Transcript Treatment

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DYSPEPSIA
URINARY TRACT INFECTION
BRONCHIAL ASTHMA
PULMONARY TUBERCULOSIS
CAP
HYPERTENSION
DIABETES MELLITUS
Chronic or recurrent pain or
discomfort in the upper abdomen
occurring > 2 weeks.
Gnawing, burning pain
Discomfort defined as: early satiety,
upper abdominal fullness, nausea,
bloating, belching
Rome Working Team formulation
1. age at onset >45 y.o.
2. weight loss >10%
3. anemia
4. hematemesis
5. melena
6. hematochezia
7. dysphagia
8. odynophagia
9. persistent vomiting
10. abdominal mass
11. jaundice
12. chronic NSAID intake
13. chronic alcohol intake
14. previous history of
peptic ulcer
15. family history of GI*
ulcer
16. lymphadenopathy*
*Rome Working Team Formulation
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Empiric trial of acid suppression with proton
pump inhibitor (PPI) for 4-8 weeks (Gr A)

Test-and-treat strategy for H. pylori* (Gr A)
*in populations with moderate to high prevalence of H. pylori infection
(>10%)
Dyspepsia
Age > 55 or with alarm
EGD
Age < 55, no alarm
HP prev <10%
PPI trial
HP prev > 10%
Test-&-treat
for H. pylori
Test-&-treat
for H. pylori
Consider EGD
PPI trial
Pharmacologic:
2-4 wks PPI, H2 blocker, antacid
Non-Pharmacologic:
avoid alcohol, milk, tea, carbonated
drinks, coffee, acidic beverages
small frequent feedings
avoid skipping meals
WOF
: increased abdominal pain, alarm symptoms,
absence of improvement after >7days of tx
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Proton pump inhibitors
 Esomeprazole 20-40 mg OD
 Omeprazole 20 mg OD
 Pantoprazole 40 mg OD
 Lansoprazole 30 mg OD
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H2 blockers
 Ranitidine 150 mg BID/ 300 mg HS/ 50 mg IM
 Famotidine 20 mg BID/ 40 mg HS
 Cimetidine 200 mg BID/ 400 mg HS/ 200 mg IM
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Antacids - Mg/Al hydroxide PO QID, pc
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Cytoprotectives – Sucralfate 500 mg QID, ac
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Prokinetic Agents - Metoclopramide 10 mg PO TID
Domperidone 10 mg PO TID
Dimethicone 40 mg PO TID
ACUTE UNCOMPLICATED CYSTITIS
ACUTE UNCOMPLICATED
PYELONEPHRITIS
RECURRENT UTI
ASYMPTOMATIC BACTERIURIA
UTI IN PREGNANCY
COMPLICATED UTI
UTI IN MALES
The Philippine Clinical Guidelines on the Diagnosis and Management of Urinary Tract
Infections in Adults 2004
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Dysuria, frequency, gross hematuria, with or without
backpain
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Without symptoms of vaginitis, pyelonephritis, risk factors for
subacute pyelonephritis or complicated UTI---Upper Tract/STI sx)
≥5 wbc/hpf (males); ≥8 wbc/hpf (females)
>100 CFU/mL
Standard urine microscopy is not a prerequisite for
treatment
Pre-treatment urine culture and sensitivity is not
recommended
ACUTE UNCOMPLICATED CYSTITIS
TMP-SMX
800/160 mg BID
3 days
NORFLOXACIN
400 mg BID
3 days
OFLOXACIN
200 mg BID
3 days
CIPROFLOXACIN
250 mg BID
3 days
LEVOFLOXACIN
250 mg OD
3 days
ACUTE UNCOMPLICATED
PYELONEPHRITIS
fever (>38°C), chills, flank pain, CVA tenderness,
nausea, vomiting ±lower UTI symptoms
>5 wbc/hpf; >10,000 CFU/mL
Urinalysis and gram stain are recommended
Urine culture and sensitivity should be performed
routinely to facilitate cost-effective use of
antibiotics
Non-pregnant patients without sepsis, adherent to
treatment and likely to return for follow-up -
treat as outpatients
OFLOXACIN
400 mg BID
14 days
CIPROFLOXACIN
500 mg BID
7-10 days
LEVOFLOXACIN
250 mg OD
7-10 days
ACUTE UNCOMPLICATED
PYELONEPHRITIS
INDICATIONS for ADMISSION:
 inability to maintain oral hydration or take
medications
 concern about compliance;
 uncertainty about the diagnosis
 severe illness with high fever, severe pain,
marked debility
 signs of sepsis
> 100,000 cfu/ml of one or more uropathogens
- 2 consecutive midstream urine specimen or in one
catheterized urine specimen
- absence of symptoms attributable to UTI
Screening:
• pxs who will undergo genitourinary manipulation or
instrumentation
• post-renal transplant patients up to the first six months
• DM patients with poor glycemic control
• ALL pregnant women
Any antibiotics for AUC can be used for treatment of ASB
in the above group of patients
7-14 day course is recommended, except for pregnant
women
Routine screening and treatment is not recommended
for healthy adults
URINE CULTURE is the recommended screening test, but
urine microscopy and stain may be used in the absence
of culture
> 100,000 cfu/ml of one or more uropathogens in
- 2 consecutive midstream urine specimen
or in one catheterized urine specimen
- absent symptoms attributable to UTI
Must be screened on their first prenatal visit
between 9-17 wks AOG
URINE CULTURE of clean catch midstream urine is
the test of choice
UTI IN PREGNANCY
Antibiotic treatment must be initiated upon the diagnosis
of ASB in pregnancy
Follow-up cultures one week after completing the course
of treatment
Treatment:
- Nitrofurantoin (not for those near term)
- Co-amoxiclav, cephalexin
- Cotrimoxazole (not in the 1st and 3rd trimester)
- 7-day course is recommended
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Episodes of acute uncomplicated UTI documented by
urine culture occurring >2x/yr in a non-pregnant
woman without known urinary tract abnormality
Treatment of individual episodes: 7-day tx
Prophylaxis (continuous and post-coital)
Low-dose daily
Norfloxacin
TMP-SMX
Ciprofloxacin
Ofloxacin
200mg HS
40/200mg HS
125mg HS
-----------
Single dose
200mg
40/200
125
100mg
Presence of INDWELLING catheter or intermittent
catheterization
INCOMPLETE EMPTYING of the bladder with >100 ml
retained urine post-voiding
OBSTRUCTIVE UROPATHY due to bladder outlet
obstruction, calculus and other causes
Renal transplant
Diabetes Mellitus
UTI in Males except in young males presenting
exclusively with lower UTI symptoms
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Cut off for significant bacteriuria is >100,000 cfu/ml
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Urine sample for gram stain, culture and sensitivity
testing must always be obtained before initiation of any
treatment
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Treatment:oral fluoroquinolones are recommended with
7-14 days of therapy recommended
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A repeat urine culture one to two weeks after
completion of therapy
ORAL REGIMEN
DOSAGE
FREQUENCY
NORFLOXACIN
400 mg BID
14 days
OFLOXACIN
200 mg BID
14 days
CIPROFLOXACIN
250 mg BID
14 days
250 mg OD
10 - 14
days
LEVOFLOXACIN
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Generally considered complicated
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However, the 1st episode of symptomatic LUTI
occurring in young (15-40 years old) otherwise healthy
sexually active men with no clinical or historical evidence of
structural or functional urologic abnormality is considered
uncomplicated UTI
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Significant pyuria is >5wbc/hpf in a clean catch
midstream urine specimen
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TREATMENT: 7-day antibiotic regimen of TMP-SMZ or
fluoroquinolones may be used
Bronchial Asthma
Chronic inflammatory disorder of the airways
 Airway hyperresponsiveness
 Airflow obstruction often reversible either
spontaneously or with treatment
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Consider asthma if :
 Wheezing-high-pitched whistling sounds when
breathing out-especially in children
 History of any of the ff:
 Cough, worse particularly at night
 Recurrent Wheeze
 Recurrent Difficult Breathing
 Recurrent Chest Tightness
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Symptoms occur or worsen in
the presence of:
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Animal with Fur
Exercise
Aerosol Chemicals
Pollen
Changes in
temperature
Respiratory (viral)
infxns
 Domestic
Dust
Mites
 Smoke
 Drugs (aspirin,
beta blockers)
 Strong emotional
expression
 Reversible
and
variable airflow
limitation- as
measured by
using a
spirometer (FEV1
and FVC) or a
peak expiratory
flow (PEF) meter.
When using a peak flow meter, consider
asthma if:

PEF increases more than 15 % 15 to 20
mins after inhalation of a rapid-acting B2
agonist
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PEF varies more than 20% from morning
measurement upon arising to
measurement 12 hours later in patients
taking a bronchodilator

PEF decreases more than 15 % after 5
minutes of sustained running or exercise.
Classification of Asthma Severity (2005)
Symptoms/Day
STEP 1
Intermittent
< 1 time a week
Asymptomatic and
normal PEF between
attacks
STEP 2
Mild persistent
>1 time a week but
< 1 time a day
Attacks may affect
activity
STEP 3
Moderate
Persistent
Daily
Attacks affect
Activity
STEP 4
Severe
Persistent
Symptoms/
Night
PEF or FEV1
PEF variability
< 2 times a
month
>80%
__________
< 20%
> 2 times a
month
>80%
__________
20 - 30%
> 1 time a week
Continuous
Limited Physical
Activity
Frequent
60%-80%
__________
> 30%
<60%
__________
> 30%
GINA 2006 CLASSIFICATION OF ASTHMA
Characteristic
Controlled
Partly Controlled
( all)
( any present in any
week)
Daytime Symptoms
None ( 2x or
less/week)
More than 2x/week
Limitations of
activities
None
Any
Nocturnal
symptoms/awakening
None
Any
Need for
reliever/rescue tx
None (2x or
less/week)
More than 2x/week
Lung Function (PEF
or FEV 1)
Normal
< 80% predicted or
personal best ( if
known)
Exacerbations
None
One or more/year
Uncontrolled
Three or more
features of partly
controlled asthma
present in any week
One in any week
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Any exacerbation should prompt review
of maintenance treatment to ensure that
it is adequate
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By definition, an exacerbation in any
week makes that an uncontrolled
asthma week
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Lung function is not a reliable test for
children 5 years and younger
Goals for successful management
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Achieve and maintain control of symptoms
Maintain normal activity levels, including
exercise
Maintain pulmonary function as close to normal
as possible
Prevent asthma exacerbations
Avoid adverse effects from asthma medications
Prevent asthma mortality
Asthma treatment: controllers
Asthma treatment: controllers
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Leukotriene modifiers
 receptor antagonists (montelukast,
pranlukast, and zafirlukast) and a 5lipoxygenase inhibitor (zileuton)
 Less effective than long acting B2 agonist as
add-on
 Less effective than glucocorticoids when
used alone
Asthma treatment: controllers
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Long acting inhaled B2 agonist
 Salmeterol and formoterol
 Should not be used as monotherapy
 Combined with inhaled glucocorticosteroid,
when medium dose of the latter fails to
achieve control
 Formoterol – more rapid onset of action
Asthma treatment: controllers
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Theophylline
 Significant side effects at higher doses 10 mkday:
gastrointestinal symptoms, loose stools, cardiac
arrhythmias, seizures, and even death
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Rapid acting inhaled B2 agonists
 Salbutamol, terbutaline, fenoterol, reproterol, and
pirbuterol
 Medications of choice for acute attacks and for pretreatment of exercise-induced bronchoconstriction
Asthma treatment: controllers
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Systemic glucocorticoids
 Treatment of severe acute exacerbations
 40-50 mg prednisolone given daily for 5 to
10 days
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Anticholinergics
 Ipratropium bromide and oxitropium bromide
 Alternative bronchodilator for patients who
experience such adverse effects as
tachycardia, arrhythmia, and tremor from
rapidacting B2-agonists
Patients at High Risk for
Asthma-related death…
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History of near-fatal death
 * Hospitalization or ER visit for asthma w/in the past year
 * prior intubation for asthma
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Current use of, or recent withdrawal from, oral
glucocorticosteroids
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Over-dependence on rapid-acting B2-agonists.
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Hx of psychosocial problems or denial of asthma or its severity
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Hx of noncompliance w/ asthma medication plan
Patients should immediately seek medical
care if…
The
attack is severe…
The response to the initial bronchodilator
treatment is not prompt and sustained for at least
3 hours
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There
is no improvement within 2 to 6 hours after
oral glucocorticosteroid treatment is started
There
is further deterioration
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81 million population (2004)
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TB – major public health problem
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1998 – 6 among 10 leading cause of
death/illnesses (75 Filipinos die/day )
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8th Worldwide – high burden of TB
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3rd – new smear (+)ve TB notification rate in
Western Pacific Region (WHO Report 2003)
Local Symptoms:
cough, hemoptysis, chest pain, dyspnea
Constitutional Symptoms:
fever, weight loss, chills, anorexia
CONCEPTS:
1. TB exposure
2. TB infection: (+) PPD
3. TB disease: (+) target organ damage
SMEAR (+) CASE:
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(+) AFB Sputum Smear [two times]
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(+) AFB Sputum Smear [once] plus Radiographic Abnormalities
(consistent with active PTB)
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(+) AFB Sputum Smear [once] plus (+) Sputum Culture
SMEAR (-) CASE:
• (-) AFB Sputum Smear [three times] plus Radiographic Abnormalities
(consistent with active PTB)
• No response to a full course of antibiotics
• Decision of a clinician to treat with a full course of anti-TB
chemotherapy
INDICATORS OF ACTIVE DISEASE:
• (+) AFB sputum smear (at least two times)
or (+) TB culture
• (+) symptoms present
• increase in apical CXR infiltrates
INDICATORS OF INACTIVE DISEASE:
• six months interval with no change in CXR infiltrates
and no constitutional symptoms noted in the patient
• preferably with history of completed TB treatment
regimen
NEW CASE:
• never had treatment for TB or has
taken anti-TB drugs for less than one
month
RELAPSE:
• previously treated for TB, declared
cured or treatment completed, with
(+) AFB sputum smear or culture
RETURN AFTER DEFAULT (RAD):
 treatment re-started with (+) AFB sputum smear or culture,
following interruption of treatment for two or more months
FAILURE:
 sputum smear (+) at 5 months during course of treatment
CURED:
 treatment completed and has (-) AFB Sputum Smear in the
last month of treatment and on at least one other occasion
TREATMENT COMPLETED:
• treatment completed but does not meet
criteria to be classified as "cure" or "failure“
TREATMENT FAILURE:
• AFB Sputum Smear (+) after five months of
treatment OR AFB Sputum Smear (-) before
treatment and becomes (+) during
treatment
Community Acquired
Pneumonia
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an acute infection of the pulmonary parenchyma
accompanied by symptoms of acute illness
accompanied by abnormal chest findings.
Community Acquired Pneumonia
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Lower respiratory tract infection acquired in in the
community w/in 24h to < 2wks
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Acute cough
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Abnormal Vital signs:
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At least one 1 abnormal
chest finding:
 tachypnea (RR >
  breath sounds
 tachycardia (CR >
 Crackles
20bpm)
100/min)
 fever (T>37.8C)
 Rhonchi
 Wheeze
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Done to confirm diagnosis in most patients
(grade A)
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New parenchymal infiltrate in CXR remains
the reference diagnostic standard for
pneumonia (Grade A)
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CXR may suggest possible etiology and
differentiate it from other conditions that
mimic it (Grade A)
Low Risk
stable VS
*RR < 30 bpm
*PR <125cpm
*DBP>/=60 mmHg
*SBP >/=90mmHg
No or stable comorbid
conditions
No evidence of
extrapulmonary sepsis
No evidence of aspiration
CXR:
Localized infiltrates
No evidence of pleural
effusion nor abscess
Not progressive within 24 hrs
Suitable for out- patient care
(grade A)
Moderate Risk
High Risk
Unstable VS
*RR >/= 30 bpm
*PR >/=125 cpm
*T < 35C or >/=40 C
Any of the clinical feature of
moderate risk CAP
plus any of the ff:
1. Shock or signs of
Unstable comorbid condition
hypoperfusion
Suspected aspiration
2. Hypotension:
Extrapulmonary sepsis
DBP <60 mmHg or
SBP < 90mmHg
• Altered mental state
CXR :
• UO <30ml/hr
Bilateral/multilobar
3. Hypoxia (PaO2<60 mmHg)
infiltrates
Pleural effusion
or acute hypercapnea
Progression of lesion to
(PaCO2 >50mmHg)
50% of initial finding w/in
24H
CXR: as in mod CAP
Need to be hospitalized (A)
Admission to ICU (A)
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Grade A
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 DM
 Neoplastic dse in remission
Grade B
 Renal insufficiency
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Grade C
 Neurologic,
 COPD
 CHF I
 CLD
 CAD
 chronic alcohol abuse
 Immunosuppresion
OUT PATIENT treatment if there are is
reasonable assurance for follow up (C)

Uncontrolled DM
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Active malignancies
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Progressing neurologic
disease
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CHF II-IV
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Unstable CAD

High doses of
immunosuppressive tx
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Renal failure on dialysis

COPD, IAE

Decompensated liver
disease

Uncontrolled alcohol
abuse
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Low Risk CAP  optional
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Mod and High Risk CAP
 Blood Culture (at least 2)--gold standard
 Gram stain/culture of respiratory specimens
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Atypical CAP
• M. pneumoniae- Particle Agglutination
Test
• C. pneumoniae- Microimmunoflorescence
• Legionella- urine antigen test and
Treatment: Low Risk CAP
ß-lactams:
Amoxicillin 500 mg TID
Trim/sulfonamide:
Cotrimoxazole 160/180 mg BID
Macrolides:
Azithromycin 500 mg OD
Clarithromycin 500 mg BID
Roxithromycin 150 mg BID or
300 mg OD
ß-lactams w/ ß-lactamase
inhibitor:
Co-amoxiclav 625 mg TID
or 1 g BID
Sultamicillin 750 mg BID
2nd gen. Cephalosporins:
Cefuroxime 500 mg BID
Cefaclor
500 mg TID
or 750 mg BID
Moderate and High Risk CAP
Macrolides:
Erythromycin IV
0.5 – 1 g q 6h
Azithromycin PO or IV 500 mg q 24h
Clarithromycin PO or IV 500 mg q 12h
Roxithromycin PO 150 – 300 mg BID
Anti-pneumococcal Fluoroquinolones:
Levofloxacin PO or IV 500 mg q 24h
Gatifloxacin PO or IV 400 mg q 24h
Moxifloxin PO or IV
400 mg q 24h
Carbapenem
Ertapenem IV 1 g q 24h
ß-lactams w/ ß-lactamase inhibitor:
Sulbactam-Ampicillin IV 1.5 g q 8h
Co-amoxiclav IV 1.2 g q 8h
2nd gen. Cephalosporins:
Cefotiam IV 1 g q 8h
Cefuroxime IV 1.5 g q 8h
Cefoxitin IV 1 – 2 g q 8h
3rd gen Cephalosporins:
Ceftriaxone IV 1 – 2 g q 24h
Cefotaxime IV 1 – 2 g q 8h
Ceftizoxime
1–2
High Risk CAP
3rd gen Cephalosporins:
Ceftriaxone
1 – 2 g q 24h
Cefotaxime
1 – 2 g q 8h
Ceftizoxime
1 – 2 g q 8h
Carbapenem:
Ertapenem
1 g q 24h
Anti-pseudomonal ß-lactams
Ceftazidime 2 g q 8h
Cefepime
2 g q 8-12h
Cefpirome 2 g q 12h
Ticarcillin-Clavulanate 3.2 g q 6h
Piperacillin-Tazobactam
2.25-4.5 g q 6-8h
Sulbactam-cefoperazone
1.5 g q 12h
Imipenem
1-2 g q 8h
Others:
Oxacillin 1-2 g q 4-6h
Clindamycin 600 mg q 8h
Metronidazole 500 mg q 6-8h
Low Risk
Medium Risk
Previously stable:
Amoxicillin or
Extended macrolides;
Alternative:
cotrimoxazole
With stable comorbids: Co-amoxiclav
OR Sultamicillin OR
2nd gen cephalosporins
OR
Extended macrolides
IV non-pseudomonal
B-lactam with or
without B-lactamase
inhibitor
Plus Macrolide
OR
Anti-pneumococcal
FQ
High Risk
No risk for P. Aeruginosa
IV
a. IV non-pseudomonal Blactam with or without Blactamase inhibitor
b. IV anti-pneumococcal FQ
With risk for P.
Aeruginosa:
IV non-pseudomonal Blactam with or without Blactamase inhibitor
PLUS
IV macrolide OR
IV Anti-pneumococcal FQ
+/- AG OR IV cipro
NORMAL
<120
<80
PRE-HPN
120-139
80-89
HPN STAGE 1
140-159
90-99
HPN STAGE 2
>160
>100
Diagnostic workup:
- FBS
- U/A
- serum Crea
- Serum K
- Lipid profile (HDL,LDL, Cholesterol, Trigly)
- 12 L-ECG
 Target BP: < 140/90
 Patients with diabetes or CKD:
Target BP< 130/80 mmHg
HYPERTENSIVE URGENCY
- no end organ damage
- oral medications given initially
- lower BP within 2-3 days
HYPERTENSIVE EMERGENCY
-(+) changes in sensorium, papilledema, or
CHF
- IV meds given STAT
- lower BP within 24 hours
MEDICATIONS:
1. Calcibloc (Nifedipine)
• 5-10 mg SL or PO, Q30 mins
2. Captopril (Capoten)
• 25 mg SL or PO, Q30 mins
3. Clonidine
• 75 mcg SL or PO, Q1
Without Compelling Indications
 Stage 1 Hypertension
SBP 140-159 or DBP 90-99mmHg
Thiazide-type diuretics
May give ACEI, BB, CCB or combination
 Stage 2 Hypertension
SBP >/= 160 or DBP >/= 100mmHg)
2-drug combination for most ( usually thiazide-type
diuretic and ACEI, or ARB, or BB, or CCB)
COMPELLING INDICATION
INITIAL THERAPY OPTION
Heart failure
THIAZ, BB, ACEI, ARB
Post MI
BB, ACEI
High CVD Risk
THIAZ, BB, ACEI, CCB
DM
THIAZ, BB, ACEI, ARB, CCB
CKD
ACEI, ARB
Recurrent stroke prevention
THIAZ, ACEI
Criteria for the diagnosis of Diabetes
1.
Symptoms of DM and a casual plasma glucose of more
than or equal to 200mg/dl (11.1mmol/L).
 Casual is defined as any time of the day w/out
regard to time since last meal.
 Symptoms of diabetes:
polyuria
polydipsia
unexplained weight loss
Criteria for the diagnosis of Diabetes
2.
FPG >/= 126 mg/dL (7.0 mmol/L).
 Fasting is defined as no caloric intake for
at least 8 hours.
3.
2-h plasma glucose >/= 200mg/dl (11.1mmol/L)
during a 75-g anhydrous OGTT.
Summary of recommendations for adults with
diabetes (ADA, 2007)
Glycemic control
 A1C 7.0%*
 Preprandial capillary plasma glucose 90–130 mg/dl (5.0–7.2
mmol/l)
 Peak postprandial capillary plasma glucose† 180 mg/dl (10.0
mmol/l)
 Blood pressure 130/80 mmHg
Lipids ‡
 LDL 100 mg/dl (2.6 mmol/l)
 Triglycerides 150 mg/dl (1.7 mmol/l)
 HDL 40 mg/dl (1.0 mmol/l)§
Chronic Complications of DM
Microvascular
Eye disease
Retinopathy (nonproliferative/proliferative)
Macular edema
Neuropathy
Sensory and motor (mono- and
polyneuropathy)
Autonomic
Nephropathy
Chronic Complications of DM
Macrovascular
Coronary artery disease
Peripheral vascular disease
Cerebrovascular disease
Others
Gastrointestinal (gastroparesis, diarrhea)
Genitourinary (uropathy/sexual dysfunction)
Dermatologic
Infectious
Cataracts
Glaucoma
DIABETES MELLITUS
FBS
OGTT
N<140mg/dL
N<100
N<140
IGT 140-199
IFG 100-125
DM =>200
DM>=126
RBS
IGT
140-199
DM>=200
DIABETES MELLITUS
A.
OBESE
BIGUANIDES
• Metformin 500mg OD, BID, TID
optimal dose 1,500mg/day
*starting dose: 500mg BID after meals
DIABETES MELLITUS
B. ELDERLY (>60 YEARS)
SULFONYLUREAS
• Glibenclamide 1.25-20 mg OD or in divided doses
**starting dose: 5mg OD 30min before meals
• Glipizide 2.5-30 mg OD or in divided doses
• Gliclazide 80-240 mg OD or in divided doses
DIABETES MELLITUS
•
may give
• ACE INHIBITORS - may slow down the
development of micro- albuminuria
Fosinopril 10mg/tab OD
Enalapril 10mg/tab OD
• ASA 80mg/tab, OD,p.c.