7-A200D-2017-Books-00020-FamilyMedicine_Essentials_MECH-FLIP-FINAL

General Resources

Primary Care Medicine: Office Evaluation and Management of the Adult Patient, 7 th Edition Allan H. Goroll, MD, MACP • Albert G. Mulley, MD, MPP

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chapter 52

Approach to thePatientwithAcuteBronchitis orPneumonia in theAmbulatorySetting

tabLe 52–2 empirictreatment for Lowerrespiratorytract infections

clinicalSyndrome

preferredempirictreatment

alternativetreatment

Acutebronchitis

None

Doxycycline, erythromycin Second-generationmacrolide, a trimethoprim–sulfamethoxazole Doxycycline, respiratory fluoroquinolone b Respiratory fluoroquinolone Respiratory fluoroquinolone

Acute exacerbationof chronicbronchitis

Second-generation cephalosporinor amoxicillin–clavulanate

Community-acquiredpneumonia Healthy young adults

Macrolide

Second-generationmacrolide a plus β -lactam c Third-generation cephalosporinplus second-generationmacrolide

Elderly (age>60 y)or comorbiddisease Hospitalizedpatient (non–intensive careunit)

a Second-generationmacrolides include clarithromycin and azithromycin. b Respiratory fluoroquinolones are agentswith adequatepneumococcal activity, including levofloxacin,moxifloxacin, andgemifloxacin. c β -Lactamswith adequate activity againstpotentially resistantpneumococci include amoxicillin1g three timesdaily and amoxicillin–clavulanate2g twicedaily.

Addresses the full spectrum of clinical problems encountered in the adult primary care practice. Whether it’s the answer to a question regarding screening, prevention, evaluation, management, or a comprehensive approach to a complex condition, you’ll find a review of the best evidence integrated with considerations of affordability, cost-effectiveness, convenience, and patient preference. All chapters are completely updated with new data from nearly 3,000 of the best and latest randomized trials, systematic reviews, meta- analyses, and cost-effectiveness studies. d d Employs a unique problem-based chapter organization that covers the full spectrum of adult primary care, including complementary and alternative therapies, men’s and women’s health issues, ADHD, posttraumatic stress disorder, and biologic therapies for cancer and autoimmune disorders d d Presents actionable, scientifically-validated guidance that allows physicians to go beyond standard consensus guidelines and provide highly personalized care d d Emphasizes team-based approaches to primary care delivery, recognizing its increasing importance in achieving high levels of practice performance d d Provides over 300 tables, figures, and photographs d d Offers quarterly updates through its digital format to provide the most current point-of-care decision support d d Includes free, unlimited INTERACTIVE eBook access

discussion);more than85%of resistantorganisms are serotypes contained in the 23-valent vaccine. In addition,penicillin resis- tance has decreased since the introduction of the pediatric conjugate vaccine (which contains serotypes responsible for almost80%of resistantorganisms) in2000. managementof influenza If the diagnosis of influenza is confirmed or highly suspected, severalmedicationsmaybeuseful indecreasing thedurationof symptoms ifadministeredwithin the first48hoursof the illness. Previously, amantadine and rimantadine were recommended as first-line therapy,although theseagentswereonlyactiveagainst influenzaA.However, increasing resistance to these agents has occurredover the lastdecade, and in the2005 to2006 influenza season, the routineuseof these agentswas abandoned. The neuraminidase inhibitors zanamivir and oseltamivir are neweragents for the treatmentof influenza.Thesedrugsare sialic acidanalogues that inhibit theviralneuraminidaseenzyme,which is essential to replication for both influenza A and influenza B. Randomized trials of these agents show a decrease in the dura- tion of illness of 1 to 1.5 days if the drug is administeredwithin 48 hours of symptom onset, similar to the effect seen with the older agents.Zanamivir is administeredby an inhaler twicedaily; oseltamivir isgivenasapill (75mg) twicedaily. Inhigh-riskpopu- lations, these agents reduce risk of death, hospitalization, and

durationof symptoms.Earlier treatment is associatedwithbetter outcomes. The advantage of these newer agents is their activity against both influenzaA and influenzaB; thedevelopmentof resistance has been documented but is of uncertain clinical significance. In addition, because the average cost of these agents is at least 10 times greater than that of influenza vaccine, vaccination is clearlythemorecost-effectivemethodforavoidingflusymptoms. Preventing influenza among health careworkers is amajor challenge.Randomized trial findswearing an everyday surgical mask provides asmuchprotection aswearing an N95 respirator. Handwashing is essential. Prophylaxis in patients and family members is a priority (seePatientEducation andPrevention). tHERaPEutic REcommEndations (50,51) antibiotictherapy for Pneumonia Treatment for lower respiratory tract infections is tailored to the clinical syndrome and likelypathogens.Table52–2 summarizes the empiric antibiotic recommendations for the various clinical syndromes, andTable 52–3 describes the recommendations for specificpathogens.

tabLe 52–3 pathogen-Specifictherapy for Lowerrespiratorytract infections

organism

First-Lineagent

alternativeagents

Streptococcus pneumoniae Penicillin sensitive (MIC<0.1 μ g/mL) Intermediatepenicillin resistance (MIC0.1–2.0 μ g/mL) Highlypenicillin resistant (MIC>2.0 μ g/mL)

Penicillinor amoxicillin

Erythromycin, respiratory fluoroquinolone

Parenteralpenicillinor ceftriaxone

Respiratory fluoroquinolone

Ceftriaxone, cefotaxime (basedon susceptibilities) Erythromycinor second-generation macrolide Second-generation cephalosporin

Vancomycin, respiratory fluoroquinolone

Respiratory fluoroquinolone

Legionellosis

Second-generationmacrolide, trimethoprim–sulfamethoxazole Second-generationmacrolide, respiratory fluoroquinolone Vancomycin (ifmethicillin resistant); cefazolin

Haemophilus influenzae,Moraxella catarrhalis

Doxycyclineor erythromycin

Chlamydophila pneumoniae,Chlamydia psittaci, Mycoplasma pneumoniae

Nafcillin

Staphylococcus aureus

β -Lactam/ β -lactamase inhibitor, fluoroquinolone Cephalosporin, erythromycin Penicillinplusmetronidazole Trimethoprim–sulfamethoxazole Chloramphenicol

Second-or third-generation cephalosporin

Klebsiella pneumoniae

Penicillin Doxycycline Clindamycin

Streptococcus pyogenes Coxiella burnetii (Q fever)

Mixed anaerobic–aerobic infection (aspiration)

Erythromycinor second-generation macrolide

Bordetella pertussis

InfluenzaA

Oseltamivir

Zanamivir

MIC,minimum inhibitory concentration.

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