Community-Acquired Pneumonia in Adults Materials

TREATMENT OF COMMUNITY-ACQUIRED PNEUMONIA IN ADULTS

AMANDA MAYER, PharmD

Amanda Mayer is a graduate of the University of Montana, Skaggs School of Pharmacy. She has clinical experience working in inpatient mental health, which is her passion. She has also done fill-in work at retail pharmacies throughout her career. Amanda appreciates the wide variety of professional opportunities available to pharmacists. Amanda loves spending time with her family and spends most of her free time exploring new restaurants, hiking in the summer, and snowboarding and cross-country skiing in the winter.

Topic Overview

Community-acquired pneumonia is a lung infection acquired outside of the hospital setting. The American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) published updated guidelines in 2019 regarding community-acquired pneumonia (CAP). The new guidelines found stronger evidence favoring a beta-lactam/macrolide combination as standard empiric therapy for severe CAP. Recommendations on treatment strategies differ based on the severity of pneumonia, the setting (inpatient/outpatient) required for treatment, and the presence of comorbidities.

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Universal Activity Number (UAN): The ACPE Universal Activity Number assigned to this activity is 

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Credits: 1 hour of continuing education credit

Type of Activity: Knowledge

Media: Internet/Home study Fee Information: $4.99

Estimated time to complete activity: 1 hour, including Course Test and course evaluation

Release Date: October 18, 2023 Expiration Date: October 18, 2026

Target Audience: This educational activity is for pharmacists.

How to Earn Credit: From October 18, 2023, through October 18, 2026, participants must:

Read the “learning objectives” and “author and planning team disclosures;”

Study the section entitled “educational activity;” and

Complete the Course Test and Evaluation form. The Course Test will be graded automatically. Following successful completion of the Course Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)

Credit for this course will be uploaded to CPE Monitor®.

Learning Objectives: Upon completion of this educational activity, participants should be able to:

List diagnostic criteria for severe community-acquired pneumonia

Identify empiric treatment options for individuals being treated in the outpatient setting with community-acquired pneumonia

Discuss treatment options for individuals in the inpatient setting with community-acquired pneumonia.

Recognize risk factors and prevention techniques for community- acquired pneumonia

Disclosures

The following individuals were involved in developing this activity: Amanda Mayer, PharmD, Jeff Goldberg, PharmD, BCPP, and Pamela Sardo, PharmD, BS. Pamela Sardo, Pharm.D., B.S., was an employee of Rhythm Pharmaceuticals until March 2022 and has no conflicts of interest or relationships regarding the subject matter discussed. There are no financial relationships relevant to this activity to report or disclose by any of the individuals involved in the development of this activity.

© RxCe.com LLC 2023: All rights reserved. No reproduction of all or part of any content herein is allowed without the prior, written permission of RxCe.com LLC.

Introduction

Community-acquired pneumonia is a lung infection acquired outside of the hospital setting. The American Thoracic Society and the Infectious Disease Society of America published guidelines for community-acquired pneumonia, outlining the criteria for severe pneumonia. The Pneumonia Severity Index is also used to help determine whether the patient will need to be hospitalized. Various antibiotics may be used to treat community-acquired pneumonia.

Background of Community-Acquired Pneumonia

Pneumonia is an infection of one or both lungs that causes the lungs’ alveoli to fill with fluid or pus.1 Bacteria, viruses, or fungi can cause pneumonia. Pneumonia symptoms may vary from mild to serious. Typical symptoms may include cough (with or without mucus), fever, chills, and trouble breathing.1 Community-acquired pneumonia is an infection of the lung parenchyma acquired outside the hospital setting.2

The American Thoracic Society (ATS) and the Infectious Disease Society of America (IDSA) published guidelines for community-acquired pneumonia (CAP) in 2019.3 Although many recommendations from the 2007 guidelines are still relevant, advances in the diagnosis, therapy, and management of patients with CAP are reported in the updates.1 The ATS/IDSA guidelines emphasize the importance of clinical judgment and experience when treating patients, as evidence using high-quality studies is often insufficient. These guidelines, which are addressed in this course, cover the management of immunocompetent adults.3

Community-acquired pneumonia is associated with high morbidity and mortality, especially in the 65+ age range.2 It is often diagnosed without the use of a chest radiograph, sputum Gram stain, and culture in the outpatient setting. Confirmation of diagnosis is ideal when available (inpatient setting) due to the inaccuracy of clinical signs and symptoms alone for diagnosis. Antibiotics used for the empiric treatment of CAP are based on common

bacterial pathogens.3 Data collected by the CDC show that more than 47,000 individuals died from pneumonia in the United States in 2020.4

Bacterial pathogens that typically cause CAP include Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, Staphylococcus aureus, Legionella species, Chlamydia pneumoniae, and Moraxella catarrhalis. Viral pathogens may also play a role or coexist in patients with CAP.3 Empiric treatment should target bacterial infection or coinfection. Tests that are accurate or fast enough to determine that CAP is due to a virus alone are lacking. Methicillin-resistant S. aureus (MRSA) and Pseudomonas aeruginosa are two multidrug-resistant pathogens with specific treatment recommendations.3 The categorization of healthcare-associated pneumonia (HCAP) has been eliminated from the ATS/IDSA guidelines, emphasizing local epidemiology and risk factors to help determine the need to treat multidrug-resistant pathogens.3

Risk factors for developing pneumonia include adults over 65, children younger than 5 years, individuals with ongoing medical conditions, and individuals who smoke cigarettes.5 Staying up to date on vaccinations can help to prevent infection as some of the viruses being vaccinated against can cause pneumonia. Avoiding individuals who are sick and staying away from others while sick can help to decrease the spread of respiratory infections. The spread of respiratory infections can be decreased by regular hand washing, cleaning and disinfecting commonly touched surfaces and coughing and sneezing into a tissue or elbow. Limiting contact with cigarette smoke and taking care of medical conditions such as asthma, diabetes, or heart disease help to prevent respiratory infections.4

Treatment Setting

The Pneumonia Severity Index (PSI) is the preferred clinical prognostic tool that helps to determine the need for hospitalization in adults with CAP.3 The PSI should be used in conjunction with clinical judgment as it may underestimate severity in some cases.6 The PSI helps to predict the 30-day mortality rate in hospitalized patients with CAP and divides patients into 5 risk

classes. Risk classes 1 and 2 can be considered for outpatient treatment, with 3-5 qualifying for inpatient treatment.6 The PSI considers sex, age, nursing home status, comorbidities (neoplasm, liver disease, congestive heart failure, cerebrovascular disease, and renal disease), physical examination findings, and laboratory and radiographic findings.7 Physical examination findings include altered mental status, respiratory rate, systolic blood pressure, temperature, and pulse. Laboratory and radiographic findings include arterial pH, blood urea nitrogen, sodium, glucose, hematocrit, partial pressure of arterial oxygen, and pleural effusion.7 The PSI gives an idea of what setting the patient should be treated in, not the level of care needed. Clinicians are encouraged to use the PSI over the CURB-65. The CURB-65 may give a false- positive hospital admission rate and is based on confusion, urea level, respiration rate, blood pressure, and age 65 or over.3

The 2007 IDSA/ATS CAP guidelines outline a list of criteria that define severe pneumonia requiring ICU admission. All patients requiring treatment with vasopressors for hypotension and mechanical ventilation for respiratory failure need ICU-level care.8 Criteria for defining Severe CAP are as follows:3,8

Either one major criterion or three or more minor criteria

Minor Criteria: Respiratory rate ≥30 breaths/min, arterial oxygen partial pressure (PaO2)/fractional inspired oxygen (Fi02) ratio ≤ 250, multilobar infiltrates, confusion/disorientation, uremia, leukopenia due to infection alone, thrombocytopenia, hypothermia, or hypotension requiring aggressive fluid resuscitation

Major Criteria: Septic shock with the need for vasopressors or respiratory failure requiring mechanical ventilation.

Sputum gram stains and cultures, as well as pretreatment blood cultures, should be obtained in patients who are in the hospital setting and are classified as at least one of the following:3,8

severe CAP (especially if intubated)

being empirically treated for MRSA or P. aeruginosa

were previously infected with MRSA or P. aeruginosa

have been hospitalized and received IV antibiotics in the last 90 days.

Mechanism of Action for Empiric Antibiotic Choices Beta Lactams

Beta-lactam antibiotics, such as penicillins and cephalosporins, disrupt the final stage of bacterial cell wall synthesis. They inhibit the synthesis of peptidoglycan, which is a fundamental element of the cell wall that causes cell lysis. The addition of a beta-lactamase inhibitor, such as clavulanic acid, sulbactam, or tazobactam, helps to protect the penicillin from enzymatic deactivation.9

Penicillins used for CAP include amoxicillin, amoxicillin-clavulanic acid, ampicillin-sulbactam, and piperacillin-tazobactam.3 Penicillins may require renal dose adjustment. Allergic or hypersensitivity reactions are the most common adverse reactions in patients taking penicillin. Gastrointestinal adverse reactions such as nausea, vomiting, diarrhea, and abdominal pain may occur, especially when administered orally.9

Under the ATS/IDSA guidelines, cephalosporins used for the treatment of CAP include cefuroxime, cefpodoxime, cefuroxime, cefotaxime, ceftriaxone, ceftaroline, ceftazidime, and cefepime.3 These medications may need dose adjustments based on renal impairment. Patients should be monitored for superinfection, including candidiasis, C. difficile-associated diarrhea, or pseudomembranous colitis.10-12 Dermatologic reactions have been reported in approximately 1 to 3% of cephalosporin treatment courses.13

Doxycycline

Doxycycline is a tetracycline antibiotic that is generally a bacteriostatic agent.14 It binds to the 30S ribosomal subunit of bacteria and blocks the binding of transfer RNA to the messenger RNA, thereby inhibiting bacterial protein synthesis. Doxycycline may be used in patients with poor renal function due to its limited renal clearance.14 Common adverse reactions to

doxycycline include diarrhea, nausea, vomiting, and dyspepsia. These common gastrointestinal side effects may be reduced by administering with food. Microbial overgrowth and superinfection may also occur in patients taking doxycycline.14 Patients should be warned about the increased risk of photosensitivity.14

Macrolide

Macrolides, such as azithromycin and clarithromycin, inhibit bacterial growth by suppressing protein synthesis. Macrolides exhibit reversible binding to the 50S ribosomal subunits, which induces the dissociation of transfer RNA from the ribosome during the elongation phase. Renal dosing adjustments may need to be made for macrolide antibiotics. Gastrointestinal intolerance is one of the primary adverse effects seen with this class of medications.15,16 They may also cause QT prolongation.17 Microbial overgrowth and superinfection should also be monitored in patients taking macrolides. Macrolides should not be used if the local resistance rate is greater than 25%.3

Respiratory Fluoroquinolones

Respiratory fluoroquinolones used to treat CAP include levofloxacin, moxifloxacin, and gemifloxacin.3 These medications inhibit bacterial DNA gyrase and topoisomerase IV, interrupting DNA replication, repair, and transcription. These agents may require renal dose adjustments. These medications have black box warnings for tendinopathy, myasthenia gravis, and neurotoxicity. Neurotoxicity that may occur includes central nervous system effects and peripheral neuropathy. This class should be used cautiously in patients with epilepsy, preexisting CNS disorders, and patients who have recently had a stroke. Caution should also be used in patients with QT interval prolongation and photosensitivity.18-20 Although there is concern about adverse events associated with fluoroquinolones, the CAP guidelines believe therapy is justified for adults with CAP and comorbidities who are managed in the outpatient setting. Benefits that outweigh the risks of fluoroquinolones in this setting include low resistance rates in common bacterial causes of CAP, coverage of typical and atypical organisms,

convenience of monotherapy, oral bioavailability, and the relatively rare rate of serious adverse effects.3

Vancomycin

Vancomycin exerts its effect by binding to the precursor units of bacterial cell walls to inhibit their synthesis.21 Vancomycin is a bactericidal agent that exhibits a concentration-independent killing. Vancomycin is a helpful agent for CAP associated with MRSA.21 Patients being administered vancomycin should be monitored for renal toxicity and ototoxicity.21 Vancomycin that is given by rapid infusion may cause a histamine-release reaction that is characterized by flushing of the face, neck, upper body, arms, and/or back. This vancomycin infusion reaction may result in anaphylactic reactions and may also cause pain and muscle spasms.21 Patients receiving IV vancomycin may also have general adverse reactions of fever and chills. Microbial overgrowth should also be monitored while using vancomycin.21

Linezolid

Linezolid is an oxazolidinone that inhibits bacterial protein synthesis by interfering with translation.22 Linezolid binds to the bacterial 23S ribosomal RNA of the 50S subunit, which prevents the formation of a functional 70S initiation complex. This prevents bacteria from multiplying. Linezolid is bactericidal against many streptococcal strains and bacteriostatic against staphylococci and enterococci.22 Gastrointestinal adverse reactions are commonly reported (diarrhea, nausea, vomiting, dysgeusia, and abdominal pain) in patients taking linezolid. Headache is one of the most common non- gastrointestinal side effects reported.22 Microbial overgrowth should be monitored in patients taking linezolid. Thrombocytopenia should be monitored in patients who receive therapy for more than 2 weeks and in patients with severe renal impairment.22 Postmarketing reports have included peripheral and optic neuropathy. Linezolid therapy should be avoided, if possible, in patients also taking selective serotonin reuptake inhibitors. If necessary and the benefits outweigh the risks, linezolid may be used in these patients with close monitoring for signs and symptoms of serotonin syndrome. The

serotonergic antidepressant should be discontinued during this time and should not be restarted until at least 24 hours have passed since the last dose of linezolid. Linezolid should not be prescribed if a patient is taking a monoamine oxidase inhibitor (MAOI) or within two weeks of MAOI therapy. 22

Initial Treatment Regimens for Outpatients with CAP

Standard regimens for individuals with no comorbidities or risk factors for MRSA or Pseudomonas aeruginosa include one of the following:3

Amoxicillin 1 gram three times daily

Doxycycline 100 mg twice daily

Macrolide (if local pneumococcal resistance is <25%)

Azithromycin 500 mg on first day, then 250 mg thereafter

Clarithromycin 500 mg twice daily

Clarithromycin ER 1000 mg daily

Initial treatment for patients with comorbidities that includes one of these two options:3

Option 1: Combination therapy with Amoxicillin/clavulanate or cephalosporin AND macrolide or doxycycline

Amoxicillin/Clavulanate options:

Amoxicillin/Clavulanate 500 mg/125 mg three times daily

Amoxicillin/Clavulanate 875 mg/125 mg or 2,000 mg/125 mg twice daily

Cephalosporin options include

Cefpodoxime 200 mg twice daily

Cefuroxime 500 mg twice daily

Macrolide options

Azithromycin 500 mg on first day then 250 mg daily

Clarithromycin 500 mg twice daily

Clarithromycin ER 1000 mg daily

Doxycycline 100 mg twice daily

Option 2: Monotherapy with respiratory fluoroquinolone

Levofloxacin 750 mg daily

Moxifloxacin 400 mg daily

Gemifloxacin 320 mg daily

Comorbidities include chronic heart, lung, liver, renal disease, diabetes, alcoholism, malignancy, or asplenia. Broader-spectrum treatment is recommended in these patients to help improve outcomes and combat the risk of antibiotic resistance based on previous contact with the healthcare system or antibiotic exposure.

Treatment Regimens for Hospitalized Patients with CAP

Treatment regimens for inpatient treatment strategies are based on the severity of the patient’s pneumonia.3 (See Table 1.)

Table 1: ATS/IDSA Initial Treatment Strategies for Inpatients with CAP3

Treatment Considerations for Inpatients and Outpatients

The duration of antibiotic therapy should be guided by clinical stability. Clinical stability includes resolution of vital sign abnormalities (heart rate, respiratory rate, blood pressure, oxygen saturation, and temperature), ability to eat, and normal mentation.3 Antibiotic therapy should last for no less than 5 days and until the patient achieves stability. Most studies show support for a 5-day course of treatment in the outpatient setting; however, in some cases, a longer duration of treatment (7 to 10 days) is indicated. Patients suspected or proven to have MRSA or P. aeruginosa CAP should be treated for 7 days.3

Patients who have had recent exposure to one class of antibiotics should receive subsequent treatment with an antibiotic from a different class to help lower the risk for bacterial resistance with the initial treatment.3 The routine use of corticosteroids in adults hospitalized with CAP is not currently recommended. The CAP guidelines endorse the Surviving Sepsis Campaign recommendations to use steroids in patients with septic shock refractory to adequate fluid resuscitation and vasopressor support with CAP.23 Increases in hyperglycemia requiring therapy and possible higher secondary infection rates are side effects associated with corticosteroids.24,25 Clinical judgment should be used, and patients presenting with comorbid diseases (COPD, asthma, autoimmune disease) may require corticosteroids.

Respiratory Fluoroquinolone

Levofloxacin 750 mg daily

Moxifloxacin 400 mg daily MRSA Coverage:

-

Vancomycin 15 mg/kg every 12 hours, adjusted based on renal

function and levels

-

Linezolid 600 mg every 12 hours

P. aeruginosa coverage:

-

-

-

-

-

Piperacillin-tazobactam 4.5 grams every 6 hours

Cefepime 2 grams every 8 hours

Ceftazidime 2 grams every 8 hours

Imipenem 1 gram every 8 hours

Aztreonam 2 grams every 8 hours

Patients who test positive for influenza and have clinical and radiographic evidence for CAP should be treated for both conditions as they may occur concurrently. Patients who test positive for influenza should receive anti-influenza treatment such as oseltamivir.3 Anti-influenza treatment that occurs within 2 days of symptom onset or hospitalization has shown the best results; however, benefits may be seen up to 4 or 5 days after symptoms begin.26,27 Anti-influenza agents show the most efficacy when given early and can help to reduce the duration of symptoms and lower complication risks in patients with influenza.28,29 Antibacterial therapy would follow the recommendations listed above.

Summary

Community-acquired pneumonia is associated with high morbidity and mortality. Some patients can be treated in the outpatient setting, while others may require inpatient hospitalization. Patients with severe CAP require care in the ICU. Several different treatment options for CAP take into account patient allergies and intolerances, as well as potential causes of infection. Cultures should be obtained in hospitalized patients, and therapy may be adjusted based on results.

Course Test

The ATS/IDSA guidelines emphasize

the importance of clinical judgment and experience when treating patients, as the evidence shows that using high-quality studies can be insufficient.

corticosteroids should be prescribed in all patients with CAP.

antibiotic treatment for CAP should last no more than 5 days.

vancomycin should only be used if a patient is positive for P. aeruginosa.

Which two of the following multidrug-resistant pathogens are commonly seen in CAP and have specific treatment recommendations?

Streptococcus pneumoniae and Haemophilus influenzae

Methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa

Mycoplasma pneumoniae and Pseudomonas aeruginosa

Chlamydia pneumonia and Moraxella catarrhalis

Which of the following is NOT a risk factor for developing pneumonia?

Adults over 65 years

Children younger than 5 years

Adults aged 18-40

Individuals with ongoing medical conditions

What are the two major criteria for defining severe CAP?

Septic shock with the need for vasopressors or respiratory failure requiring mechanical ventilation

Septic shock with confusion/disorientation or hypothermia

Thrombocytopenia and hypertension requiring aggressive fluid resuscitation

Respiratory rate ≥30 breaths/min or respiratory failure requiring mechanical ventilation

Sputum gram stains and cultures should be obtained in which of the following patients?

Patients with severe CAP

Patients being empirically treated for MRSA or P. aeruginosa

Patients who have been hospitalized and received IV antibiotics in the last 90 days

All of the above

Which of the following medications may be used in patients with poor renal function due to its limited renal clearance?

Vancomycin

Amoxicillin

Doxycycline

Levofloxacin

Standard regimens for individuals with no comorbidities or risk factors for MRSA or Pseudomonas aeruginosa include all of the following except

amoxicillin 1 gram three times daily.

doxycycline 100 mg twice daily.

clarithromycin 500 mg twice daily.

linezolid 600 mg every 12 hours.

The ATS/IDSA Guidelines recommend monotherapy with a respiratory fluoroquinolone for outpatients with comorbidities with which of the following options?

Levofloxacin 500 mg daily

Levofloxacin 750 mg daily

Moxifloxacin 250 mg daily

Moxifloxacin 600 mg daily

The two options for add-on treatment in patients with MRSA are

ceftazidime 2 grams every 8 hours and Imipenem 1 gram every 8 hours.

ceftazidime 2 grams every 8 hours and Linezolid 600 mg every 12 hours.

vancomycin 15 mg/kg every 12 hours, adjusted based on renal function and levels, and Linezolid 600 mg every 12 hours.

vancomycin 15 mg/kg every 12 hours, adjusted based on levels, and piperacillin-tazobactam 4.5 grams every 6 hours.

Clinical stability that helps determine the duration of antibiotic therapy includes all except

resolution of vital sign abnormalities.

up to date with all vaccinations.

the ability to eat.

normal mentation.

References

National Institutes of Health. National Heart, Lung, and Blood Institute. Pneumonia. What Is Pneumonia? NIH-NHLBI. 2022. http://www.nhlbi.nih.gov/health/health-topics/topics/pnu. Accessed September 13, 2023.

McLaughlin JM, Khan FL, Thoburn EA, Isturiz RE, Swerdlow DL. Rates of hospitalization for community-acquired pneumonia among US adults: A systematic review. Vaccine. 2020;38(4):741-751. doi:10.1016/j.vaccine.2019.10.101

Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45-e67.

Centers for Disease Control and Prevention. Pneumonia Can Be Prevented—Vaccines Can Help. CDC. 2022. https://www.cdc.gov/pneumonia/prevention.html. Accessed September 13, 2023.

Centers for Disease Control and Prevention. Risk Factors for Pneumonia. CDC. 2022. https://www.cdc.gov/pneumonia/prevention.html. Accessed September 13, 2023.

Arnold FW, Ramirez JA, McDonald LC, Xia EL. Hospitalization for community-acquired pneumonia: the pneumonia severity index vs clinical judgment. Chest. 2003;124(1):121-124. doi:10.1378/chest.124.1.121

Aujesky D, Fine MJ. The pneumonia severity index: a decade after the initial derivation and validation. Clin Infect Dis. 2008;47 Suppl 3:S133- S139. doi:10.1086/591394

Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44 Suppl 2(Suppl 2):S27-S72. doi:10.1086/511159

Wright AJ. The penicillins [published correction appears in Mayo Clin Proc 1999 Nov;74(11):1184]. Mayo Clin Proc. 1999;74(3):290-307. doi:10.4065/74.3.290

Cefdinir oral suspension package insert. Sellersville, PA: Teva Pharmaceuticals USA; 2015 Nov.

Cefpodoxime proxetil suspension package insert. East Windsor, NJ: Aurobindo Pharma USA, Inc.; 2018 Oct.

Cefotaxime Powder for solution for injection package insert. Berkeley Heights, NJ: Hikma Pharmaceuticals USA, Inc.; 2021 Jun.

Moreno E, Macías E, Dávila I, Laffond E, Ruiz A, Lorente F. Hypersensitivity reactions to cephalosporins. Expert Opin Drug Saf. 2008;7(3):295-304. doi:10.1517/14740338.7.3.295

Vibramycin and Vibra-Tabs (doxycycline suspension, syrup, capsules, tablets) package insert. New York, NY: Pfizer Labs; 2021 Apr.

Biaxin (clarithromycin) package insert. North Chicago, IL: AbbVie, Inc.; 2019 Sep.

Zithromax (azithromycin 600 mg tablets and 1 g oral suspension) package insert. New York, NY: Pfizer Inc.; 2021 Nov.

Ray WA, Murray KT, Hall K, Arbogast PG, Stein CM. Azithromycin and the risk of cardiovascular death. N Engl J Med. 2012;366(20):1881- 1890. doi:10.1056/NEJMoa1003833

Avelox (moxifloxacin) package insert, Whippany, NJ: Bayer HealthCare Pharmaceuticals Inc.; 2020 May.

Factive (gemifloxacin mesylate) package insert. Toronto, ON: Merus Labs International, Inc.; 2019 May.

Levofloxacin tablets package insert. Livonia, MI; Major Pharmaceuticals: 2019 Nov.

Vancomycin single-dose lypophilized powder for injection vials package insert. Morgantown, WV: Mylan Institutional LLC; 2022 Apr.

Zyvox (linezolid) package insert. New York, NY: Pharmacia and Upjohn Company; 2023 July.

Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017;43(3):304-377. doi:10.1007/s00134-

017-4683-6

Keh D, Trips E, Marx G, et al. Effect of Hydrocortisone on Development of Shock Among Patients With Severe Sepsis: The HYPRESS Randomized Clinical Trial. JAMA. 2016;316(17):1775-1785. doi:10.1001/jama.2016.14799

Waljee AK, Rogers MA, Lin P, et al. Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study. BMJ. 2017;357:j1415. Published 2017 Apr 12. doi:10.1136/bmj.j1415

Lee EH, Wu C, Lee EU, et al. Fatalities associated with the 2009 H1N1 influenza A virus in New York city. Clin Infect Dis. 2010;50(11):1498- 1504. doi:10.1086/652446

Louie JK, Yang S, Acosta M, et al. Treatment with neuraminidase inhibitors for critically ill patients with influenza A (H1N1)pdm09. Clin Infect Dis. 2012;55(9):1198-1204. doi:10.1093/cid/cis636

Dobson J, Whitley RJ, Pocock S, Monto AS. Oseltamivir treatment for influenza in adults: a meta-analysis of randomised controlled trials [published correction appears in Lancet. 2015 May 2;385(9979):1728] [published correction appears in Lancet. 2015 May 2;385(9979):1728]. Lancet. 2015;385(9979):1729-1737.

Venkatesan S, Myles PR, Leonardi-Bee J, et al. Impact of Outpatient Neuraminidase Inhibitor Treatment in Patients Infected With Influenza

A(H1N1)pdm09 at High Risk of Hospitalization: An Individual Participant Data Metaanalysis. Clin Infect Dis. 2017;64(10):1328-1334. doi:10.1093/cid/cix127

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