Drug Topics- August 11, 2008

56 DRUG TOPICS AUGUST 11, 2008 www.drugtopics.com CONTINUING EDUCATION Table 2 CURB-65 criteria Clinical factor Confusion Uremia Respiratory rate Low blood pressure Age 65 or greater Total points Determination Based on testing or disorientation to person, place or time BUN > 7mmol/L (20mg/dl) ≥ 30 breaths/min < 90mm Hg systolic or ≤ 60mm Hg diastolic As defined Points 1 1 1 1 1 outpatient setting include Streptococcus pneumonia, Mycobacteria pneumonia, Haemophilus influenzae, Chlamydophilia pneumoniae, and respiratory viruses. Influenza A and B remain the leading causes of viral pneumonia, but consideration should also be given to RSV, adenovirus, parainfluenza virus, and less often other viruses. It is important to note that specific organisms may be linked with particular co-morbid conditions, specific environmental risks, or other disease states. Twenty percent of patients with the diagnosis of CAP will be hospitalized, increasing their risk of mortality from other comorbid conditions. Thus the decision on whether to hospitalize a patient is of significant importance. The current IDSA/ATS guidelines recommend using the CURB-65 criteria. These five objective criteria may be found in Table 2. In the primary care office CRB-65 may suffice. A patient score of zero to one suggests that the patient may be safely treated as an outpatient with a few exceptions. A score of two or greater indicates the need for admission to a hospital. Admission to the ICU is recommended for patients with a score of three or greater. (In facilities where high-level monitoring is present, this may suffice for those patients not identified as “severe.”) The guidelines note the following exceptions for hospital admission in addition to the prior objective data. These may include complications of pneumonia, exacerbation of underlying disease(s), inability to obtain or take medication in an outpatient setting, and those patients who have multiple factors that are close to the suggested cutoffs. Identification of a specific pathogen helps to refine treatment, with the goal of reducing cost, drug adverse effects, and the development of antimicrobial resistance. Yet empiric therapy is routinely effective. It is important for the medical provider to rule out specific organisms if the patient has particular risk factors or there are particular environmental concerns. These organisms should include influenza, RSV, SARS, avian (H5N1) influenza, diseases of bioterrorism, Legionella infection, community-acquired methicillin-resistant staphylococcus aureus (CA-MRSA), Mycobacterium tuberculosis, and endemic fungal infections. Since these organisms are infrequent causes of outpatient pneumonia, sputum analysis and blood cultures are optional. Epidemiologic conditions or risk factors for specific pathogens may be found in Table 3. Prior to choosing empiric therapy for a patient, antibiotic resistance within the local community should be taken into consideration. Individual risk factors for resistant S. pneumoniae should also be assessed. These include age 65 Table 3 Risk factors for particular pneumonia pathogens Risk factors Alcoholism COPD/smoking Aspiration Lung abscess Hotel or cruise ship within two weeks Influenza active in community Cough >two weeks with whoop or posttussive vomiting Injection drug use Common pathogen Streptococcus pneumoniae, oral anaerobes, Klebsiella pneumoniae, Acinetobacter species, M. tuberculosis Haemophilis influenza, Pseudomonas aeruginosa, Legionella species, S. pneumoniae, Moraxella catarrhalis, Chlamydophila pneumoniae Gram-negative enteric pathogens, oral anaerobes CA-MRSA, oral anaerobes, fungal, M. tuberculosis, atypical mycobacteria Legionella species Influenza, S. pneumoniae, S. aureus, and H. influenzae Bordetella pertussis S. aureus, anaerobes, M. tuberculosis, S. pneumoniae * Adjusted from Table 8 pg S46 IDSA Community-Acquired Pneumonia Guidelines, CID 2007;44 (supplement 2) http://www.drugtopics.com

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Drug Topics- August 11, 2008 Contents Latebreakers Letters DEA Proposes Rule To Allow Electronic Prescriptions for Controlled Substances Merger, Medicare Reform Could Mean Broader E-Prescribing Adoption New Combination Pill Approved for Type 2 Diabetes New Eczema Guildlines Promote Use of Emollients, Then Topical Corticosteroids Agencies Flush Original Strategies in Favor of Promoting Drug Take-Back Programs JP at Large: You Laughing at Me? Pharmacists Find Themselves at Mercy of Prior Authorization State Law Requiring PBM Transparency See Some Gains, Some Losses Global Counterfeiting Still Growing, Says U.S. Commerce Official FDA Saftey Page: Prophylthiouracil Still Confused with Purinethol (mercaptopurine) New Products Bring Lice Treatment to a Head NACDS Marketplace Showcases New Product that Fill Unmet Needs Update on Respiratory Tract Infections Execs Share War Stories About Adopting Technology in their Stores New Products Advertisters Index Classified Viewpoint: Medicare Part D Revisions sorely needed

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