Infection Treatment Other
Influenza

(flu)
Pediatric - CDC recommendations
  • Acute infection
    • Oseltamivir (Tamiflu®)
      • Age 14 days - 1 year: 3 mg/kg/dose twice daily for 5 days
      • Age > 1 year (dose based on weight)
        • 15 kg or less, the dose is 30 mg twice a day for 5 days
        • > 15 to 23 kg, the dose is 45 mg twice a day for 5 days
        • > 23 to 40 kg, the dose is 60 mg twice a day for 5 days
        • > 40 kg, the dose is 75 mg twice a day for 5 days ($$$)
    • Zanamivir (Relenza®)
      • Age ≥ 7 years: 10mg (inhalation powder) twice a day for 5 days ($$)

  • Prophylaxis
    • Oseltamivir (Tamiflu®)
      • Age 3 months - 1 year: 3 mg/kg/dose once daily for 7 days
      • Age > 1 year (dose based on weight)
        • 15 kg or less, the dose is 30 mg once a day for 7 days
        • > 15 to 23 kg, the dose is 45 mg once a day for 7 days
        • > 23 to 40 kg, the dose is 60 mg once a day for 7 days
        • > 40 kg, the dose is 75 mg once a day for 7 days ($$$)
    • Zanamivir (Relenza®)
      • Age ≥ 5 years: 10mg (inhalation powder) once a day for 7 days ($$)

Adults - CDC recommendations

OTHER
  • The strongest evidence for a benefit from oseltamivir and zanamivir is when they are initiated within 48 hours of symptom onset
  • Prophylaxis is for 7 days after last known exposure
  • In trials, oseltamivir reduced the length of flu symptoms by about 16 hours, but increased the incidence of nausea and vomiting
  • The overall benefits of oseltamivir are questionable - see Cochrane meta-analysis and Roche meta-analysis for more
  • The CDC recommends antivirals (oseltamivir or zanamivir) in patients who are at "high-risk" for flu-related complications.

    High-risk defined as having one of the following:
    • Children aged younger than 2 years
    • Adults aged 65 years and older
    • Persons with chronic medical conditions (Asthma, COPD, DM, CAD, kidney disease, etc.)
    • Immunosuppressed patients (HIV, medications, cancer)
    • Pregnant or postpartum (2 weeks after delivery)
    • ≤ 19 years old and receiving chronic aspirin
    • Morbid obesity (BMI ≥ 40)
    • American Indians/Alaska Natives
    • Nursing home residents

  • For outbreaks in institutional settings - CDC recommends antiviral chemoprophylaxis for a minimum of 2 weeks, and continuing up to 1 week after the last known case was identified. Antiviral chemoprophylaxis should be considered for all exposed residents, including those who have received influenza vaccination, and for unvaccinated institutional employees. [19]

STUDIES
  • NEURAMINIDASE INHIBITORS DURING PREGNANCY, BMJ (2017) RESULTS: This large multinational register study found no increased risks of adverse neonatal outcomes or congenital malformations associated with exposure to neuraminidase inhibitors during embryo-fetal life. [PubMed abstract]

Infection Treatment Other
Pneumonia,
community-acquired

(ADULTS)
2007 IDSA recommendations
  • Recommended outpatient treatment in patients with any of the following conditions:
    • Chronic heart, lung, liver, or kidney disease
    • Diabetes mellitus
    • Alcoholism
    • Malignancies
    • Asplenic
    • Immunosuppressing conditions or use of immunosuppressing drugs
    • Use of antimicrobials within the previous 3 months (in which case an alternative from a different class should be selected)
    • Other risks for drug-resistant S. pneumoniae infection
    • Regions with a high rate (> 25%) of infection with high-level (MIC, ≥ 16 mcg/mL) macrolide-resistant S. pneumoniae

  • Treatment options include (one of the following):
    • Levofloxacin - 750mg once daily for 5 days ($)
    • Moxifloxacin - 400mg once daily for 7 - 14 days ($$$)
    • Gemifloxacin - 320mg once daily for 5 - 7 days ($$$$)
    • Beta-lactam + Macrolide (or doxycycline)

Symptoms
  • Symptoms of pneumonia include cough, fever, sputum production, shortness of breath, hypoxia, and pleuritic chest pain
  • Chest X-ray should be performed to confirm the diagnosis
  • For outpatient treatment, sputum and blood cultures are not typically performed
  • In 2017, the FDA approved the procalcitonin (PCT) blood test to help distinguish bacterial vs viral pneumonia. High levels of PCT suggest a bacterial infection, while low levels suggest a viral infection or noninfectious causes. [FDA press release]

Etiology
  • A study published in 2015 found the following etiologies of community-acquired pneumonia in 2259 hospitalized adults:
    • No pathogen detected - 62%
    • Rhinovirus- 9%
    • Influenza virus - 6%
    • Streptococcus pneumoniae - 5%
    • Human metapneumovirus - 4%
    • Respiratory syncytial virus - 3%
    • Parainfluenza virus 1,2,3 - 2%
    • Coronaviruses- 2%
    • Mycoplasma pneumoniae - 2%
    • S. aureus - 2%
    • Adenovirus- 1%
    • L. pneumophila - 1%
    • Enterobacteriaceae - 1% [10]

Inpatient vs outpatient treatment
  • The CURB-65 criteria can be used to help guide decision-making regarding inpatient vs outpatient treatment

    • CURB-65 criteria include:
      • Confusion - disorientation to person, place, or time
      • BUN - > 20mg/dl (may be excluded in office settings)
      • Respiratory rate - ≥ 30 breaths/min
      • Low Blood pressure - systolic < 90mmHg or diastolic ≤ 60mmHg
      • Age ≥ 65 years

  • Patients receive one point for each criteria they meet
  • Patients with a score of 0 - 1 can be treated as outpatients
  • patients with a score ≥ 2 should be hospitalized [1]

  • 30-day mortality based on CURB-65 score:
    • 0 - 0.7%
    • 1 - 2.1%
    • 2 - 9.2%
    • 3 - 14.5%
    • 4 - 40%
    • 5 - 57%

Recent Studies
  • Antibiotics - A study published in the NEJM in 2015 compared beta-lactam vs beta-lactam + macrolide vs fluoroquinolone therapy in community-acquired pneumonia (N=2283). Median age in the study was 70 years and the primary outcome was 90-day mortality. Preferred beta-lactam therapy was amoxicillin, amoxicillin plus clavulanate, or a third-generation cephalosporin. At 90 days, there was no significant difference in the primary outcome - beta-lactam - 9%; beta-lactam + macrolide - 11.1%; fluoroquinolone - 8.8% [PubMed abstract]

  • Steroids - a study published in the Lancet in 2015 found that prednisone 50 mg/day was superior to placebo when added to antibiotics in patients with community-acquired pneumonia. The study is detailed here - prednisone vs placebo in CAP.

Infection Treatment Other
Pneumonia,
community-acquired

(PEDIATRIC)
2011 IDSA recommendations for children ≥ 3 months old
NOTE: Recommendations are for previously healthy, appropriately-immunized patients

First-line outpatient treatment for presumed bacterial pneumonia
Alternatives
  • Cefpodoxime - 10mg/kg/day given in 2 divided doses for 7 - 10 days ($$-$$$)
  • Cefuroxime - 30mg/kg/day (max 1000mg/day) given in 2 divided doses for 7 - 10 days ($-$$)
  • Cefprozil - 30mg/kg/day (max 1000mg/day) given in 2 divided doses for 7 - 10 days ($-$$)
  • Ceftriaxone - 50 - 100mg/kg/day IM (max 2000mg/day) given once daily for 7 - 10 days ($)
  • Levofloxacin ($$-$$$ for suspension, $ tablet)
    • 6 months - 5 years old - 16 - 20mg/kg/day given in 2 divided doses for 7 - 10 days
    • 5 - 16 years old - 8 - 10mg/kg/day (max 750mg/day) given once daily for 7 - 10 days
  • Linezolid ($$$$)
    • < 12 years old - 30mg/kg/day given in 3 divided doses for 7 - 10 days
    • ≥ 12 years old - 20mg/kg/day (max 1200mg/day) given in 2 divided doses for 7 - 10 days

For suspected Mycoplasma pneumoniae or Chlamydophila pneumoniae:
For Influenza:
Symptoms
  • Symptoms of pneumonia include cough, fever, sputum production, shortness of breath, hypoxia, and pleuritic chest pain
  • Infants < 6 months old with suspected bacterial pneumonia should be hospitalized
  • Patients with respiratory distress should be hospitalized [8]

    • Signs of respiratory distress include:
      • Tachypnea
        • Defined as respiratory rate (breaths/min):
          • Age 0–2 months: > 60
          • Age 2–12 months: > 50
          • Age 1–5 Years: > 40
          • Age > 5 Years: > 20
      • Dyspnea
      • Retractions (suprasternal, intercostals, or subcostal)
      • Grunting
      • Nasal flaring
      • Apnea
      • Altered mental status
      • Pulse oximetry measurement < 90% on room air

Workup
  • Blood and sputum cultures should not be routinely obtained for outpatient treatment
  • Routine chest X-ray is not necessary in children well enough to be treated as outpatients. Patients with signs of respiratory distress should have a chest X-ray.
  • In children who recover uneventfully from pneumonia, follow-up chest X-ray is not necessary [8]

Etiology
  • In preschool-aged children (2 - 5 years), viruses are responsible for the vast majority of pneumonias, and antibiotics are not routinely required

    • A study published in 2015 found the following etiologies of community-acquired pneumonia in 2222 hospitalized children (median age 2 years):
      • Respiratory Syncytial Virus (RSV) - 28%
      • Human rhinovirus - 27%
      • Human metapneumovirus (HMPV) - 13%
      • Adenovirus - 11%
      • M. pneumoniae - 8%
      • Parainfluenza virus - 7%
      • Influenza virus - 7%
      • Coronavirus - 5%
      • S. pneumoniae - 4%
      • S. aureus - 1%
      • S. pyogenes - 1% [9]

  • Streptococcus pneumoniae is the most common cause of bacterial pneumonia. Haemophilus influenzae is uncommon since the advent of the H. flu vaccine.
  • Mycoplasma pneumonia is marked by slowly progressing cough, malaise, sore throat, and low-grade fever developing over 3–5 days. It's unclear if antibiotics are beneficial in children with Mycoplasma pneumonia. [8]