO • Tos con flema >15 dias CONTACTO DOMICILIARIO • Mismo domicilio que paciente BK+ CONTACTO EXTRADOMICILIARIO • Comparte ambientes comunes o frecuentan pacientes BK+ (minimo6h)
CASO TBC PULMONAR • Pac con Dx TB pulmonar c/ o s/ BK+ CASO TBC EXTRAPULMONAR • Pac con Dx TB en organos diferentes a los pulmones • Necesidad de demostracion (cultivo, PCR, histopatologico y/o clinica) • La TB pleural es extrapulmonar y la +fr CASO TBC SISTEMICO • No existe en la guia!!! TB pulmonar + otro lado EXTRAPULMONAR
TBC PANSENSIBLE • Sensibilidad a todos los farmacos de 1ra linea TBC MDR • Resistente a H y R TBC XDR (Extensamente) • Resistente a H, R, fluroQ y 1 inyectable de 2da linea (amikacina, kanamicina o capreomicina) TBC MONORESISTENTE • Resistente a solo un farmaco anti-TB TBC POLIRESISTENTE • Resistente a >1 farmaco anti-TB (que no cumpla criterios de MDR o XDR)
TBC INFANTIL TBC INFANTIL CONFIRMADO • Estudio bacteriologico + para Mycobacterium tuberculosis o muestra histologica compatible TBC INFANTIL PROBABLE • Fiebre, tos y perdida de peso • Exposicion a un caso de TBC infecciosa activa • PPD positivo (>10mm) • Hallazgo en radiografia de torax compatible con TBC activa • Evidencia por otros examenes de apoyo diagnostico
CONDICION DE INGRESO
CASO NUEVO
CASO ANTES TRATADO
CURADO
TTO COMPLETO
RECAIDA
ÉXITO DE TTO CONDICION DE EGRESO DE TBC SENSIBLE
ABANDONO
ABANDONO RECUPERADO
FRACASO
FALLECIDO
NO EVALUADO
CONDICION DE INGRESO Y EGRESO • CASO NUEVO: 1er episodio de TB o q recibio tto por <30dias (o 25 dosis continuas) • CURADO: se vio BK(+) al inicio + termina tto + BK( –) al ultimo mes del tto. • TRATAMIENTO COMPLETO: se vio BK(+) al inicio + termino tto SIN tener prueba de BK al ultimo mes. • ÉXITO DE TRATAMIENTO: la suma de los casos CURADO y TTO COMPLETO • ABANDONO: deja de recibir tto por >30 dias • FRACASO: BK(+) en esputo o cultivo apartir del 4to mes de tto • FALLECIDO: muerte por cualquier causa durante el tto • NO EVALUADO: paciente sin condicion de egreso. • CASO ANTES TRATADO: pac con dx de TB y antec de haber recibido tto por >30dias • RECAIDA: otro episodio de TB despues de haber CURADO ó TTO COMPLETO • ABANDONO RECUPERADO: paciente que fue ABANDONO y se reinicia tto desde 1ra dosis • FRACASO: idem • FALLECIDO: idem • NO EVALUADO: idem
TUBERCULOSIS
TUBERCULOSIS
HISTORIA NATURAL
TBC 1° retenida
1. 2. 3. 4.
Liquidación inmediata del organismo La infección crónica o latente Enfermedad activa rápidamente progresiva (o enfermedad primaria) Enfermedad activa muchos años después de la infección (reactivación de la enfermedad)
TBC 1° no retenida
TBC REACTIVADA: Miliar y ExtraPulm
TBC REACTIVADA: TBC 2°
• Via hematogena x eso BK• Micronodular (<3mm) • 25% hacen MEC TB
TBC REACTIVADA: TBC 2° CLINICA • TOS • TAMBIEN • Esputo no purulento • Fiebre • Malestar general • Astenia • Anorexia • Perdida de peso • Sudoracion nocturna • Hemoptisis (cavernas) PRONOSTICO • 60% s/tto mueren a 2.5 años • Aspergiloma
DETECCION Y DIAGNOSTICO DE CASOS
RADIOGRAFIA • Infiltrado infreclavicular • Broncograma aereo • Tendencia a la cavitacion
1. DETECCION DE SINTOMATICO RESPIRATORIO 2. SEGUIMIENTO DIAGNOSTICO 3. DEFINICION DE CASO
BACILOSCOPIA Generalmente Positivo
• PPD (>10mm[>5mm], medir
PRUEBAS induracion, x IFN-gamma)
RADIOGRAFIA BACILOSCOPIA CULTIVO BIOPSIA PRUEBAS DE SENSIBILIDAD CONVENCIONAL • PRUEBAS DE SENSIBILIDAD RAPIDA • • • • •
(MODS, Griess, MGIT, Genotype MTBDplus) ahora a todo BK+.
Informe de resultados de baciloscopía: • Negativo (-): No se encuentra bacilos ácido alcohol resistente (BAAR) en 100 campos microscópicos. • Paucibacilar: Se observan de 1 a 9 BAAR en 100 campos observados • Positivo (+): Menos de 1 BAAR promedio por campo en 100 campos observados (10-99 bacilos en 100 campos). • Positivo (++): De 1 a 10 BAAR promedio por campo en 50 campos Observados. • Positivo (+++): Más de 10 BAAR promedio por campo en 20 campos observados.
TRATAMIENTO NT-TBC-MINSA-2010
TUBERCULOSIS
NT-TBC-MINSA-2013 QUIMIOPROFILAXIS
ISONIACIDA • • •
<15 años 10mg/Kg/dia x 6m (max 300mg/dia) >15 años 5mg/Kg/dia x 6m (max 300mg/dia) VIH (+) dosis según la edad y x 12m + Piridoxina (por neuropatia x def VitB6)
• Paciente < 5años con contacto de caso indice
(no importa BK, no importa PPD) • Paciente 5-15 años con contacto de caso indice y PPD>10 • Paciente con conversion reciente de PPD (<2años) para trabajadores de Salud y personas que atienden a poblacion privada de libertad • Paciente con VIH(+) (no importa el PPD)
INFECCIÓN AGUDA DEL PARENQUIMA PULMONAR (ASOCIADA A UN INFILTRADO NUEVO EN LA RADIOGRAFÍA DE TÓRAX.
VÍA DE INFECCION MICROASPIRACION: mas fc sanos. Neumococo, pyogenes, algunos stafilococos, neisseria, corynebacterium, Haemofiilus, Moraxella, Mycoplasma. INHALACION: mycoplasma, clamidophila, C. pssitaci, Coxiella burnetti, virus, TBC, legionella, aspergillus. HEMATOGENA: stafilococo aureus.
FACTORES DE RIESGO ADULTO MAYOR- DM – EPOC - BRONQUIECTASIA ALCOHOLISMO – VIH - ADVP
ETIOLOGÍA
BATERIA TIPICAS (60-70%): Neumococo 20-60% - Haemophylus pneu. 3-10% - Sf. aureus 3-5% Enterobacteriaceae 3-5% ATIPICOS (10-20): M. Pneumoniae C. pneumoniae - L. pneumoniae VIRUS (5-10%): Influenza – Parainfluenza - Rsv
Clínica típica: Tos, Expectoración, Fiebre, Dolor pleurítico, Disnea. En ancianos hiporexia, confusión y deshidratación. En el examen físico: roncantes o crepitantes
CLINICA Clinica atipica: febricula, tos seca, artromialgia, confusion, hematuria, mielitis transversa, miringitis bulosa, anemia hemolitica, etc
Table 257-3 Epidemiologic Factors Suggesting Possible Causes of Community-Acquired Pneumonia
Factor
Possible Pathogen(s)
Alcoholism
Streptococcus pneumoniae, oral anaerobes, Klebsiella pneumoniae, Acinetobacter spp., Mycobacterium tuberculosis
COPD and/or smoking
Haemophilus influenzae, Pseudomonas aeruginosa, Legionella spp., S. pneumoniae, Moraxella catarrhalis, Chlamydia pneumoniae
Structural lung disease
P. aeruginosa, Burkholderia cepacia, Staphylococcus aureus
Dementia, stroke, decreased level of consciousness
Oral anaerobes, gram-negative enteric bacteria
Lung abscess
CA-MRSA, oral anaerobes, endemic fungi, M. tuberculosis, atypical mycobacteria
Travel to Ohio or St. Lawrence river valleys
Histoplasma capsulatum
Travel to southwestern United States
Hantavirus, Coccidioides spp.
Travel to Southeast Asia
Burkholderia pseudomallei, avian influenza virus
Stay in hotel or on cruise ship in previous 2 weeks
Legionella spp.
Local influenza activity
Influenza virus, S. pneumoniae, S. aureus
Exposure to bats or birds
H. capsulatum
Exposure to birds
Chlamydia psittaci
Exposure to rabbits
Francisella tularensis
Exposure to sheep, goats, parturient cats
Coxiella burnetii
SEVERIDAD CURB-65 PNEUMONIA SEVERITY INDEX (PSI) CRITERIOS DE INGRESO A UCI
PSI class and mortality Class
Points
Mortality, %
I
No predictors
0.1
II
<70
0.6
III
71-90
0.9
IV
91-130
9.3
V
>130
27.0
EX. AUXILIARES
RADIOGRAFÍA DE TÓRAX: PA-L GRAM-CULTIVO DE ESPUTO BRONCOFIBROSCOPÍA (CP, LBA) IFI, ELISA o FIJACIÓN COMPLEMENTO - TEST URINARIO – HEMOCULTIVO HEMOGRAMA GLUCOSA – UREA - CREATININA ELECTROLITOS- AGA
COMPLICACIONES •ATELECTASIA • DERRAME PARANEUMÓNICO • EMPIEMA • ABSCESO PULMONAR • BRONQUIECTASIA
Abnormality
Days
Tachycardia and hypotension
2
Fever, tachypnea, and hypoxia
3
Cough
14
Fatigue
14
Infiltrates on chest radiograph
30
TTO
ALVEOLAR: LOBAR: Gram+, Mycoplasma - MULTILOBAR: gram -, St neumoniae INTERSTICIAL: Mycoplasma, legionella, chlamydia, P. carinii, CMV, VHZ, sarampión. CAVITADA: anaerobio, Sf.aureus, St penumoniae serotipo III, BGN, TBC, hongos.
•ANTIBIOTICOTERAPIA • HIDRATACIÓN ADECUADA • ANTIPIRÉTICOS / ANALGÉSICOS
Blood culture
Indication Intensive care unit admission Failure of outpatient antibiotic therapy Cavitary infiltrates Leukopenia Active alcohol abuse Chronic severe liver disease Severe obstructive/structural lung disease Asplenia (anatomic or functional) Recent travel (within past 2 weeks) Positive Legionella UAT result Positive pneumococcal UAT result
X X X X X
Sputum culture
Legionella UAT
Pneumococcal Multiplex PCR¶ UAT
X X X
X X
X X
X X
X
X
X X X
X X X X X X
X X
X
X X X
¥
X NA NA
Description >=2: temperature >38.5°C or <35.0°C; heart rate of >90 beats/min; respiratory rate of >20 breaths/min or
Systemic inflammatory PaCO2 of <32 mm Hg; and WBC count of >12,000 cells/mL, <4000 cells/mL, or >10 percent immature (band) response syndrome forms Sepsis
SIRS in response to documented infection (culture or Gram stain of blood, sputum, urine, or normally sterile body fluid positive for pathogenic microorganism; or focus of infection identified by visual inspection)
Severe sepsis
Sepsis and at least one of the following signs of organ hypoperfusion or organ dysfunction: areas of mottled skin; capillary refilling of ≥3 s; urinary output of <0.5 mL/kg for at least 1 h or renal replacement therapy; lactate >2 mmol/L; abrupt change in mental status or abnormal EEG findings; platelet count of <100,000 cells/mL or disseminated intravascular coagulation; acute lung injury/ARDS; and cardiac dysfunction (echocardiography)
Septic shock
Severe sepsis and one of the following conditions: systemic mean BP of <60 mm Hg (<80 mm Hg if previous hypertension) after 20 to 30 mL/kg starch or 40 to 60 mL/kg saline solution, or PCWP between 12 and 20 mm Hg; and need for dopamine of >5 mcg/kg/min, or norepinephrine or epinephrine of <0.25 mcg/kg/min to maintain mean BP at >60 mm Hg (80 mm Hg if previous hypertension)
Refractory septic shock
Need for dopamine at >15 mcg/kg/min, or norepinephrine or epinephrine at >0.25 mcg/kg/min to maintain mean BP at >60 mm Hg (80 mm Hg if previous hypertension)
Organism Preferred antimicrobial(s) Streptococcus pneumoniae Penicillin nonresistant; MIC <2 Penicillin G, amoxicillin microgram/mL
Alternative antimicrobial(s) Macrolide, cephalosporins (oral cefuroxime, cefdinir] or parenteral ceftriaxone, clindamycin, doxycyline, respiratory fluoroquinolone*
Penicillin resistant; MIC ≥2 microgram/mL Haemophilus influenzae
Basis of susceptibility, including cefotaxime, ceftriaxone, fluoroquinolone
Non-beta-lactamase
Amoxicillin
Fluoroquinolone, doxycycline, azithromycin, clarithromycin•
Beta-lactamaseproducing
2-3RA generation cephalosporin, amoxiclav
Fluoroquinolone, doxycycline, azithromycin, clarithromycin•
Macrolide, a tetracycline
Fluoroquinolone
M. pneumoniae/C. pneumoniae Legionella species Chlamydophila psittaci Coxiella burnetii Francisella tularensis Yersinia pestis
Vancomycin, linezolid, high-dose amoxicillin (3 g/day with penicillinMIC ≤4 microgram/mL)
Fluoroquinolone, azithromycin A tetracycline A tetracycline Doxycycline Streptomycin, gentamicin Ciprofloxacin, levofloxacin, doxycycline (usually with Bacillus anthracis (inhalation) second agent)
Doxycyline Macrolide Macrolide Gentamicin, streptomycin Doxycyline, fluoroquinolone Other fluoroquinolones; beta-lactam, if susceptible; rifampin; clindamycin; chloramphenicol
Enterobacteriaceae
3RA cephalosporin, carbapenemΔ
Beta-lactam/beta-lactamase inhibitor◊, fluoroquinolone
Pseudomonas aeruginosa
Antipseudomonal beta-lactam§ plus (ciprofloxacin or levofloxacin¥ or aminoglycoside)
Aminoglycoside plus (ciprofloxacin or levofloxacin¥)
Acinetobacte species
C b
C h l
i
i
l
id
i illi
lb t
li ti
Staphylococcus aureus Methicillin susceptible Methicillin resistant Bordetella pertussis Anaerobe (aspiration) Influenza virus
Antistaphylococcal penicillin ‡ Vancomycin or linezolid Macrolide Beta-lactam/beta-lactamase inhibitor◊, clindamycin See associated topic reviews† For uncomplicated infection in a normal host, no therapy generally recommended; for therapy, itraconazole, fluconazole Itraconazole** Itraconazole**
Coccidioides species Histoplasmosis Blastomycosis
CURB65 Low severity (eg, CURB65 = 0-1 <3 percent mortality) Low severity+ comorbilidad o problema social.
Moderate severity (eg, CURB65 = 2, 9 percent mortality)
High severity (eg, CURB65 = 3-5, 1540 percent mortality)
Cefazolin, clindamycin TMP-SMX TMP-SMX Carbapenem Amphotericin B Amphotericin B** Amphotericin B**
Treatment site
Preferred treatment
Alternative treatment
Home
Amoxicillin 500 mg VO C/8H
Doxycycline 2 00 mg carga - 100 mg VO c/24h or c larithromycin 5 00 mg VO c/12h
Hospital
Hospital
Hospital (consider critical care review)
Amoxicillin 500 mg VO C/8H Amoxicillin 500 mg IV C/8h Amoxicillin 1g VO C/8H plus clarithromycin 500 mg VO c/12h Amoxicillin 500 mg IV c/8h or benzylpenicillin (penicillin G) 1.2 grams IV c/6h plus clarithromycin 500 mg IV c/12h
Doxycycline 200 mg carga - 100 mg VO c/24h or clarithromycin 500 mg VO c/12h
Doxycycine 200 mg carga + 100 mg orally or levofloxacin 500 mg Vo c/24h or moxifloxacin 400 mg VO c/24h
Antibiotics given as soon as possible
Benzylpenicillin (penicillin G) 1.2 grams IV c/6h plus either levofloxacin 500 mg IV c/12h or ciprofloxacin 400 mg IV c/12h
Co-amoxiclav 1.2 grams IV c/8h* plus clarithromycin 500 mg IV c/12h*
OR
(If Legionella strongly suspected, consider )
Cefuroxime 1.5 grams IV c/8h or cefotaxime 1 gram IV c/8h or ceftriaxone 2 grams IV c/24h, plus clarithromycin 500 mg IV c/12h
Outpatient treatment 1. Previously healthy and no use of antimicrobials within the previous 3 months: A macrolide (azithromycin, clarithromycin, or erythromycin) OR Doxycyline* 2. Presence of comorbidities such as chronic heart, lung, liver or renal disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing conditions or use of immunosuppressing drugs; or use of antimicrobials within the previous 3 months (in which case an alternative from a different class should be selected): A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) OR A beta-lactam (first-line agents: high-dose amoxicillin, amoxicillinclavulanate; alternative agents: ceftriaxone, cefpodoxime, or cefuroxime) PLUS a macrolide (azithromycin, clarithromycin, or erythromycin)* 3. In regions with a high rate (>25 percent) of infection with high-level (MIC ≥16 µg/mL) macrolide-resistant Streptococcus pneumoniae, consider use of alternative agents listed in (2) above. Inpatients, non-ICU treatment A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) OR An antipneumococcal beta-lactam (preferred agents: cefotaxime, ceftriaxone, or ampicillin-sulbactam; or ertapenem for selected patients)• PLUS a macrolide (azithromycin, clarithromycin, or erythromycin)*Δ Inpatients, ICU treatment An antipneumococcal beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) PLUS azithromycin OR An antipneumococcal beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) PLUS a respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) OR For penicillin-allergic patients, a respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) PLUS aztreonam Special concerns If Pseudomonas is a consideration: An antipneumococcal, antipseudomonal beta-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) PLUS either ciprofloxacin or levofloxacin (750 mg) OR The above beta-lactam PLUS an aminoglycoside PLUS azithromycin OR The above beta-lactam PLUS an aminoglycoside PLUS a respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]); for penicillin-allergic patients, substitute aztreonam for above beta-lactam If CA-MRSA is a consideration: Add vancomycin or linezolid
NAC
DEFINICION FACTORES DE RIESGO •TABAQUISMO -
ALCOHOLISMO • ADULTO MAYOR • USO PREVIO A ATB UREMIA • INTUBACIÓN ENDOTRAQUEAL • USO DE SNG - COMA • CIRUGÍA MAYOR • DESNUTRICIÓN • FALLA MULTIORGÁNICA • NEUTROPENIA • USO DE ANTI H2/IBP
ETIOLOGÍA • MRSA. • PSEUDOMONA • OTROS SF. • KLEBSIELLA PNEUMONIAE • ENTEROBACTER • E. COLI • ACINETOBACTER
Table 257-6 Pathogenic Mechanisms and Corresponding Prevention Strategies for Ventilator-Associated Pneumonia Pathogenic Mechanism Prevention Strategy Oropharyngeal colonization with pathogenic bacteria Elimination of normal flora
Avoidance of prolonged antibiotic courses
Gastroesophageal reflux
Postpyloric enteral feedingb; avoidance of high gastric residuals, prokinetic agents
Bacterial overgrowth of stomach
Prophylactic agents that raise gastric pHb; selective decontamination of digestive tract with nonabsorbable antibioticsb
Cross-infection from other colonized patients
Hand washing, especially with alcohol-based hand rub; intensive infection control educationa; isolation; proper cleaning of reusable equipment
Large-volume aspiration
Endotracheal intubation; avoidance of sedation; decompression of small-bowel obstruction
Microaspiration around endotracheal tube Endotracheal intubation
Noninvasive ventilationa
Abnormal swallowing function
Early percutaneous tracheostomya
Secretions pooled above endotracheal tube
Head of bed elevateda; continuous aspiration of subglottic secretions with specialized endotracheal tubea; avoidance of reintubation; minimization of sedation and patient transport
Altered lower respiratory host defenses
Tight glycemic controlb; lowering of hemoglobin transfusion threshold; specialized enteral feeding formula
Pneumonia types ●Hospital-acquired (or nosocomial) pneumonia (HAP) 48H.. ●Ventilator-associated pneumonia (VAP) 48 to 72 hours. ●Healthcare-associated pneumonia (HCAP) is defined as pneumonia that occurs in a nonhospitalized patient with extensive healthcare contact, as defined by one or more of the following: •Intravenous therapy, wound care, or intravenous chemotherapy within the prior 30 days •Residence in a nursing home or other long-term care facility •Hospitalization in an acute care hospital for two or more days within the prior 90 days •Attendance at a hospital or hemodialysis clinic within the prior 30 days
Temperature ≥36.5 or ≤38.4 = 0 point - ≥38.5 or ≤38.9 = 1 point - ≥39 or <36.5 = 2 points
Blood leukocytes, microL ≥4000 or ≤11,000 = 0 points - <4000 or >11,000 = 1 point - Band forms ≥50 percent = add 1 point Tracheal secretions Absence of tracheal secretions = 0 point Presence of non-purulent tracheal secretions = 1 point Presence of purulent tracheal secretions = 2 points Oxygenation PaO2/FIO2, mmHg >240 or ARDS (defined as PaO2/FIO2 ≤200, PAWP ≤18 mmHg and acute bilateral infiltrates) = 0 points PaO2/FIO2 ≤240 and no ARDS = 2 points
Pulmonary radiography No infiltrate = 0 point Diffuse (patchy) infiltrate = 1 point Localized infiltrate = 2 points Progression of pulmonary infiltrate No radiographic progression = 0 point Radiographic progression (after HF and ARDS excluded) = 2 points Culture of tracheal aspirate Pathogenic bacteria cultured in rare or few quantities or no growth = 0 point Pathogenic bacteria cultured in moderate or heavy quantity = 1 point
TERAPIA EMPIRICA ATB: GUIA ATS
Table 257-8 Empirical Antibiotic Treatment of Health Care –Associated Pneumonia Patients without Risk Factors for MDR Pathogens Ceftriaxone (2 g IV q24h) or Moxifloxacin (400 mg IV q24h), ciprofloxacin (400 mg IV q8h), or levofloxacin (750 mg IV q24h) or Ampicillin/sulbactam (3 g IV q6h) or Ertapenem (1 g IV q24h)
Patients with Risk Factors for MDR Pathogens 1. A -lactam: Ceftazidime (2 g IV q8h)or cefepime(2 g IV q8 –12h) or Piperacillin/tazobactam (4.5 g IV q6h), imipenem (500 mg IV q6h or 1 g IV q8h), or meropenem (1 g IV q8h) plus The serum gentamicin or tobramycin concentration should be obtained six hours (or up to 14 hours) after the initial dose of 7 mg/kg and plotted on the above nomogram. The interval for drug administration of subsequent doses of 7 mg/kg is then determined based on the interval specified on the graph. * Application of the nomogram for amikacin requires the measured concentration be divided by two. The new value should be plotted on the nomogram in order
2. A second agent active against gram-negative bacterial pathogens: Gentamicin or tobramycin (7 mg/kg IV q24h) or amikacin (20 mg/kg IV q24h) or Ciprofloxacin (400 mg IV q8h) or levofloxacin (750 mg IV q24h) plus 3. An agent active against gram-positive bacterial pathogens: Linezolid (600 mg IV q12h) or Vancomycin (15 mg/kg up to 1 g IV q12h)
NEUMONIA NOSOCOMIAL
NEUMONIA NOSOCOMIAL
