Amoxicillin clavulanic acid

Patients in nursing homes appear amoxy clavulanic to fare even worse, as they often have several comorbidities and poor nutritional status and are often physically inactive.

[5] In-hospital mortality is significantly higher, even after adjusting for age and sex. Common causative organisms in elderly people admitted to hospital with pneumonia include Streptococcus pneumoniae and Mycoplasma pneumoniae . Less commonly, Haemophilus influenzae and Staphylococcus aureus may be responsible. aureus , Klebsiella pneumoniae , and Pseudomonas aeruginosa are common causative organisms. In community acquired pneumonia, the causative agent is often not known. Older patients may have polymicrobial infections, which could be a factor in those who do not respond to initial antimicrobial treatment. Sputum cultures are often not reliable, as the microbial aetiology of severe pneumonia based on invasive diagnostic techniques often differs from the organisms found in the sputum. Assessment of 12,945 US Medicare in-patients with pneumonia, aged over 65, showed that initial treatment with a second-generation cephalosporin plus a macrolide, or a non-antipseudomonal third-generation cephalosporin plus a macrolide, or a fluoroquinolone alone lowered 30-day mortality.

And an analysis of 101 patients aged > 75 (mean and SD, 82 ± 5.5) admitted to an intensive care unit reported significantly higher mortality in those

who

Coronavirus causes inflammatory damage in the lungs, preventing clearance of bacteria. Most deaths in the influenza pandemics of 1918, 1957, and 1968 were caused by secondary bacterial infections. Concurrent bacterial pneumonia was highlighted as a particular problem in elderly people in the 2003 SARS outbreak. Early use of antibiotics in older adults Non-response to initial antimicrobial therapy increases mortality, and so the initial selection of antimicrobials is critical. According to NICE, to cover atypical and multiple pathogens in older patients with pneumonia and at risk of severe complications, the recommended choices of antibiotics in the community are: Amoxicillin with 500 mg 3 times a day (higher doses can be used – see BNF) for 5 days Clarithromycin (if atypical pathogens) 500 mg twice a day for 5 days.

Alternative oral antibiotics for penicillin allergy, if the pneumonia is of moderate-intensity; treatment should be guided by microbiological results when available Doxycycline or 200 mg on the first day, then 100 mg once a day for a further 4 days (5?day course in total) Clarithromycin 500 mg twice a day for 5 days. Please note there was an error with the prescribing strategy and this has been corrected as of 20th March – Please Check NICE guidance for all recommendations.

‘ Prescribe oral amoxicillin 500 mg three times a day for 5 days (higher doses can be used — see the BNF) and (if atypical pathogens suspected) oral clarithromycin 500 mg twice a day for 5 days, or oral erythromycin (in pregnancy) 500 mg four times a day for 5 days. Alternatively, if there is a penicillin allergy, or amoxicillin is unsuitable (for example atypical pathogens are suspected) options are oral doxycycline 200 mg on the first day then 100 mg once a day for 4 days (total course of 5 days), or oral clarithromycin 500 mg twice a day for 5 days, or oral erythromycin (in pregnancy) 500 mg four times a day for 5 days.’ The intensity of pneumonia in the community can be assessed using the CRB65 score; each factor scores one point: confusion (abbreviated Mental Test score 8 or less, or new disorientation in person, place, or time); a raised respiratory rate (30 breaths per minute or more); a low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg); age 65 years or over.

Score 1 or 2: intermediate risk (1?10% mortality risk). Score 3 or 4: high risk (more than 10% mortality risk). NICE recommends that anyone with a score of 2 should be admitted to hospital. NICE’s approach, however, doesn’t account for the high risk in very elderly people.

The mortality rate from COVID-19 approaches 15% at age 80 (Figure 1).

Current NICE guidance requires starting antibiotic treatment as soon as possible after establishing a diagnosis of community-acquired pneumonia, and certainly within 4 hours. This strategy is supported by the results of a US multicenter retrospective cohort study, a medical record review of 14,069 patients aged over 65 years and hospitalized with pneumonia.

A lower 30-day mortality was associated with antibiotic administration within 8 hours of hospital arrival (odds ratio = 0.85; 95% CI = 0.75-0.96). However, this may not be possible within the constraints of an overstretched service in a pandemic.

If antibiotics have to be taken within 4 hours of onset, there needs to be in place a self-management strategy that permits rapid access to the right antimicrobial treatment. Nursing homes could hold stocks of antibiotics for rapid deployment.

Health professional confirmation could then be used to facilitate timely self-prescribing for those most at risk. Examination strategy The least amount of equipment that is clinically appropriate should be used to assess a patient who might have COVID-19.

This should include a pulse oximeter, a thermometer, and a stethoscope. The ‘eyeball’ test, incorporating information on temperature, oxygen saturation, and pulse rate, should be sufficient to assess severity and cut down significantly on

contact

Assessing blood pressure significantly increases contact time and should be considered only in those in whom it contributes to the decision to admit or not. We recommend documenting that a ‘limited examination’ was performed. In assessing patients, carry antibiotics in a pre-sealed bag, to cut down entry and exit times from the person’s home or nursing home.

COVID Monitoring Service (CMS) Patients at high risk deemed to be managed at home require monitoring, to ensure that they do not deteriorate.

This is essential for nursing homes, where the potential for further spread in their patient population is significant.

Telephone monitoring services can follow up patients to determine whether deterioration occurs, and to detect spread in nursing homes .

Based on evolving NHS England guidance we recommend the following pathways. Category 1: May require admission When it is uncertain that safe care can be provided in the

community

Clinical pathway: Start antibiotics immediately; discuss management with a designated hospital admitting consultant. Category 2: Home isolation with active health monitoring Higher risk group for severe COVID-19, with stable illness that can be managed in the community. Clinical pathway: Signs of bacterial pneumonia–start antibiotics; active health monitoring (every other day calls and symptom monitoring) and point of contact if deteriorates. Nursing homes with active cases–daily calls to monitor individuals and case progression; patients should remain in isolation until 5 days after resolution of symptoms. Category 3: Home isolation with health advice Mild illness in a patient who can be managed safely in the community AND who is not in a higher risk group for complications.

Clinical pathway: Self isolate at home; health advice on how to identify deterioration; call CMS if more unwell . Gov.UK on those at increased risk of severe illness from coronavirus (COVID-19) includes: aged 70 or older (regardless of medical conditions) under 70 with an underlying health condition listed below (ie anyone instructed to get a flu jab as an adult each year on medical grounds): chronic (long-term) respiratory diseases, such as asthma, chronic obstructive pulmonary disease (COPD), emphysema or bronchitis chronic heart disease, such as heart failure chronic kidney disease chronic liver disease, such as hepatitis chronic neurological conditions, such as Parkinson’s disease, motor neurone disease, multiple sclerosis (MS), a learning disability or cerebral palsy diabetes problems with your spleen – for example, sickle cell disease or if you have had your spleen removed a weakened immune system as the result of conditions such as HIV and AIDS, or medicines such as steroid tablets or chemotherapy being seriously overweight (a body mass index (BMI) of 40 or above) those who are pregnant.

Oxygen The use of oxygen in pneumonia is based on expert opinion.

A Cochrane systematic review of the effectiveness of oxygen in adults with pneumonia highlights that the evidence is weak and limited owing to a small number of studies.

The British Thoracic Society suggests that for patients with pneumonia not at risk of hypercapnic respiratory failure, it is appropriate to aim for an oxygen saturation of 94–98%. Very elderly patients may tolerate an abnormally low SaO2 at rest when clinically stable; however, COVID-19 pneumonia may significantly worsen SaO2. Access to oxygen therapy will be challenging at the height of a pandemic.

Corticosteroids In the initial phase of pneumonia, elderly patients can present with wheezing and respiratory distress. It is not uncommon to consider corticosteroids at this stage, because of their anti-inflammatory effects.

Corticosteroids were widely used during the 2002-3 SARS outbreak. However, in a subsequent systematic review, including amoxicillin acid 29 low-quality studies of steroid use, 25 studies were inconclusive and four reported possible harm from steroid use.

A further evidence review did not support corticosteroid treatment, reporting no evidence of net benefit with corticosteroids in “respiratory infection due to RSV, influenza, SARS-CoV, or MERS-CoV”, and that corticosteroids probably impair clearance of SARS-CoV.

In contrast to pneumonia, corticosteroids show much clearer benefit in patients with sepsis. Potential harms of rapid deployment of antibiotics for pneumonia The main disadvantage of this proposed strategy is that it would tend to drive increased bacterial resistance. However, in a pandemic with a high mortality rate in a specific subpopulation, in this case very elderly people, this needs to be weighed against the benefits of the policy. Apart from penicillin allergy, adverse reactions to the recommended antibiotics, e.g. Conclusions Interventions that affect mortality in pneumonia are of great significance amoxicillin potassium clavulanate 625mg for public health, particularly during the current pandemic.

Rescue prescribing strategies, initiated by the patient at an early stage, could aid effective delivery of antimicrobials, significantly reduce hospital admissions, and reduce mortality.