RISK FACTORS: Smoking, Alcohol abuse, Immunosuppression/HIV, Chronic cardiopulmonary disease, Surgery, Advanced age, Renal failure, Fever > 39Β°C, Hyponatremia, Liverdysfunction
,Creatine kinase elevation
APPROPRIATE HEALTH CARE Severity of illness and support available in the outpatient setting will dictate the appropriate site for care
GENERAL MEASURES
β’ Supportive care
β’ Maintaining oxygenation, hydration, and electrolyte balance while providing antibiotic therapy
ACTIVITY As tolerated
DIET As tolerated
PATIENT EDUCATION
β’ Can educate patients regarding prevention/avoidance measures, lowering their risk status, and if infected
already, about the expected course of the disease
β’ Disease prevention - elimination of the pathogens from water supplies
β’ Person-to-person transmission has not been observed
DRUG(S) OF CHOICE
β’ Azithromycin 500 mg po qd
β’ Clarithromycin 500 mg po bid
β’ Levofloxacin 500 mg po or IV every 24 hours
β’ Ciprofloxacin IV 400 mg every 8 hours or po 750 mg every 12 hours
β’ Addition of rifampin 600 mg q 12 hours po or IV should be provided along with above in very ill patients
ALTERNATIVE DRUGS
. Erythromycin 30-60 mg/kg/day po or IV divided into four doses for 10-21 days
. Tetracyclines may be used along with rifampin
. Doxycycline IV 200 mg every 12 hours x 2 doses, then 100 mg bid or po 200 mg x 1 dose, then 100 mg bid
. Minocycline 100 mg IV or po every 12 hours
. Trimethoprim-sulfamethoxazole IV or po 5 mg/kg TMP every 8 hours
PATIENT MONITORING
β’ Respiratory status, hydration and electrolyte status should be monitored closely
β’ Chest x-ray not useful to monitor clinical response
PREVENTION/AVOIDANCE Heating water to 60-70 degrees centigrade may help prevent water contamination. UV light or copper-silver ionization are bactericidal.
POSSIBLE COMPLICATIONS
β’ Dehydration
β’ Hyponatremia
β’ Respiratory insufficiency requiring ventilator support
β’ Endocarditis
β’ Disseminated intravascular coagulation
β’ Renal failure
β’ Multiple organ dysfunction syndrome (MODS)
β’ Coma
β’ Death in 10% of treated non-immunocompromised
patients, and in up to 80% of untreated immunocompromised patients
β’ Bacteremia or abscess formation in immunocompromised
EXPECTED COURSE/PROGNOSIS
β’ Recovery is variable, some patients experience rapid improvement with defervescence in 3-5 days and
recovery in 6-10 days, while others may have a much more protracted course despite treatment
β’ Mortality rate can approach 50% with nosocomial infections