Step 3: Verify P-drug

• The 2010 CPG on CAP recommends the use of the following for MR-CAP:

• IV non-antipseudomonal β-lactam (BLIC, cephalosporin or carbapenem) + an extended macrolide OR

• IV non-antipseudomonal β-lactam + fluoroquinolone

• Patient’s hypersensitivity to β-lactam antibiotics, however compels us to choose monotherapy using a respiratory fluoroquinolone such as levofloxacin or moxifloxacin

Efficacy Safety Suitability

Penicilline.g. Co-amoxiclav

Pharmacodynamics:-active against most strep, pneumococci, meninggococci, oral anaerobes, spirochetes, listeria, Corynebacterium spp. Clavunalic acid extends activity to gram negatives such as H.influenzae and E. coli.Pharmacokinetics: -half-life: 1 hr in adults, well absorbed orally.

Nausea, vomiting, diarrhoea, indigestion, rash and urticaria, candida superinfection.Potentially Fatal: Anaphylactic reaction with CV collapse esp with parenteral use.

Contraindicated in hypersensitive patients

Efficacy Safety SuitabilityCephalosporine.g. Cefuroxime

Pharmacodynamics:- Active against community acquired E.coli, Klebsiella, Proteus, H. influenzae, Enterobacteriaceae, Serratia, Neisseria gonorrhea, Pseudomonas aeruginosaPharmacokinetics: -half-life: 45 min, 89% metabolized in kidneys, high concn in urine.Distributed in pleural and joint fluids, bile, sputum, bone, aqueous humor, and in CSF if meninges are inflammed.

Thrombophlebitis. Pruritus, urticaria, +ve Coombs' test, diarrhea, nausea, pseudomembranous colitis. Decrease in Hb & hematocrit, transient increase in liver enzymes, elevation in serum creatinine & BUN. Possibly seizure & angioedema.

Hypersensitivity to penicillins. Possible superinfection in prolonged use. Nephrotoxicity & ototoxicity.

Efficacy Safety SuitabilityCarbapenem

Pharmacodynamics:-Lower resp tract, UTI including complicated, intra-abdominal, gynecological including postpartum, skin & skin structure infections. Septicemia, meningitis. Pharmacokinetics: Good oral absorption & distributes widely throughout the body, except to the brain and CSF. Should not be administered with food.extensive tissue distribution and high drug concentrations within cells. Major excretion:bile, minor in liver.

Thrombocythemia. Nausea, vomiting, diarrhea. Increases in serum transaminases, bilirubin, alkaline phosphatase, lactic dehydrogenase. Inflammation, thrombophlebitis, pain

Hypersensitivity. Infants <3 mos. Pregnancy & lactation

Efficacy Safety Suitability

Extended MacrolidesEx. Azithromycin

Pharmacodynamics:-Resp tract infections; Skin and soft tissue infections ; Uncomplicated genital chlamydial infections ; Uncomplicated gonorrhoea ;. Prophylaxis of disseminated MAC infectionsPharmacokinetics: -absorbed rapidly thru oral route; extensive tissue distribution w/n cells; minor hepatic metabolism but primarily metabolized in kidneys,

Mild to moderate nausea, vomiting, abdominal pain, dyspepsia, flatulence, diarrhoea, cramping; angioedema, cholestatic jaundice; dizziness, headache, vertigo, somnolence; transient elevations of liver enzyme values

Hypersensitivity.

Efficacy Safety Suitability

Respiratory Fluoroquinolonese.g. LevofloxacinPharmacodynamics:-urinary and GI infections, non-gonococcal urethritis, severe infections due to gram - infections, combination treatment of MDR TB, prophylaxis for meningococcal infections and antrax infeactions and CAPPharmacokinetics: -absorbed well in oral preparations, good distribution, half-life of 1-3 hrs; renal clearance

mild nausea, vomiting, diarrhea,hallucinations, delirium, and seizures, hypoglycemia, Rashes, including photosensitivity reactions

Good for patient but might interfere with glycemic control

Drug Efficacy Safety Suitability

Penicillin e.g. Co-amoxiclav

++++ ++++ -

Cephalosprin 2nd and 3rd generation

++++ ++++ -

Cabapenem ++++ +++ -

IV Extended Macrolidee.g. Azithromycin

++++ ++++ +++

IV Fluoroquinolone e.g. Levofloxacin

+++ ++++ +

Cost per day Total Cost of Treatment

Penicillin e.g. Co-amoxiclav

2,400 + 1,800 44,800 - 88,200

Cephalosprin 2nd and 3rd generation

1,800 + 1,800 50,400 - 75, 600

Carbapenem 2,000-5,000 + 1,800

28,000-70,000+25200

Extended Macrolidee.g. Azithromycin

300 4200-6400

IV Fluoroquinolone e.g. Levofloxacin

1,400-2,800 19,600-58,800

Decision to chose Fluoroquinolone over an extended macrolide

• A respiratory fluoroquinolone as monotherapy was chosen over an extended macrolide due to the severity of the patient's situation.

• Presence of sepsis and concomittant uncontrolled diabetes in the patient compels us to choose a respiratory fluoroquinolone due to its stronger activity against the suspected pathogens.

Decision to choose Levofloxacin over Moxifloxacin

• Though Levofloxacin and Moxifloxacin shows equal efficacy in the treatment of CAP-MR, Levofloxacin is chosen due to its more affordable price.

Dosage•Patient should be started with 750mg IV Levothyroxine q24 hour.

•Assessment should be done after 3days so that parenteral therapy can be descalated to oral therapy once patient starts improving.

•Nonresponse to therapy is an indication to examine Culture-Sensitivity of the etiologic agent and proper adminstration of adequate antimicrobial