Clase 2 Nac Nih TBC

MEDICINA INTERNA
NEUMOLOGA
Dr. Christiam Ochoa

UNMSM
TUBERCULOSIS PULMONAR
BACILO DE KOCH
Mycobacterium tuberculosis
Envoltura Ac. Micolico
1-4x0.3-0.6 micras
Inmvil
No esporulado
Define el
Aerobio estricto
genero
Desarrollo 35-37C
Resiste a
No es cromogeno
la
Tincion:
decolorac
Ziehl-Neelsen/Kinyoun
in
Auramina (+ sensible, pero no
distingue de los M. no tubercul..)
Cultivo:
Middlebrook 7H10 o 7H11
Lowenstein-Jensen
Pruebas Bioquimicas
Niacina (+)
Nitrato reductasa (+)
Catalasa (debil +)
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DEFINICIONES OPERACIONALES
SINTOMATICO RESPIRATORIO CASO TBC PULMONAR
Pac con Dx TB pulmonar c/ o s/ BK+
Tos con flema >15 dias
CASO TBC EXTRAPULMONAR
CONTACTO DOMICILIARIO Pac con Dx TB en organos diferentes a los pulmones
Mismo domicilio que paciente BK+ Necesidad de demostracion (cultivo, PCR, histopatologico y/o clinica)
CONTACTO EXTRADOMICILIARIO La TB pleural es extrapulmonar y la +fr
Comparte ambientes comunes o frecuentan CASO TBC SISTEMICO
pacientes BK+ (minimo6h) No existe en la guia!!! TB pulmonar + otro lado EXTRAPULMONAR
TBC PANSENSIBLE TBC INFANTIL

Sensibilidad a todos los farmacos de 1ra linea TBC INFANTIL CONFIRMADO
TBC MDR Estudio bacteriologico + para Mycobacterium tuberculosis o muestra histologica compatible
TBC INFANTIL PROBABLE
Resistente a H y R Fiebre, tos y perdida de peso
TBC XDR (Extensamente) Exposicion a un caso de TBC infecciosa activa
Resistente a H, R, fluroQ y 1 inyectable de 2da PPD positivo (>10mm)
linea (amikacina, kanamicina o capreomicina) Hallazgo en radiografia de torax compatible con TBC activa
TBC MONORESISTENTE Evidencia por otros examenes de apoyo diagnostico
Resistente a solo un farmaco anti-TB
TBC POLIRESISTENTE
Resistente a >1 farmaco anti-TB (que no cumpla
criterios de MDR o XDR)

CONDICION DE INGRESO Y EGRESO
CASO NUEVO: 1er episodio de TB o q recibio tto por <30dias (o 25 dosis
CONDICION DE
CASO NUEVO
CASO ANTES continuas)
INGRESO TRATADO
CURADO: se vio BK(+) al inicio + termina tto + BK() al ultimo mes del tto.
TRATAMIENTO COMPLETO: se vio BK(+) al inicio + termino tto SIN tener
CURADO
prueba de BK al ultimo mes.
XITO DE TRATAMIENTO: la suma de los casos CURADO y TTO COMPLETO
TTO COMPLETO RECAIDA
ABANDONO: deja de recibir tto por >30 dias
FRACASO: BK(+) en esputo o cultivo apartir del 4to mes de tto
XITO DE TTO
FALLECIDO: muerte por cualquier causa durante el tto
CONDICION DE
NO EVALUADO: paciente sin condicion de egreso.
ABANDONO
EGRESO DE TBC ABANDONO
RECUPERADO
CASO ANTES TRATADO: pac con dx de TB y antec de haber recibido tto por
SENSIBLE
>30dias
FRACASO RECAIDA: otro episodio de TB despues de haber CURADO TTO
COMPLETO
FALLECIDO ABANDONO RECUPERADO: paciente que fue ABANDONO y se reinicia tto
desde 1ra dosis
NO EVALUADO
FRACASO: idem
FALLECIDO: idem
NO EVALUADO: idem

TUBERCULOSIS
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TUBERCULOSIS

HISTORIA NATURAL 1. Liquidacin inmediata del organismo
2. La infeccin crnica o latente
3. Enfermedad activa rpidamente progresiva (o enfermedad primaria)
4. Enfermedad activa muchos aos despus de la infeccin (reactivacin de la
enfermedad)
TBC 1 retenida TBC 1 no retenida
TBC REACTIVADA: Miliar y ExtraPulm
Via hematogena x eso BK-

TBC REACTIVADA: Micronodular (<3mm)
TBC 2 25% hacen MEC TB

TBC REACTIVADA: TBC 2 DETECCION Y DIAGNOSTICO DE CASOS
CLINICA RADIOGRAFIA 1. DETECCION DE SINTOMATICO RESPIRATORIO
TOS Infiltrado infreclavicular 2. SEGUIMIENTO DIAGNOSTICO
TAMBIEN Broncograma aereo 3. DEFINICION DE CASO
Esputo no purulento Tendencia a la cavitacion
Fiebre
PRUEBAS Informe de resultados de
baciloscopa:
Malestar general BACILOSCOPIA PPD (>10mm[>5mm], medir Negativo (-): No se encuentra
Astenia Generalmente Positivo induracion, x IFN-gamma) bacilos cido alcohol resistente
Anorexia RADIOGRAFIA (BAAR) en 100 campos
microscpicos.
Perdida de peso BACILOSCOPIA Paucibacilar: Se observan de 1 a 9
Sudoracion nocturna CULTIVO BAAR en 100
Hemoptisis (cavernas) BIOPSIA campos observados
Positivo (+): Menos de 1 BAAR
PRUEBAS DE promedio por campo en 100
PRONOSTICO SENSIBILIDAD campos observados (10-99
60% s/tto mueren a 2.5 aos CONVENCIONAL bacilos en 100 campos).
Aspergiloma Positivo (++): De 1 a 10 BAAR
PRUEBAS DE
promedio por campo en 50
SENSIBILIDAD RAPIDA campos Observados.
(MODS, Griess, MGIT, Positivo (+++): Ms de 10 BAAR
Genotype MTBDplus) ahora a promedio por campo en 20
todo BK+. campos observados.

TRATAMIENTO
NT-TBC-MINSA-2010

TUBERCULOSIS


NT-TBC-MINSA-2013
QUIMIOPROFILAXIS
ISONIACIDA
<15 aos 10mg/Kg/dia x 6m (max 300mg/dia)
>15 aos 5mg/Kg/dia x 6m (max 300mg/dia)
VIH (+) dosis segn la edad y x 12m + Piridoxina
(por neuropatia x def VitB6)
Paciente < 5aos con contacto de caso indice

(no importa BK, no importa PPD)
Paciente 5-15 aos con contacto de caso
indice y PPD>10
Paciente con conversion reciente de PPD
(<2aos) para trabajadores de Salud y
personas que atienden a poblacion privada de
libertad
Paciente con VIH(+) (no importa el PPD)

NEUMONIA ADQUIRIDA EN LA COMUNIDAD
INFECCIN AGUDA DEL PARENQUIMA PULMONAR (ASOCIADA A UN INFILTRADO NUEVO EN LA RADIOGRAFA DE TRAX.
ETIOLOGA BATERIA TIPICAS (60-70%):

VA DE INFECCION Neumococo 20-60% - Haemophylus Clnica tpica: Tos, CLINICA
pneu. 3-10% - Sf. aureus 3-5% - Expectoracin, Fiebre,
MICROASPIRACION: mas fc
sanos. Neumococo, pyogenes,
Enterobacteriaceae 3-5% Dolor pleurtico, Clinica atipica: febricula,
algunos stafilococos, ATIPICOS (10-20): M. Pneumoniae - Disnea. En ancianos tos seca, artromialgia,
neisseria, corynebacterium, C. pneumoniae - L. pneumoniae hiporexia, confusin y confusion, hematuria,
Haemofiilus, Moraxella, VIRUS (5-10%): Influenza deshidratacin. En el mielitis transversa,
Mycoplasma. Parainfluenza - Rsv examen fsico: miringitis bulosa, anemia
INHALACION: mycoplasma, roncantes o crepitantes hemolitica, etc
clamidophila, C. pssitaci,
Coxiella burnetti, virus, TBC,
legionella, aspergillus.
HEMATOGENA: stafilococo
aureus.
FACTORES DE RIESGO
ADULTO MAYOR- DM EPOC
- BRONQUIECTASIA -
ALCOHOLISMO VIH - ADVP

Table 257-3 Epidemiologic Factors Suggesting Possible Causes of Community-Acquired Pneumonia
Factor Possible Pathogen(s)
Streptococcus pneumoniae, oral anaerobes, Klebsiella pneumoniae, Acinetobacter
Alcoholism
spp., Mycobacterium tuberculosis
Haemophilus influenzae, Pseudomonas aeruginosa, Legionella spp.,
COPD and/or smoking
S. pneumoniae, Moraxella catarrhalis, Chlamydia pneumoniae
Structural lung disease P. aeruginosa, Burkholderia cepacia, Staphylococcus aureus
Dementia, stroke, decreased level of consciousness Oral anaerobes, gram-negative enteric bacteria
Lung abscess CA-MRSA, oral anaerobes, endemic fungi, M. tuberculosis, atypical mycobacteria
Travel to Ohio or St. Lawrence river valleys Histoplasma capsulatum
Travel to southwestern United States Hantavirus, Coccidioides spp.
Travel to Southeast Asia Burkholderia pseudomallei, avian influenza virus
Stay in hotel or on cruise ship in previous 2 weeks Legionella spp.
Local influenza activity Influenza virus, S. pneumoniae, S. aureus
Exposure to bats or birds H. capsulatum
Exposure to birds Chlamydia psittaci
Exposure to rabbits Francisella tularensis
Exposure to sheep, goats, parturient cats Coxiella burnetii

ALVEOLAR: LOBAR: Gram+, Mycoplasma - MULTILOBAR: gram -, St neumoniae
SEVERIDAD INTERSTICIAL: Mycoplasma, legionella, chlamydia, P. carinii, CMV, VHZ, sarampin.
CURB-65 CAVITADA: anaerobio, Sf.aureus, St penumoniae serotipo III, BGN, TBC, hongos.
PSI class and mortality PNEUMONIA SEVERITY INDEX (PSI)
CRITERIOS DE INGRESO A UCI EX. AUXILIARES RADIOGRAFA DE TRAX: PA-L
Class Points Mortality, %
GRAM-CULTIVO DE ESPUTO
No COMPLICACIONES BRONCOFIBROSCOPA (CP, LBA)
I 0.1
predictors IFI, ELISA o FIJACIN
II <70 0.6 ATELECTASIA COMPLEMENTO - TEST
DERRAME PARANEUMNICO URINARIO HEMOCULTIVO -
III 71-90 0.9 EMPIEMA HEMOGRAMA
IV 91-130 9.3 ABSCESO PULMONAR GLUCOSA UREA - CREATININA
BRONQUIECTASIA ELECTROLITOS- AGA
V >130 27.0
Blood Sputum Legionella Pneumococcal
Abnormality Days Indication Multiplex PCR
culture culture UAT UAT
Tachycardia and hypotension 2 Intensive care unit admission X X X X X
Failure of outpatient antibiotic therapy X X X X
Fever, tachypnea, and hypoxia 3
Cavitary infiltrates X X
Cough 14 Leukopenia X X X
Fatigue 14 Active alcohol abuse X X X X X
Chronic severe liver disease X X X
Infiltrates on chest radiograph 30 Severe obstructive/structural lung disease X X
Asplenia (anatomic or functional) X X X
ANTIBIOTICOTERAPIA Recent travel (within past 2 weeks) X X
HIDRATACIN ADECUADA Positive Legionella UAT result

X NA
TTO ANTIPIRTICOS / ANALGSICOS Positive pneumococcal UAT result X X NA
OXIGENOTERAPIA Pleural effusion X X X X

Description
>=2: temperature >38.5C or <35.0C; heart rate of >90 beats/min; respiratory rate of >20 breaths/min or
Systemic inflammatory
PaCO2 of <32 mm Hg; and WBC count of >12,000 cells/mL, <4000 cells/mL, or >10 percent immature (band)
response syndrome forms
SIRS in response to documented infection (culture or Gram stain of blood, sputum, urine, or normally
Sepsis sterile body fluid positive for pathogenic microorganism; or focus of infection identified by visual
inspection)
Sepsis and at least one of the following signs of organ hypoperfusion or organ dysfunction: areas of mottled
skin; capillary refilling of 3 s; urinary output of <0.5 mL/kg for at least 1 h or renal replacement therapy;
Severe sepsis lactate >2 mmol/L; abrupt change in mental status or abnormal EEG findings; platelet count of <100,000
cells/mL or disseminated intravascular coagulation; acute lung injury/ARDS; and cardiac dysfunction
(echocardiography)
Severe sepsis and one of the following conditions: systemic mean BP of <60 mm Hg (<80 mm Hg if previous
hypertension) after 20 to 30 mL/kg starch or 40 to 60 mL/kg saline solution, or PCWP between 12 and 20
Septic shock
mm Hg; and need for dopamine of >5 mcg/kg/min, or norepinephrine or epinephrine of <0.25 mcg/kg/min
to maintain mean BP at >60 mm Hg (80 mm Hg if previous hypertension)
Need for dopamine at >15 mcg/kg/min, or norepinephrine or epinephrine at >0.25 mcg/kg/min to

Refractory septic shock
maintain mean BP at >60 mm Hg (80 mm Hg if previous hypertension)

Organism Preferred antimicrobial(s) Alternative antimicrobial(s)
Streptococcus pneumoniae
Penicillin nonresistant; MIC <2 Macrolide, cephalosporins (oral cefuroxime, cefdinir] or parenteral ceftriaxone,
Penicillin G, amoxicillin
microgram/mL clindamycin, doxycyline, respiratory fluoroquinolone*
Penicillin resistant; MIC 2 Basis of susceptibility, including cefotaxime, Vancomycin, linezolid, high-dose amoxicillin (3 g/day with penicillin MIC 4
microgram/mL ceftriaxone, fluoroquinolone microgram/mL)
Haemophilus influenzae
Non-beta-lactamase Amoxicillin Fluoroquinolone, doxycycline, azithromycin, clarithromycin
Beta-lactamase producing 2-3RA generation cephalosporin, amoxiclav Fluoroquinolone, doxycycline, azithromycin, clarithromycin
M. pneumoniae/C.
Macrolide, a tetracycline Fluoroquinolone
pneumoniae
Legionella species Fluoroquinolone, azithromycin Doxycyline
Chlamydophila psittaci A tetracycline Macrolide
Coxiella burnetii A tetracycline Macrolide
Francisella tularensis Doxycycline Gentamicin, streptomycin
Yersinia pestis Streptomycin, gentamicin Doxycyline, fluoroquinolone
Ciprofloxacin, levofloxacin, doxycycline (usually with Other fluoroquinolones; beta-lactam, if susceptible; rifampin;
Bacillus anthracis (inhalation)
second agent) clindamycin; chloramphenicol
Enterobacteriaceae 3RA cephalosporin, carbapenem Beta-lactam/beta-lactamase inhibitor, fluoroquinolone
Antipseudomonal beta-lactam plus (ciprofloxacin or
Pseudomonas aeruginosa Aminoglycoside plus (ciprofloxacin or levofloxacin)
levofloxacin or aminoglycoside)
Acinetobacter species Carbapenem Cephalosporin-aminoglycoside, ampicillin-sulbactam, colistin

Staphylococcus aureus
Methicillin susceptible Antistaphylococcal penicillin Cefazolin, clindamycin
Methicillin resistant Vancomycin or linezolid TMP-SMX
Bordetella pertussis Macrolide TMP-SMX
Anaerobe (aspiration) Beta-lactam/beta-lactamase inhibitor, clindamycin Carbapenem
Influenza virus See associated topic reviews
For uncomplicated infection in a normal host, no therapy
Coccidioides species Amphotericin B
generally recommended; for therapy, itraconazole, fluconazole
Histoplasmosis Itraconazole** Amphotericin B**
Blastomycosis Itraconazole** Amphotericin B**
Treatment
CURB65 Preferred treatment Alternative treatment
site
Low severity (eg, CURB65 = 0-1 <3
Home Amoxicillin 500 mg VO C/8H Doxycycline 200 mg carga - 100 mg VO c/24h or clarithromycin 500 mg VO c/12h
percent mortality)
Low severity + comorbilidad o Amoxicillin 500 mg VO C/8H
Hospital Doxycycline 200 mg carga - 100 mg VO c/24h or clarithromycin 500 mg VO c/12h
problema social. Amoxicillin 500 mg IV C/8h
Amoxicillin 1g VO C/8H plus clarithromycin
500 mg VO c/12h
Moderate severity (eg, CURB65 = 2, Doxycycine 200 mg carga + 100 mg orally or levofloxacin 500 mg Vo c/24h or
Hospital Amoxicillin 500 mg IV c/8h or
9 percent mortality) moxifloxacin 400 mg VO c/24h
benzylpenicillin (penicillin G) 1.2 grams IV
c/6h plus clarithromycin 500 mg IV c/12h
Benzylpenicillin (penicillin G) 1.2 grams IV c/6h plus either levofloxacin 500 mg IV
Antibiotics given as soon as possible c/12h or ciprofloxacin 400 mg IV c/12h
Hospital
Co-amoxiclav 1.2 grams IV c/8h* plus OR
High severity (eg, CURB65 = 3-5, 15- (consider
clarithromycin 500 mg IV c/12h*
40 percent mortality) critical care Cefuroxime 1.5 grams IV c/8h or cefotaxime 1 gram IV c/8h or ceftriaxone 2 grams IV
review) (If Legionella strongly suspected, consider c/24h, plus clarithromycin 500 mg IV c/12h
adding levofloxacin)
(If Legionella strongly suspected, consider adding levofloxacin)
Outpatient treatment
1. Previously healthy and no use of antimicrobials within the previous 3 months:
A macrolide (azithromycin, clarithromycin, or erythromycin) OR Doxycyline*
2. Presence of comorbidities such as chronic heart, lung, liver or renal disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing
conditions or use of immunosuppressing drugs; or use of antimicrobials within the previous 3 months (in which case an alternative from a different class
should be selected):
A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) OR A beta-lactam (first-line agents: high-dose amoxicillin, amoxicillin-
clavulanate; alternative agents: ceftriaxone, cefpodoxime, or cefuroxime) PLUS a macrolide (azithromycin, clarithromycin, or erythromycin)*
3. In regions with a high rate (>25 percent) of infection with high-level (MIC 16 g/mL) macrolide-resistant Streptococcus pneumoniae, consider use of
alternative agents listed in (2) above.
Inpatients, non-ICU treatment
A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) OR
An antipneumococcal beta-lactam (preferred agents: cefotaxime, ceftriaxone, or ampicillin-sulbactam; or ertapenem for selected patients) PLUS a macrolide
(azithromycin, clarithromycin, or erythromycin)*
Inpatients, ICU treatment
An antipneumococcal beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) PLUS azithromycin OR An antipneumococcal beta-lactam (cefotaxime,
ceftriaxone, or ampicillin-sulbactam) PLUS a respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) OR For penicillin-allergic
patients, a respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) PLUS aztreonam
Special concerns
If Pseudomonas is a consideration:
An antipneumococcal, antipseudomonal beta-lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) PLUS either ciprofloxacin or levofloxacin
(750 mg) OR The above beta-lactam PLUS an aminoglycoside PLUS azithromycin OR The above beta-lactam PLUS an aminoglycoside PLUS a respiratory
fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]); for penicillin-allergic patients, substitute aztreonam for above beta-lactam
If CA-MRSA is a consideration:
Add vancomycin or linezolid

NAC

NEUMONIA INTRAHOSPITALARIA DEFINICION
Table 257-6 Pathogenic Mechanisms and Corresponding Prevention Strategies for Pneumonia types
Ventilator-Associated Pneumonia
Hospital-acquired (or nosocomial)
FACTORES DE RIESGO Pathogenic Mechanism Prevention Strategy
pneumonia (HAP) 48H..
TABAQUISMO - Oropharyngeal colonization with pathogenic bacteria Ventilator-associated pneumonia
ALCOHOLISMO Elimination of normal flora Avoidance of prolonged antibiotic courses (VAP) 48 to 72 hours.
ADULTO MAYOR Healthcare-associated
Postpyloric enteral feedingb; avoidance of high gastric
USO PREVIO A ATB - Gastroesophageal reflux
residuals, prokinetic agents pneumonia (HCAP) is defined as
UREMIA
INTUBACIN Prophylactic agents that raise gastric pHb; selective pneumonia that occurs in a
Bacterial overgrowth of
ENDOTRAQUEAL decontamination of digestive tract with nonabsorbable nonhospitalized patient with
stomach
USO DE SNG - COMA antibioticsb extensive healthcare contact, as
CIRUGA MAYOR Hand washing, especially with alcohol-based hand rub; defined by one or more of the
Cross-infection from other
DESNUTRICIN intensive infection control educationa; isolation; proper following:
colonized patients
FALLA MULTIORGNICA cleaning of reusable equipment Intravenous therapy, wound
NEUTROPENIA Endotracheal intubation; avoidance of sedation; care, or intravenous
USO DE ANTI H2/IBP Large-volume aspiration
decompression of small-bowel obstruction chemotherapy within the prior
ETIOLOGA Microaspiration around endotracheal tube 30 days
Endotracheal intubation Noninvasive ventilationa Residence in a nursing home
MRSA.
PSEUDOMONA Abnormal swallowing or other long-term care facility
Early percutaneous tracheostomya
OTROS SF. function Hospitalization in an acute
KLEBSIELLA Head of bed elevateda; continuous aspiration of subglottic care hospital for two or more
Secretions pooled above
PNEUMONIAE secretions with specialized endotracheal tubea; avoidance of days within the prior 90 days
endotracheal tube
ENTEROBACTER reintubation; minimization of sedation and patient transport Attendance at a hospital or
E. COLI Altered lower respiratory Tight glycemic controlb; lowering of hemoglobin transfusion hemodialysis clinic within the
ACINETOBACTER host defenses threshold; specialized enteral feeding formula prior 30 days
NEUMONIA INTRAHOSPITALARIA
Temperature
36.5 or 38.4 = 0 point - 38.5 or 38.9 = 1 point - 39 or <36.5 = 2 points
Blood leukocytes, microL
4000 or 11,000 = 0 points - <4000 or >11,000 = 1 point - Band forms 50 percent = add
1 point
Tracheal secretions
Absence of tracheal secretions = 0 point
Presence of non-purulent tracheal secretions = 1 point
Presence of purulent tracheal secretions = 2 points
Oxygenation
PaO2/FIO2, mmHg >240 or ARDS (defined as PaO2/FIO2 200, PAWP 18 mmHg and
acute bilateral infiltrates) = 0 points
PaO2/FIO2 240 and no ARDS = 2 points
Pulmonary radiography
No infiltrate = 0 point
Diffuse (patchy) infiltrate = 1 point
Localized infiltrate = 2 points
Progression of pulmonary infiltrate
No radiographic progression = 0 point
Radiographic progression (after HF and ARDS excluded) = 2 points
Culture of tracheal aspirate
Pathogenic bacteria cultured in rare or few quantities or no growth = 0 point
Pathogenic bacteria cultured in moderate or heavy quantity = 1 point
Same pathogenic bacteria seen on Gram's stain, add 1 point
MEDICINA INTERNA www.qxmedic.com
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NEUMONIA INTRAHOSPITALARIA
TERAPIA EMPIRICA Table 257-8 Empirical Antibiotic Treatment of Health CareAssociated
ATB: GUIA ATS Pneumonia
Patients without Risk Factors for MDR Pathogens
Ceftriaxone (2 g IV q24h) or
Moxifloxacin (400 mg IV q24h), ciprofloxacin (400 mg IV q8h), or levofloxacin (750 mg IV q24h) or
Ampicillin/sulbactam (3 g IV q6h) or
Ertapenem (1 g IV q24h)
Patients with Risk Factors for MDR Pathogens
1. A -lactam:
Ceftazidime (2 g IV q8h) or cefepime (2 g IV q812h) or
Piperacillin/tazobactam (4.5 g IV q6h), imipenem (500 mg IV q6h or 1 g IV q8h), or meropenem
(1 g IV q8h) plus
2. A second agent active against gram-negative bacterial pathogens:

The serum gentamicin or tobramycin concentration
should be obtained six hours (or up to 14 hours) after Gentamicin or tobramycin (7 mg/kg IV q24h) or amikacin (20 mg/kg IV q24h) or
the initial dose of 7 mg/kg and plotted on the above
nomogram. The interval for drug administration of Ciprofloxacin (400 mg IV q8h) or levofloxacin (750 mg IV q24h) plus
subsequent doses of 7 mg/kg is then determined based
on the interval specified on the graph. 3. An agent active against gram-positive bacterial pathogens:
* Application of the nomogram for amikacin requires
the measured concentration be divided by two. The Linezolid (600 mg IV q12h) or
new value should be plotted on the nomogram in order
to obtain the appropriate dosing interval. Vancomycin (15 mg/kg, up to 1 g IV, q12h)

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MEDICINA INTERNA

Dr. Christiam Ochoa

TBC PANSENSIBLE TBC INFANTIL

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TBC 1 retenida TBC 1 no retenida

TBC REACTIVADA: Miliar y ExtraPulm

Via hematogena x eso BK-

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Paciente < 5aos con contacto de caso indice

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ETIOLOGA BATERIA TIPICAS (60-70%):

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Need for dopamine at >15 mcg/kg/min, or norepinephrine or epinephrine at >0.25 mcg/kg/min to

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2. A second agent active against gram-negative bacterial pathogens:

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