Pathogens that lead to CAP

• 75% cases: Streptococcus pneumoniae

• 10-15% cases: Haemophilus influenzae

• ~20% cases: Mycoplasma pneumonia

• 5-15% cases: Chlamydophila pneumoniae

• 2-15% cases: Legionella pneumophila

Empiric Therapy for CAP

• The 2019 IDSA/ATS guideline states empiric treatment targeting the most likely organisms, antibiotic should cover BOTH typical (S. pneumoniae and H. influenzae) and atypical (M. pneumoniae, C. pneumoniae, and Legionella) organisms.

• Beta-lactams do NOT cover atypical pathogens as compared to macrolides, doxycycline, and fluoroquinolones

CAP Duration of Therapy

• Durations are dependent on the patient reaching clinical stability (afebrile for 48-72 hours and stable, traditionally takes ~5 days)

• 2019 IDSA/ATS guideline: a minimum of 5 days

• 2025 ATS guideline: a duration of less than 5 days (minimum of 3 days)

CAP Treatment

The 2019 IDSA/ATS guidelines recommend that in patients who have CAP and the presence of comorbidities (diabetes, alcoholism, immunosuppression, asplenia) or use of antimicrobials in past 3 months, the treatment could be a respiratory fluoroquinolone (levofloxacin, moxifloxacin) OR a beta-lactam plus a macrolide/doxycycline 

Active TB Symptoms

• Cough lasting longer than 3 weeks with or without hemoptysis

• Chest pain

• Weakness/fatigue

• Weight loss

• Chills, fever, night sweats

Active TB Treatment

• RIPE – rifampin + isoniazid + pyrazinamide + ethambutol

  • Starts with RIPE daily for 2 months, followed by just rifampin + isoniazid daily for 4-7 months (total treatment length = 6-9 months)

• Rifapentine + isoniazid + moxifloxacin + pyrazinamide x 2 months, then rifapentine + isoniazid + moxifloxacin x 9 weeks

Latent TB Treatment

• Isoniazid + rifapentine once weekly for 3 months 

• Isoniazid + rifampin daily for 3 months 

• Rifampin monotherapy once daily for 4 months 

• Isoniazid daily (or twice weekly) for 6 or 9 months

  • Not preferred due to length of treatment 

TB Medications Counseling

• Must be taken with food: rifapentine

• Must be taken on an empty stomach: rifampin, isoniazid

• May be taken with or without food: pyrazinamide, ethambutol, moxifloxacin

Pyrazinamide

• Potential side effect of worsening gout

• Contraindicated in patients with acute gout and severe hepatic impairment

• Corticosteroids 10-20 mg for >4 weeks

• Anti IL-6, IL-12, and IL-23 drugs

Moderate risk:

• B-cell depleting agents in the past 12 months (rituximab, ocrelizumab)

• Abatacept

• Tyrosine kinase inhibitors (ibrutinib, acalabrutinib)

• High-dose corticosteroids (>20mg prednisone or equivalent for >4 weeks)

• CAR-T therapy in past 12 months

High risk:

Therapeutics associated with higher risk of progression to severe COVID-19 illness

Treatment for COVID-19

1. If no contraindications exist or there are no severe drug interactions, nirmatrelvir/ritonavir (Paxlovid) is recommended as first line.

2. If Paxlovid is not clinically appropriate and IV medications are feasible, remdesivir (Veklury) is recommended as a second line agent

3. Molnupiravir (Logevrio) is recommended as the last line agent if Paxlovid and Veklury are not appropriate/feasible.

Drug interactions

• Nirmatrelvir/ritonavir (Paxlovid): ritonavir is a strong CYP3A4 inhibitor

• Remdesivir (Veklury): minor CYP3A4 inhibitor

• Molnupiravir (Logevrio): no CYP interactions!

Risk factors for severe influenza illness

• Pregnant patients

• Immunocompromised patients

• Children <5 years of age and adults >65 years of age

• Diabetes

• Asthma

• Atherosclerotic disease, heart failure

• HIV/AIDS

• Treatment dose: 2 inhalations twice daily for 5 days

• Prophylactic dose: 2 inhalations once daily for 7 days

• Not recommended for patients with asthma/COPD​

Relenza Diskhaler (zanamivir)

Influenza vaccine

As of the 2023-2024 influenza season, patients with an egg allergy can receive any influenza vaccine with no additional safety measures, regardless of the severity of their previous reaction to eggs.

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