Bronchitis and Pneumonia Treatment

In this episode, listen in as our expert panel digs into identifying and treating acute bronchitis and community-acquired pneumonia. They’ll discuss when antibiotics are appropriate, which antibiotics to use, and other management tips.

You’ll also hear practical advice from panelists on TRC’s Editorial Advisory Board:

• Stephen Carek, MD, CAQSM, DipABLM, Program Director for the Prisma Health/USC School of Medicine Greenville Family Medicine Residency Program and Clinical Associate Professor at the University of South Carolina School of Medicine, Greenville
• Andrea Darby Stewart, MD, Associate Director, Honor Health Family Medicine Residency Program and Clinical Professor of Family, Community & Occupational Medicine at the University of Arizona College of Medicine - Phoenix
• Craig D. Williams, PharmD, FNLA, BCPS, Clinical Professor of Pharmacy Practice at the Oregon Health and Science University

None of the speakers have anything to disclose.

This podcast is an excerpt from one of TRC’s monthly live CE webinars, the full webinar originally aired in January 2025.

TRC Healthcare offers CE credit for this podcast. Log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter, or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.

Claim Credit

The clinical resources mentioned during the podcast are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights: 

• Chart: Managing Community-Acquired Pneumonia and Aspiration Pneumonia in Adults
• FAQ: Antibiotic Therapy: When Are Shorter Courses Better?
• Chart: Managing Cough and Cold Symptoms

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The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

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Transcript

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00:00:07 Andrea Darby Stewart

I tell people I've got good news and bad news for.

00:00:09 Andrea Darby Stewart

Which would you like first? And their response is usually will give me the bad news and I'm like, OK.

00:00:14 Andrea Darby Stewart

Bad news is I don't have anything that I can give you to cure you of this.

00:00:19 Andrea Darby Stewart

It's a viral illness.

00:00:21 Andrea Darby Stewart

There are no antibiotics that are going to make this better, and if I gave them to you, they could cause you some pretty significant side effects.

00:00:28 Andrea Darby Stewart

But the good news is that this is going to follow the typical course that your other upper respiratory tract infections going into a lower respiratory tract. Bronchitis have followed and that we do have some symptomatic management that we can.

00:00:45 Narrator

Welcome to Medication Talk, the official podcast of TRC Healthcare, home of Pharmacist’s Letter, Prescriber Insights, and the most trusted clinical resources. Proud to be celebrating 40 years of unbiased evidence and recommendations.

00:00:59 Narrator

On today’s episode, listen in as our expert panel digs into identifying and treating acute bronchitis and community-acquired pneumonia. They’ll discuss when antibiotics are appropriate, which antibiotics to use, and other management tips.

00:01:12 Narrator

Our panel for this conversation includes: Dr. Stephen Carek[MU1]  from the USC School of Medicine Greenville; Dr. Andrea Darby Stewart from The University of Arizona College of Medicine - Phoenix; and Dr. Craig Williams from the Oregon Health and Science University.

00:01:28 Narrator

This podcast is an excerpt from one of TRC’s monthly live CE webinars. Each month, experts and frontline providers discuss and debate challenges in practice, evidence-based practice recommendations, and other topics relevant to our subscribers.

00:01:43 Narrator

And now the CE information.

00:01:47 Narrator

This podcast offers Continuing Education credit for pharmacists, p harmacy technicians, physicians, and nurses. Please log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter, or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.

00:02:03 Narrator

None of the speakers have anything to disclose.

00:02:08 Narrator

Now, let’s join TRC Editor, Dr. Sara Klockars, and start our discussion!

00:02:15 Sara Klockars

We often refer to acute bronchitis as a chest cold, and this is where the inflammation and mucus and larger Airways of the lungs often will see bronchitis. In addition to Uri symptoms or symptoms may shift and bronchitis may follow. An upper respiratory infection.

00:02:34 Sara Klockars

Acute bronchitis is usually.

00:02:36 Sara Klockars

Rarely is there a bacterial cause.

00:02:41 Sara Klockars

The lung inflammation and mucus can lead to coughing with or without sputum or mucus, chest soreness, headache, fatigue, and these symptoms can last for weeks.

00:02:52 Sara Klockars

They can also overlap with other health conditions.

00:02:56 Sara Klockars

And Steven, can you comment on other respiratory?

00:02:59 Sara Klockars

We'd want to rule out for patients with bronchitis symptoms.

00:03:03 Stephen Carek

Yeah, during viral season, flu COVID being the most common one.

00:03:08 Stephen Carek

Pertussis. Still, it's out there, you know, we hope that all the patients are getting their vaccines and we know there is some, you know, hesitancy with receiving certain vaccines.

00:03:18 Stephen Carek

And and boosters and some of our population, so certainly some keeping the back of your mind that requires some additional testing to make sure that clinics have access to.

00:03:27 Stephen Carek

The flu COVID RSV probably being the big ones to think about because viral pathogens and then we think about other forms of potential pneumonia that could be causing patients ongoing symptoms, especially if they have fever.

00:03:40 Stephen Carek

Maybe bloody prurulant.

00:03:42 Stephen Carek

Really bad shortness of breath.

00:03:44 Stephen Carek

Maybe the elderly have other comorbidities like heart failure, COPD, diabetes.

00:03:48 Stephen Carek

In which case we really want to be mindful of, of potentially a commute acquired pneumonia.

00:03:53 Stephen Carek

But there's something like strep, pneumo, or even some of the more atypical pathogens like Mycoplasma. But being very mindful of those things. Fortunately, we have some rapid tests for things like flu COVID that can give us those answers pretty quickly, but definitely using a lot more of our.

00:04:08 Stephen Carek

Gestalt and whatever. You know, labs that we have available to us, whether it's inflammatory markers like Pro Calc.

00:04:14 Stephen Carek

RPESR chest X.

00:04:15 Stephen Carek

Something that's just to help guide us through those patients that may have something more complex than a, you know, a viral pathogen or a viral bronchitis, but maybe something worse, significant or severe like a communicable pneumonia.

00:04:28 Sara Klockars

Thank you.

00:04:29 Sara Klockars

That's a great overview.

00:04:32 Sara Klockars

So Craig, can you comment on when should we refer folks to a prescriber?

00:04:37 Sara Klockars

What would you tell, say, for example, a pharmacist to look for and and, you know, have patients follow up right away?

00:04:44 Craig Williams

Yeah, it does kind of tend a little bit on the.

00:04:46 Craig Williams

So if you're in an ambulatory setting and have access to things like chart, notes and labs, and can know a bit more about the patient, it does make it a little bit easier in the community setting where you might not have access to those or don't know, bas.

00:05:01 Craig Williams

A patient may.

00:05:01 Craig Williams

It does make it a bit tougher, but what I'm really looking for.

00:05:05 Craig Williams

Are signs of is this progressing to pneumonia? And then even among pneumonia, we have kind of mild, moderate and severe?

00:05:12 Craig Williams

But what I'm worried about is pneumonia for a patient, which you know for us means the infection is spread from just the air tubes into the actual lung or ankle.

00:05:20 Craig Williams

And that can become severe fairly quickly and and pneumonia and our older at risk adults has.

00:05:26 Craig Williams

Of mortality.

00:05:27 Craig Williams

As well as morbidity so.

00:05:29 Craig Williams

I'm looking for signs of pneumonia are against a bigger infection. So, you know, we think about our surg signs. So if I know their temperature, if they're febrile, that's pretty uncommon for bronchitis. Much more common in pneumonia. If I have access to their labs in the last 40.

00:05:44 Craig Williams

If.

00:05:45 Craig Williams

Have a White County above 10. That's much more likely, pneumonia.

00:05:48 Craig Williams

Really. Bronchitis.

00:05:50 Craig Williams

And part of this too, just kind of a bit of a gut check if the patients there in your setting sick pneumonia patients look really bad and otherwise healthy folks with bronchitis, they have a cough and maybe a sputum, but they don't look that sick, so.

00:06:04 Craig Williams

You know, for our experienced clinicians in all settings, you know you can somewhat trust your.

00:06:08 Craig Williams

But but I'm looking for objective signs of this patient really looks ill and for pneumonia, again, the big ones for us are fever.

00:06:15 Craig Williams

County, if I have it, and then if it's progressing a rapid respiratory rate.

00:06:19 Craig Williams

And a low blood.

00:06:20 Craig Williams

But that's not going to be available in all settings.

00:06:24 Sara Klockars

Great. Thank you.

00:06:26 Sara Klockars

Since acute bronchitis is usually viral, antibiotics won't.

00:06:30 Sara Klockars

This may be a good time to use that viral prescription pad to reinforce that antibiotics won't help.

00:06:36 Sara Klockars

Andrea, can you share how you talk to your patients about lower respiratory tract infections like acute bronchitis that are likely viral?

00:06:46 Andrea Darby Stewart

This is one of my actually favorite conversations to have with people, which I think makes me a little bit of an outlier in the medical community.

00:06:53 Andrea Darby Stewart

So I basically I tell people I've got good news and bad news for you.

00:06:57 Andrea Darby Stewart

Would you like first?

00:06:58 Andrea Darby Stewart

And their responses usually don't give me the bad.

00:07:01 Andrea Darby Stewart

And I'm like, OK, the bad news is I don't have anything that I can give.

00:07:04 Andrea Darby Stewart

To cure you of this.

00:07:06 Andrea Darby Stewart

It's a viral illness.

00:07:08 Andrea Darby Stewart

There are no antibiotics that are going to make this better, and if I gave them to you, they could cause you some pretty significant side effects.

00:07:15 Andrea Darby Stewart

But the good news is that this is going to follow the typical course that your other upper respiratory tract infections going into a lower respiratory tract. Bronchitis have followed and that we do have some symptomatic management.

00:07:28 Andrea Darby Stewart

We can do and for that I.

00:07:31 Andrea Darby Stewart

To rest, I want you to treat yourself to some chicken noodle soup or whatever has been appropriate for you, and is the thing that in your family has made everybody feel better when they're feeling poorly?

00:07:42 Andrea Darby Stewart

Increase your fluids.

00:07:44 Andrea Darby Stewart

You can use some.

00:07:46 Andrea Darby Stewart

Nasal saline use hot showers, coolness. All of these things can really help you with your respiratory symptoms and it will get better.

00:07:55 Andrea Darby Stewart

But the cough can last for several weeks, and so it's important for us to make sure that.

00:08:00 Andrea Darby Stewart

You know you're taking good care of yourself.

00:08:04 Sara Klockars

And Steven, how do you counsel a patient with a lingering cough and congestion?

00:08:08 Stephen Carek

Yeah. One thing I always will reference is that typically during bowel seasons in clinics, we just see so much of this and I think telling patients that your symptoms are seeing a lot of these kind of symptoms going out the community right now you're not alone in this.

00:08:20 Stephen Carek

Your symptoms seem pretty typical, and here's why I think that this is likely a viral pathogen and and kind of going through this list. Maybe they have a lack of or.

00:08:29 Stephen Carek

Low gate fever.

00:08:30 Stephen Carek

Their cough is nearly productive.

00:08:33 Stephen Carek

Maybe some?

00:08:34 Stephen Carek

They're presenting with kind of the typical symptoms, maybe a little bit of fatigue myalgias and then saying, I'm reassured that you don't have a pneumonia because of these things.

00:08:42 Stephen Carek

They're not successfully short of breath.

00:08:44 Stephen Carek

Again, that mucus cough.

00:08:46 Stephen Carek

High fevers.

00:08:47 Stephen Carek

Can I anticipate these symptoms to improve a little bit of time, but sometimes it takes about 7 to 10 days.

00:08:53 Stephen Carek

The cough can be a lingering.

00:08:54 Stephen Carek

It may take a week or two to go away, but I think we can really manage these symptoms and I hope that we can get you better a little bit quicker.

00:09:01 Stephen Carek

And then also counseling them on here, the red flag symptoms are things that want you to lookout for if you're not getting better in this period of time or if these symptoms evolve or change in any way.

00:09:10 Stephen Carek

That's the time that we need to see in person so we can.

00:09:13 Stephen Carek

Consider if you need additional testing and then providing whether recommendations on medications for the be over the counter prescription. But just those management strategies to help them navigate those symptoms so they can feel a little bit better.

00:09:26 Stephen Carek

It's no fun being sick.

00:09:27 Stephen Carek

And so we want to give people back to being able to enjoy their lives as quick as we can.

00:09:31 Stephen Carek

Knowing that you know these are just.

00:09:33 Stephen Carek

Hopefully this is just a mild viral pathogen that we can get you feeling better a little bit quicker with, you know, some common remedies.

00:09:40 Stephen Carek

Anti Inflammatory's Tylenol, fluids, rest, hydration all that.

00:09:46 Sara Klockars

Thank you.

00:09:48 Sara Klockars

You can review the pros and cons of non drug measures and OTC options in our chart. Managing cough and cold symptoms on our website.

00:09:58 Sara Klockars

And Steve, I'll turn it back over to you.

00:10:02 Stephen Small

Thanks.

00:10:02 Stephen Small

And you know, I'm glad we mentioned pneumonia earlier when differentiating bronchitis because community acquired pneumonia or tap is our next topic and you'll see that treatment here is more extensive, which we will review for both adults and kids.

00:10:18 Stephen Small

So I like to think of pneumonia as coming in all sorts of shapes and.

00:10:21 Stephen Small

Sometimes patients can acquire pneumonia in the hospital, but here we're focusing on when it's only acquired in the community.

00:10:28 Stephen Small

Cap is defined as pneumonia developing in patients who are not admitted to a hospital.

00:10:33 Stephen Small

Within 48 hours before a diagnosis.

00:10:36 Stephen Small

And cap can be caused by many different types of organisms.

00:10:40 Stephen Small

Today we'll only focus on bacterial cap.

00:10:44 Stephen Small

The most common culprits include bacteria like strep pneumoniae, Haemophilus influenzae, and even a typical bugs like mycoplasma.

00:10:52 Stephen Small

As with many infections, we're going to see that comorbidities like diabetes and renal disease can increase the chance of having resistant versions of all these bugs and that will affect how we treat them.

00:11:04 Stephen Small

So when deciding how to treat bacterial cap, we need to divide our patients into two separate groups. Those who get standard treatment, which are healthy patients and those who need broader spectrum coverage due to resistant risks.

00:11:19 Stephen Small

So patients at risk for resistance are those with comorbid conditions like chronic heart or lung disease, diabetes and even cancer.

00:11:27 Stephen Small

Others include patients who maybe had prior MRSA or Pseudomonas respiratory infections. Since we know those bugs.

00:11:34 Stephen Small

Have a lot of resistance factors.

00:11:36 Stephen Small

Or we have to think about if they needed four antibiotics in a hospital in the past 90 days.

00:11:42 Stephen Small

Since they may have picked up a resistant bug in that setting as well.

00:11:48 Stephen Small

So for healthy patients, CAP treatment is relatively.

00:11:52 Stephen Small

Patients can get a high dose of amoxicillin, which is 1 gram tid, or they can get doxycycline 100 milligrams twice a day and macrolides like azithromycin or clarithromycin are recommended as an alternative.

00:12:06 Stephen Small

And the newest CAP guidelines really emphasize this approach of using more amoxicillin for otherwise healthy patients.

00:12:13 Stephen Small

Steven are using this in a lot in your practice. Since these guidelines came out.

00:12:17 Stephen Small

See a shift after that.

00:12:21 Stephen Carek

I personally.

00:12:22 Stephen Carek

I mean, I'm always a big fan.

00:12:23 Stephen Carek

Especially if we're treating any bacterial infection, just keep it as simple as we can.

00:12:28 Stephen Carek

Amoxicillin is just kind of the most for me, the most basic antibiotic, and I think it works really effectively, and I think that's what the guidelines for what suggested, right?

00:12:37 Stephen Carek

Still seeing, you know, I think a good bit of of macrolide used for especially presumed pneumonia. But I do worry about kind of the emerging resistance to that antibiotic as well in my own clinical practice, it's usually amoxicillin.

00:12:50 Stephen Carek

If they have some sort of sniffing allergy to amoxicillin, doxycycline.

00:12:54 Stephen Carek

Those are kind of the two that I stay.

00:12:55 Stephen Carek

I try to avoid using macrolides just because I just know there's used so often in the Community, whether it's for pneumonia or whether for some other respiratory illness.

00:13:05 Stephen Carek

Yeah, that's my general clinical practice.

00:13:09 Stephen Small

Excellent.

00:13:11 Stephen Small

But if you have a patient that can't tolerate amoxicillin or doxycycline, or perhaps there's even a shortage.

00:13:18 Stephen Small

Using Azure Mysen could be an option here. However, it will be important to cancel patients on when to come back for evaluation if those symptoms still don't improve after two or three days and have a back up plan for next steps with broader antibiotic coverage to handle Poss.

00:13:35 Stephen Small

Resistance like we talked about earlier.

00:13:38 Stephen Small

Now, Andrew, I'm curious, since the CAP guidelines came out in 2019, has your use of macro lens for CAP changed?

00:13:45 Stephen Small

How often are we even still recommending macro lens for CAP? Perhaps even in your?

00:13:50 Andrea Darby Stewart

Yeah, I love that question.

00:13:51 Andrea Darby Stewart

Absolutely has changed again.

00:13:53 Andrea Darby Stewart

Super easy to you.

00:13:55 Andrea Darby Stewart

Click in your electronic health record and type AZ pack and hit enter. But in our community our streptoco resistance is well over 25% and so.

00:14:05 Andrea Darby Stewart

Macro lives are not going to be appropriate for my patients who are non hospitalized, you know, walking around in the community but having to have a community acquired pneumonia. So I do avoid.

00:14:14 Andrea Darby Stewart

Those I would direct everybody to take a look at the IDSA.

00:14:18 Andrea Darby Stewart

I think that they did a really nice job with them and are pretty clear about the recommendations for using amoxicillin or doxycycline for the majority of our patients and those medications that the doses recommended are generally very well tolerated.

00:14:32 Stephen Small

Very important points here about resistance. I really like this discussion and you know, I'm actually broadcasting out of Iowa right now. And I actually found a recent study that suggest our region had the highest overall resistance.

00:14:44 Stephen Small

Something like 54%.

00:14:46 Stephen Small

So I would be very hesitant to get a macro Lite if I came down with cap right now.

00:14:54 Stephen Small

All right, switching.

00:14:55 Stephen Small

What if our patient has a comorbidity like diabetes that increases their resistance risks and poor outcome risks? We need to cover for possible resistance up front with a broader antibiotic coverage.

00:15:08 Stephen Small

O here.

00:15:09 Stephen Small

We'll cover resistant strep, pneumo, and Haemophilus influenzae with amoxicillin clavulanate.

00:15:14 Stephen Small

Or a third generation Cephalosporin like cefdoxine.

00:15:20 Stephen Small

But we'll also add a macrolide or doxycycline to that to cover atypicals.

00:15:26 Stephen Small

Another option here though, is to give a respiratory fluoroquinolone like vivofluoxacin as monotherapy.

00:15:33 Stephen Small

Now I could see someone looking at this saying. Why don't we just give everybody this monotherapy?

00:15:37 Stephen Small

Just so darn simple.

00:15:38 Stephen Small

But that is true.

00:15:40 Stephen Small

It is simple and convenient, but it could come with some risks.

00:15:46 Stephen Small

So, for example, fluoroquinolone warnings have grown over the years.

00:15:50 Stephen Small

Hypo and hyperglycemia and even CNS side effects like altered mental status are important ones to consider, and it may not be dose or duration related.

00:16:01 Stephen Small

So avoid using fluoroquinolones for elderly patients, those with renal disease.

00:16:04 Stephen Small

Or maybe they're taking insulin or sulfoneria like glipizide.

00:16:09 Stephen Small

If used, I'd recommend close glucose monitoring and ensure patients have adequate testing supplies.

00:16:15 Stephen Small

And educate how to recognize and treat that hypoglycemia.

00:16:20 Stephen Small

And we know that quinolones have several risks, although they can be rare, things like Achilles tendon rupture, Qt prolongation, things like that.

00:16:28 Stephen Small

I'm curious even how much do these factors come up in your decision making when you've used a fluoroquinolone for a cap and has your use changed with fluoroquinolones over the years?

00:16:38 Stephen Carek

Yeah, I.

00:16:39 Stephen Carek

Just just cause all of the side effects and complications that can arise with four.

00:16:42 Stephen Carek

I I really reserve these as sort of a last line. I mean, unless we are absolutely this is the embark we have to use.

00:16:50 Stephen Carek

Mean. I just think the patient's.

00:16:51 Stephen Carek

But we tend to put these on.

00:16:53 Stephen Carek

Tend to have.

00:16:54 Stephen Carek

They tend to be older.

00:16:55 Stephen Carek

They tend to have some sort of, you know, seem like diabetes.

00:16:59 Stephen Carek

You worry about the risk of tendinopathy for patients, and maybe that affects mobility, and in some ways, and so I really again, for one alone. I I just think there's so many potential complications with their use.

00:17:10 Stephen Carek

They're good antibiotics and they they.

00:17:12 Stephen Carek

Place, but I think it's really important to identify the right patient for the right infection to utilize.

00:17:17 Stephen Carek

And as I said, it's probably more of a lower tier antibiotic for me when I'm dealing with community acquired pneumonia and most other infections that I will treat with antibi.

00:17:28 Stephen Carek

Addicts again, just because of there's so many secondary side effects, black box warnings that could potentially put our patients in danger situations.

00:17:38 Craig Williams

These are really wonderful antibiotics, and so I'll say when it comes to Quinn loans, I'm a cautiously aggressive user of Quinn loans, meaning if I don't need them, we've always somewhat shield away from them for like going back 20 years.

00:17:53 Craig Williams

More because we knew resistance was going to be a.

00:17:56 Craig Williams

So, you know, 20 years ago these were kind of our our more potent.

00:17:59 Craig Williams

We could save and potenti use betalactams and macro lids and tetracyclines first and then quinolones were kind of our our hip pocket as we needed them and we have seen resistance evolve.

00:18:10 Craig Williams

Unfortunately, but not surprisingly.

00:18:13 Craig Williams

So we never use them for things where we thought we didn't need them and that honestly, when the warning first came out from the F.

00:18:18 Craig Williams

We.

00:18:19 Craig Williams

With that, a bit like others did, but if you go to black box warning, it mentions them specifically, not across the board, but in certain conditions and it mentions the conditions you guys are partly talking about tonight.

00:18:31 Craig Williams

Sinusitis, otitis and then urinary tract cystitis and often those are conditions where we can use something else so.

00:18:38 Craig Williams

Umm.

00:18:39 Craig Williams

You know, we kind of took the FDA warning in stride because we already were.

00:18:43 Craig Williams

We're tending not to use these agents. If we had something else.

00:18:46 Craig Williams

Could.

00:18:46 Craig Williams

1st that we thought would manage that patient and yeah for things like otitis and cystitis, I've got better other options. I don't need to risk.

00:18:56 Craig Williams

The resistance of giving that patient a Quinn loan. But I think where people have gotten a bit overboard, where maybe I maybe disagree with some of my colleagues if I have.

00:19:05 Craig Williams

Appropriate infection that would benefit from a.

00:19:09 Craig Williams

I don't tend to hesitate because of the new.

00:19:12 Craig Williams

So the new the fortunately for us, these are very rare adverse effects.

00:19:17 Craig Williams

If I have someone with a severe.

00:19:20 Craig Williams

In this case, pneumonia or frequently for us on our inpatient practice, a severe urinary tract infection that goes beyond the bladder.

00:19:27 Craig Williams

Can be wonderful drugs to treat patients. So in the here and now for severe infection.

00:19:32 Craig Williams

We tend to not be too cowed by the warnings, and we use these where appropriate, but they are for severe infections where we think they're the best drug and for other infections we're happy to use. Other first line agents, which are safer these side effects, while rare, are.

00:19:47 Craig Williams

And we didn't really appreciate that until we started getting a lot of post marketing surveillance of these drugs.

00:19:52 Craig Williams

These are.

00:19:53 Craig Williams

Effects that.

00:19:54 Craig Williams

Come out in smaller randomized trials of 2 or 300 people, but but they clearly.

00:20:00 Craig Williams

And we actually know going back into the FD approval databases in the animal studies, some of these things came out. If you give super high doses of quinolones to animals, you can see some of these observed side effects.

00:20:13 Craig Williams

There's there's underlying mechanistic reasons.

00:20:16 Craig Williams

That they're true.

00:20:17 Craig Williams

But again, in a severe infection with the right drug, we don't hesitate to use them.

00:20:21 Craig Williams

These warnings.

00:20:22 Stephen Small

Yeah, a great example of weighing benefits versus risks. Love that.

00:20:27 Stephen Small

We can tailor therapy with these risks in mind.

00:20:31 Stephen Small

1st we could recommend considering fluoroquinolone monotherapy when patients can't take a beta lactam with a macrolide or doxycycline.

00:20:39 Stephen Small

For example, if there is a severe betalactom allergy or they can be considered for patients who are likely to have.

00:20:45 Stephen Small

Maybe very notable non adherence with those combo options, but have a low risk.

00:20:51 Stephen Small

Of side effects from those quinolones.

00:20:53 Stephen Small

It would also be good to check for cardiovascular disease history due to that vessel issue.

00:20:59 Stephen Small

That we may see, but also arrhythmias, which can frankly also apply to macrolytes and as always, we should be considering medication interactions since comorbidities do add up in terms of patients need to take multiple medications that could pose a risk for that.

00:21:15 Stephen Small

One example I can think of I've encountered in my practice is levafloxacin with warfarin and how that can increase the INR and risk for bleeding.

00:21:25 Stephen Small

So newer cap antibiotics like omatocycline and bifamilin have made the news. When they came onto the market a couple years ago.

00:21:33 Stephen Small

But we still aren't completely sure what their place in therapy is.

00:21:37 Stephen Small

They can be quite costly.

00:21:39 Stephen Small

For example, a three day supply of Omatocycline is over $1500.

00:21:45 Stephen Small

So it would seem appropriate to avoid routinely using these newer meds at this time.

00:21:50 Stephen Small

I'm.

00:21:50 Stephen Small

Our panelists have you used these newer CAP agents in practice, and if so, can you share any experiences or pros and cons you can think of?

00:22:00 Craig Williams

Yeah, I know, I.

00:22:00 Craig Williams

I definitely share that they should not be routinely.

00:22:03 Craig Williams

And.

00:22:03 Craig Williams

In fact, I believe that's so much I have not used these yet in.

00:22:06 Craig Williams

So yeah, at our academic medical centre, these uses will certainly be in the context of certain protocols for where they'd be appropriate.

00:22:15 Craig Williams

Yeah, newer.

00:22:16 Craig Williams

Definitely safer where we don't have alternatives. And yeah, I do.

00:22:20 Craig Williams

Yet have.

00:22:20 Craig Williams

Any personal experience with either?

00:22:23 Craig Williams

So I'm practicing what I preach in Seville for special circumstances.

00:22:28 Stephen Carek

I honestly have not seen them used.

00:22:30 Stephen Carek

I don't even think I've seen them used, at least in our community, by our infectious disease colleagues.

00:22:34 Stephen Carek

So I don't have a whole lot of knowledge first hand use of them, unfortunately.

00:22:40 Stephen Carek

Yeah, it's. I guess that's where it is.

00:22:42 Stephen Carek

Just don't see.

00:22:42 Stephen Carek

I haven't seen our infectious disease colleagues use them yet.

00:22:46 Stephen Small

Yeah, they definitely seem like they need to get more.

00:22:49 Stephen Small

And.

00:22:50 Stephen Small

Find their place in therapy.

00:22:53 Stephen Small

Also think about antibiotics. The patient has taken recently.

00:22:56 Stephen Small

Recent exposure may make bacteria resistant and using the same antibiotic again right away may be less likely to help.

00:23:03 Stephen Small

So using a different class can prevent this.

00:23:08 Stephen Small

For example, let's say a patient recently completed a course of a MOX clav for sinusitis.

00:23:14 Stephen Small

Instead of using that again, we can give CEF Podoxin plus doxycycline instead of that same approach.

00:23:22 Stephen Small

With all that in mind, I briefly want to point out differences with adult cap treatment to what we do for.

00:23:28 Stephen Small

I am a pediatric pharmacist after all. So keep in mind cap and kids under 5 is usually caused by viruses, so antibiotics typically aren't helpful.

00:23:38 Stephen Small

Strep, pneumonia and homophospholenza are still the most common bugs. When we do have bacterial cap in kids, but we recently saw a surge in mycoplasma cases in 2024 with kids under 17.

00:23:51 Stephen Small

Having the highest increases.

00:23:55 Stephen Small

So unlike adults, instead of dividing treatment by comorbidities or no comorbidities in kids, it's actually divided by whether we think that the pneumonias bacterial, atypical, or even both. We'll use high dose amoxicillin first line or amoxicillin, cladulan 8 second line.

00:24:13 Stephen Small

If we think it's presumed bacterial cap without a concern for atypicals.

00:24:18 Stephen Small

Like mycoplasma.

00:24:20 Stephen Small

And usually this decision about a typical is based on the prescriber's impression.

00:24:25 Stephen Small

So think about the same dosing administration principles of high dose amoxicillin and amoxiclav that we talked about earlier with otitis.

00:24:35 Stephen Small

Now for prescriber thinks the patient is cap caused by a bug like Mycoplasma.

00:24:40 Stephen Small

Then we can add on a macrolide or doxycycline here, or potentially use them solo depending.

00:24:46 Stephen Small

So for Andrea, my question for you is what do you look for when diagnosing a patient with a typical pneumonia?

00:24:51 Stephen Small

Most pharmacists may not be able to to see that from our perspective. Yeah, absolutely.

00:24:58 Andrea Darby Stewart

So you know, the majority of our kids that are, you know, under, you know, kind of elementary school kids when they come in with community acquired.

00:25:05 Andrea Darby Stewart

Pneumonia actually have an atypical pneumonia and unfortunately we experienced one heck of a mycoplasma season this most recent fall.

00:25:14 Andrea Darby Stewart

So majority of the listeners may be very familiar with what an atypical pneumonia looks like in a kid with this presentation.

00:25:20 Andrea Darby Stewart

They still have the high fevers.

00:25:22 Andrea Darby Stewart

I still feel.

00:25:23 Andrea Darby Stewart

They're still coughing if you get a chest X-ray, you're not going to see that low bar component that you'll typically see with a bacterial community acquired.

00:25:31 Andrea Darby Stewart

And these kids generally respond very well to azithromycin.

00:25:36 Andrea Darby Stewart

So that has been my go to for kids.

00:25:38 Andrea Darby Stewart

We think have an atypical pneumonia.

00:25:40 Andrea Darby Stewart

For adults, it's a little trickier because we have a larger spectrum of bacteria that may be likely to cause this, and obviously we can't forget to rule out things like COVID and RSV and influenza as well.

00:25:52 Andrea Darby Stewart

Peak of our viral season.

00:25:53 Andrea Darby Stewart

Right now, but for adults, if I'm not seeing a low bar component and I am concerned about an atypical in my practice, I would use doxycycline because I don't want to miss that strep pneumo in an adult that I know may be resistant to azathioprine in my commun.

00:26:10 Stephen Small

Yes, you can hit two birds with one stone.

00:26:12 Andrea Darby Stewart

Exactly.

00:26:12 Stephen Small

That's perfect.

00:26:15 Stephen Small

And I want to take a moment just to go back to doxycycline.

00:26:18 Stephen Small

Many of us know doxycycline gets a bad rap with kids.

00:26:22 Stephen Small

Initially, doxycycline was never used in kids under 8 years old due to concerns about teeth staining.

00:26:28 Stephen Small

And most of that was actually due to data from older tetracyclines that did indeed lead to teeth issues.

00:26:35 Stephen Small

But this isn't really supported by newer data regarding short courses of doxycycline.

00:26:42 Stephen Small

So in fact, the AAP said in the 2010 that kids of any age can safely use doxycycline for up to 21 days.

00:26:49 Stephen Small

So this could be an option if a child can't use azithromycin, for example, due to an allergy or a or a product shortage.

00:26:57 Stephen Small

But keep in mind some doxycycline oil suspensions may need prior authorization due to their higher.

00:27:04 Stephen Small

Cost, for example 160 mill version.

00:27:06 Stephen Small

That bottle costs about $130.00, so not exactly inexpensive.

00:27:11 Stephen Small

I'm curious for a panellist.

00:27:13 Stephen Small

Have you been using more doxycycline in children since the AEP change their recommendations.

00:27:19 Stephen Small

And how do you communicate these risks with parents in that case?

00:27:23

Yeah.

00:27:23 Craig Williams

Yeah, I.

00:27:24 Craig Williams

It's great question and working with Valley Medicine and we definitely have Pediatrics as part of our practice setting.

00:27:29 Craig Williams

So it's been a slow evolution, but.

00:27:33 Craig Williams

Is.

00:27:33 Craig Williams

To say we should not paint the tetracycline warnings across all the drugs.

00:27:38 Craig Williams

It's it was reassuring.

00:27:40 Craig Williams

To a lot of us, that doxycycline is potentially available as an.

00:27:43 Craig Williams

But say there's still a lot of inertia against this, and a lot of concerns, and if we do have alternatives.

00:27:50 Craig Williams

I'm not seeing a lot of change yet in our practice patterns, but I think the AAP was right in that change and it's nice to have this alternative. But I think it is going to be a slow evolution. So I'm not seeing a lot yet, but we know.

00:28:04 Craig Williams

It is.

00:28:05 Craig Williams

An option for kids now, and it is very nice to have that in the guideline.

00:28:10 Stephen Small

And being a pediatric pharmacist myself, I'm really excited to kind of see what the next guidelines will say.

00:28:14 Stephen Small

I'm kind of waiting for that.

00:28:18 Stephen Carek

Am I using doxycycline?

00:28:19 Stephen Carek

Whole lot.

00:28:21 Stephen Carek

Not.

00:28:22 Stephen Carek

You know, mainly treating pneumonias with whether it's amoxicillin or Cephalosporin usually is is.

00:28:32 Stephen Carek

Most of the antibiotics prescribing that we'll utilize for this heavy use, I said a few.

00:28:36 Stephen Carek

Yeah. And it will kind of let them know that, hey, you may see that there may have been some concerns about teeth staining.

00:28:42 Stephen Carek

Something especially choosing for a short course and lower doses probably not going to be a big risk.

00:28:46 Stephen Carek

So I think it'd be a fine antibiotic to use for this, especially when you think about, you know how you want to worry about rates of resistance to things like azithromycin.

00:28:55 Stephen Carek

And so it has a place in it.

00:28:57 Stephen Carek

I use it a whole.

00:28:58 Stephen Carek

Probably not, but I think it's becoming more common.

00:29:01 Stephen Carek

To be used for those patients that it's indicated for.

00:29:06 Stephen Small

Can you comment on the role of steroids for cat? This is actually a common question I've gotten in my practice, and I'm curious about.

00:29:12 Stephen Small

Thoughts. Yeah, it is.

00:29:13 Craig Williams

It's a great question and actually it really kind of got accelerator highlighted during and coming out of.

00:29:20 Craig Williams

COVID it's become a complex question, but it's easy on the ambulatory side. When I get this question from an ambulatory.

00:29:26 Craig Williams

A definite no. And it's a maybe yes, per severe in patients and it's it's a fun debate to have when it comes up in the hospital setting, but.

00:29:35 Craig Williams

Generally not outside of the ICU setting or generally not using steroids. Even in the hospital.

00:29:40 Stephen Small

Yeah, it's always been kind of a pros and cons discussion on a case by case basis.

00:29:46 Stephen Small

So based on all this, how long should we be treating out?

00:29:50 Stephen Small

Cap let you go first, Steven.

00:29:53 Stephen Carek

Usually say about 5.

00:29:54 Stephen Carek

I know if there's been some studies out that even said shorter for hospitalized patients like as low as 3 days, I think so 5 tends to be about where I settled and probably my common practice right now, maybe a little bit longer if they maybe 7 days more.

00:30:08 Stephen Carek

Little bit longer if, say they have significant comorbidities.

00:30:13 Stephen Carek

Older patients treatment failure.

00:30:15 Stephen Carek

And so those are the kind of cases where I'll see that. But for most outpatient cases of community acquired immune 5 days close follow up, I think close to important these patients just to make sure they're doing better.

00:30:26 Stephen Carek

But the five day iteration is usually where I start with.

00:30:31 Craig Williams

I'd say for the.

00:30:31 Craig Williams

Decade we've been doing, we can to kind of shorten durations with the one qualification that.

00:30:37 Craig Williams

If you improve in the time course, I expect you to improve.

00:30:40 Craig Williams

So you know the lungs are nicely perfused and if the antibiotic gets there and does what it should do, we generally start seeing patients feel a bit better even on day 2. But certainly by day three.

00:30:53 Craig Williams

We're going to give you kind of 48 hours to hopefully start looking better and if you start.

00:30:57 Craig Williams

Looking better in that 48 hour time period that we've been kind of a five day duration.

00:31:03 Craig Williams

Organization for quite a while and the guidelines kind of endorse that, maybe even shorter than that is effective once you seem to be heading the right direction and you know you've got the right antibiotic or potentially as we admit to ourselves, the patients getting better despite our Ant.

00:31:19 Craig Williams

Once they're on the mend, it seems to be you can really shorten up the duration compared to what we.

00:31:24 Craig Williams

So we train our residents and we teach our students is no one should be going longer than 10 days unless you've got a good reason for it. And generally 5 days is your target.

00:31:34 Craig Williams

The exception would be if I'm not getting better in that window and we definitely have that come.

00:31:39 Craig Williams

So patients that have really severe underlying lung disease, patients with obstructions underlying lung cancer and there can be times where it almost becomes like treating Abscess.

00:31:49 Craig Williams

In the lungs rather than attritional.

00:31:51 Craig Williams

So if we're not seeing that nice time course of improvement, we're going to need to extend and that generally if you're not looking better within 72 hours, I'm not going to be stopping your therapy at five days. But again a a good clinical response.

00:32:04 Craig Williams

Within 48 hours, that five days is still our target and maybe in the future it will be even shorter.

00:32:08 Craig Williams

See how the studies EV.

00:32:11 Stephen Small

Yeah. With the trends and how they're going and this is such a low hanging fruit in terms of stewardship of pharmacist is one of the first things I look at at a script for really any antibiotic. And we can really take some great actions to to curb ex.

00:32:23 Stephen Small

Antibiotic use.

00:32:25 Stephen Small

Very important points.

00:32:26 Stephen Small

Thank you. And any final thoughts from the group before we move on?

00:32:31 Stephen Carek

At least in my conversations with patients this year and maybe a little bit of last year, I'm seeing less resistance with just naming it as a viral illness.

00:32:41 Stephen Carek

And the conversations regarding antibiotics have not been as confrontational. I guess I should say.

00:32:46 Stephen Carek

I don't know if there's a lot of information that's going around or or people with COVID or just like have kind of accepted just the nature of viruses given that's what we were, you know, was just in the front of our mind for any illness for for the.

00:32:58 Stephen Carek

Period of time.

00:32:59 Stephen Carek

So hopefully that represents some baby culture.

00:33:02 Stephen Carek

I know there's probably still. I still got a lot of patients that are like, you know, I need my CPAC.

00:33:05 Stephen Carek

Need my.

00:33:07 Stephen Carek

I need this or that, but at the same.

00:33:11 Stephen Carek

As if I've had to do less counselling and more patients on antibiotics stewardship and more patients have been pretty receptive to watchful waiting, delayed antibiotics if needed. Utilization of prescription medications to handle symptoms.

00:33:25 Stephen Carek

So for me that's been a good thing.

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