الفهرس 
Community acquired pneumoniaOnly 14 pages are availabe for public view
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Abstract
Most initial treatment regimens for community-acquired pneumonia (CAP) are empiric. A limited number of pathogens are responsible for the majority of cases of CAP.
Emerging drug-resistant S. pneumoniae (DRSP) complicates the use of empiric treatment. Treatment failures have been demonstrated with use of macrolides for macrolide-resistant organisms. We recommend not prescribing macrolide monotherapy for patients who have received a macrolide antibiotic within the preceding three months.
Despite in vitro resistance, penicillin-resistant pneumococci may respond to higher dose beta-lactams, other than cefuroxime. Drug toxicity limits the use of telithromycin which should be reserved for patients with ”high-level” macrolide-resistant CAP in whom other agents are contraindicated
North American and British guidelines differ in their recommendations for first-line therapy for outpatient pneumonia. British guidelines promote amoxicillin and place less significance on atypical pathogens. North American guidelines advocate treating both atypical pathogens and pneumococcus, and suggest macrolides when antibiotic resistance is not anticipated.
We support the IDSA/ATS guideline recommendations for empiric treatment of CAP in non-hospitalized patients:
• For uncomplicated pneumonia in patients who have no significant comorbidities and/or use of antibiotics within the last three months, we suggest treatment with an advanced macrolide. Regimens include azithromycin (500 mg on day one followed by four days of 250 mg a day, or 500 mg for three days, or 2 g as single dose microsphere regimen) or clarithromycin XL (two 500 mg tablets once daily). We suggest NOT using fluoroquinolones for uncomplicated ambulatory patients with CAP. Alternative regimens are acceptable.
• For non-hospitalized patients with comorbidities or recent antibiotic use, we suggest treatment with a fluoroquinolone as monotherapy, or combination therapy with a beta-lactam plus a macrolide.
We recommend antibiotic treatment for a minimum of five days, although a shorter duration may be indicated with azithromycin because of its prolonged half-life. Therapy should not be stopped until the patient is afebrile for 48 to 72 hours and is clinically stable. When this is achieved, the persistence of other symptoms (eg, dyspnea, cough) is not an indication to extend the course of antibiotic therapy.
Infection is one of the major problems in the critical care units. Even when antibiotics are given for prophylaxis or treatment, the rate of infection is still high due to many factors such as decreased immunity, prolonged mechanical ventilation, large volume aspiration, nursing manipulation, sedation, disturbed conscious level and resustation.
The most common organisms causing hospital acquired pneumonia are the gram negative organisms. The most common is klebsiella followed by pseudomonas aeroginosa,E.Coli and MRSA.
This study consists of 239 patients who were admitted the major five military hospitals during the period from March 2012 to August 2012 and were selected due to suspicion of developing pneumonia either community (187 cases) or hospital acquired (52) according to clinical, laboratory and/or radiological evidence .Sputum, endotracheal aspiration (EA), blood culture were done to determine the cause of pneumonia. In this study 20 cases(8.3%) cases were subjected to mechanical ventilation who are 3 cases of 187 CAP (1.7%) & 17 cases of 52 HAP (32.7%) while 219 cases (91.6%) were not subjected to mechanical ventilation who are 184 cases of 187 CAP (98.3%) & 35 cases of 52 HAP (67.3%) .
This denotes those patients subjected to mechanical ventilation are more likely to develop ICU acquired pneumonia (VAP) than nonventilated patient. This most probably due to large-volume aspiration, sedation, decreased level of consciousness, Glasgow coma scale rating < 9, emergency procedure, cardiopulmonary resuscitation and continuous sedation.
Our study showed that gram positive organisms were the most prevalent in CAP especially strept pneumonia followed by staph aureus, while klebsiella was the most prevalent gram negative organism. On the other hand our study showed that gram negative organisms were the most prevalent in HAP especially klebsiella followed by pseudomonas aerginosa , while Staphylococcus hemolyticus was the most prevalent gram positive organism.