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{{familytree/start |summary=Opioid withdrawal treatment algorithm.}}
{{familytree/start|summary=Community acquired pneumonia}}
{{familytree | | | | | | | | | | A01 | | | | | | | | | | |A01='''Induction: (day 1)'''}}
 
{{familytree | | | | | | | | | | |!| | | | | | | | | | |}}
{{familytree | | | | | | | | | A01 |A01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Characterize the symptoms & signs:'''<br>; Fever <br> ; Cough with sputum <br> ;[[Dyspnea]]<br>; [[Pleuritic]] chest pain </div> }}
{{familytree | | | | | | | | | | B01 | | | | | |B01=Identify the opioid's the patient has been using}}
 
{{familytree | | | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | C01 | | | | | | C02 | | | | | | | |C01=Short acting opioids|C02=Long acting opioids}}
 
{{familytree | | | | | | |!| | | | | | | |!| | | | | | | | |}}
{{familytree | | | | | | | | | B01 | | | | | |B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Examine the patient:''' <br> ; [[Fever]] and/or <br> ; [[Tachypnea]] and/or <br> ; [[Rales]] and/or <br> ; [[Increased TVF]]</div>}}
{{familytree | | | | | | D01 | | | | | | D03 | | | | | | | | |D01=<div style="float: left; text-align: left"> ❑ Discontinue short acting opioids <br> ❑ Look for withdrawal symptoms (12-24 hours after last dose)</div>|D03=<div style="float: left; text-align: left"> ❑ Taper long acting opioids<br>
 
:❑ Methadone to ≤ 30 mg/day
{{familytree | | | | | | | | | |!| | | | | | | | }}
:❑ LAAM to ≤ 40 mg/48 hours<br>
 
❑ Look for withdrawal symptoms:<br>
{{familytree | | | | | | | | | C01 |-|-|-|-| |C01=<div style="float: left; text-align: left; width: 20em; padding:1em;">; Order CBC <br>;  Perform Sputum gram stain <br>; Sputum culture <br>; Blood culture</div>}}
:❑ For methadone: 24+ hours after last dose
 
:❑ For LAAM: 48+ hours after last dose</div>}}
{{familytree | | | | | | | | | |!| | | | |!| | | }}
{{familytree | | | | | | |)|-|-|-|v|-|-|-|(| | | | | | |}}
 
{{familytree | | | | | | E01 | | E02 | | E03 | | | | | |E01=<div style="float: left; text-align: left">Withdrawal symptoms present:<br> ❑ Administer buprenorphine/naloxone 4/1 mg <br> ❑ Observe for 2+ hours </div> |E02=<div style="float: left; text-align: left"> Withdrawal symptoms absent: <br> ❑ Reevaluate the suitability for induction </div> |E03=<div style="float: left; text-align: left">Withdrawal symptoms present:<br> ❑ Administer buprenorphine 2 mg <BR> ❑ Observe for 2+ hours</div>}}
{{familytree | | | | | | | | | D01 | | | D02 | |D01=<div style="float: left; text-align: left; width: 20em; padding:1em;">; Order a chest X-ray <br>; Evaluate for severity of illness <br>; Comorbid factors if any<br>; Start oxygenation if needed</div>|D02=<div style="float: left; text-align: left; width: 20em; padding:1em;">; If suspecting '''[[atypical pneumonia]]''' then obtain <br> ; Urine [[legionella]] antigen<br>; [[Enyzme Immunoassay]] (EIA) <br>; [[Immunoflorescence]] <br>; PCR <br>; [[Fibre optic bronchoscopy]]  <br>; Biopsy for Histopathology</div> }}
{{familytree | | | | | | |)|-|-|-|v|-|-|-|(| | | | | | |}}
 
{{familytree | | | | | | F01 | | F02 | | F03 | | | | | |F01=<div style="float: left; text-align: left">Withdrawal symptoms not relieved: <br> ❑ Repeat buprenorphine 4mg (up to maximum of 8mg/24 hours <br> ❑ Naloxone 1 mg (up to maximum of 2 mg/24 hours)</div>|F02=<div style="float: left; text-align: left">Withdrawal symptoms relieved:<br> ❑ Day 1 dose established <BR> ❑ Send patient home<BR> ❑ Schedule patient to return on day 2 for forward induction</div> |F03=<div style="float: left; text-align: left">Withdrawal symptoms not relieved: <br> ❑ Repeat buprenorphine 2mg (up to maximum of 8mg/24 hours)</div> }}
{{familytree | | | | | | | | | |!| | | | | | | | }}
{{familytree | | | | | | |`|-|-|-|v|-|-|-|'| | | | | | | | | |}}
 
{{familytree | | | | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | |}}
{{familytree | | | | | | | | | E01 | | | | | |E01=Start empiric therapy for<br> '''Community acquired pneumonia''' <br>while awaiting culture results}}
{{familytree | | | | | | G01 | | | | | | G02 | | | | | | | | | |G01=<div style="float: left; text-align: left">Withdrawal symptoms relieved:<br>❑ Day 1 dose established<BR> ❑ Send patient home <BR> ❑ Schedule patient to return on day 2 for forward induction</div>|G02=<div style="float: left; text-align: left">Withdrawal symptoms not relieved:<br>Manage withdrawal symptoms symptomatically<br>
 
:❑ [[Clonidine]] 0.2 mg every 4 hours, tapered after day 3,<ref name="O'Connor-1995">{{Cite journal  | last1 = O'Connor | first1 = PG. | last2 = Waugh | first2 = ME. | last3 = Carroll | first3 = KM. | last4 = Rounsaville | first4 = BJ. | last5 = Diagkogiannis | first5 = IA. | last6 = Schottenfeld | first6 = RS. | title = Primary care-based ambulatory opioid detoxification: the results of a clinical trial. | journal = J Gen Intern Med | volume = 10 | issue = 5 | pages = 255-60 | month = May | year = 1995 | doi =  | PMID = 7616334 }}</ref> or <br>  
{{familytree | | | | | | | | | |!| | | | | | | | }}
:❑ [[Lofexidine]] 0.2 mg BD daily, titrated to 1.2 mg BD daily <ref name="Strang-1999">{{Cite journal  | last1 = Strang | first1 = J. | last2 = Bearn | first2 = J. | last3 = Gossop | first3 = M. | title = Lofexidine for opiate detoxification: review of recent randomised and open controlled trials. | journal = Am J Addict | volume = 8 | issue = 4 | pages = 337-48 | month =  | year = 1999 | doi =  | PMID = 10598217 }}</ref> <br>
 
:❑ Chlordiazepoxide as needed<BR>
{{familytree | |,|-|-|-|v|-|-|-|^|-|-|-|v|-|-|-|.| | }}
❑ Return next day for repeat induction attempt</div>}}
 
{{familytree | | | | | | |!| | | | | | | | | | | | | | | | | |}}
{{familytree | F01 | | F02 | | | | | | F03 | | F04 |F01='''Outpatients'''<br> with no recent antibiotic exposure <br>and no comorbidities |F02='''Outpatients'''<br> with recent antibiotic exposure <br>and no comorbidities |F03='''Hospitalized patient'''|F04='''Critically ill patients'''}}
{{familytree | | | | | | H01 | | | | | | | | | | | | | | | | | |H01='''Induction-day 2 forward'''}}
 
{{familytree | | | | | | |)|-|-|-|-|-|-| I01 | | | | | | | | |I01=<div style="float: left; text-align: left">On return withdrawal symptoms absent:<br>❑ Administer a daily dose established equal to total buprenorphine & naloxone administered on previous day </div>}}
{{familytree | |!| | | |!| | | | | | | |!| | | |!|}}
{{familytree | | | | | | J01 | | | | | | | | | | | | | | | | | |J01=<div style="float: left; text-align: left">On return withdrawal symptoms present:<br>❑ Administer dose equal to total amount of buprenorphine & naloxone administered on previous day<br>'''+'''<br>4mg of buprenorphine (up to maximum of 12mg on day 2)<br>&<br>1mg of naloxone (up to maximum of 3mg on day 2)<br>❑ Observe 2+ hours</div> }}
 
{{familytree | | | | | | |)|-|-|-|-|-|-| K01 | | | | | | | | |K01=<div style="float: left; text-align: left">Withdrawal symptoms relieved:<br>❑ Daily buprenorphine & naloxone dose established </div>}}
{{familytree | G01 | | G02 | | | | | | G03 | | G04 |G01=<div style="float: left; text-align: left; width: 20em; padding:1em;">; [[Azithromycin]] 500 mg PO single dose <br> followed by 250 mg PO daily for 4 more days <br> OR <br>; [[Doxycycline]] 100 mg PO for 5 days </div>|G02=<div style="float: left; text-align: left; width: 20em; padding:1em;">; Respiratory fluoroquinolone ( [[Moxifloxacin]] )<br> OR <br> ; Macrolide ([[Azithromycin]] or [[clarithromycin]]) <br> With or Without <br>; [[Amoxicillin]] 1 g PO for atleast 5 days</div>|G03=<div style="float: left; text-align: left; width: 20em; padding:1em;">; [[Ceftriaxone]] 1g IV daily <br> OR <br>; [[Cefotaxime]] 1g IV q8h <br> PLUS <br> ; [[Azithromycin]] or [[Clarithromycin]]  <br> OR <br> ; Respiratory fluoroquinolone ( [[Moxifloxacin]] )</div> |G04=<div style="float: left; text-align: left; width: 20em; padding:1em;">; Add [[Azithromycin]] or a Respiratory fluoroquinolone ( [[Moxifloxacin]] )to [[B-Lactam]] for [[L.pneumophila]] <br>; Add [[Vancomycin]] for [[MRSA]] coverage <br>; Add IV [[penicillin G]] to cover [[S.Pneumoniae]] <br>; Add antipseudomonal B-Lactam to antipseudomonal fluoroquinolone <br>; ( [[Ciprofloxacin]] / [[Levofloxacin]] ) <br> to cover [[Pseudomonas aeruginosa ]] </div>}}
{{familytree | | | | | | L01 | | | | | | | | | | | | | | | | | |L01=<div style="float: left; text-align: left">Withdrawal symptoms not relieved:<br>❑ Administer buprenorphine 4 mg (up to maximum of 16mg on day 2) & naloxone 1 mg (up to maximum of 4 mg on day 2)</div> }}
 
{{familytree | | | | | | |)|-|-|-|-|-|-| M01 | | | | | | | | |M01=<div style="float: left; text-align: left">Withdrawal symptoms relieved:<br>❑ Daily buprenorphine & naloxone dose established </div>}}
{{familytree | |`|-|-|-|!|-|-|v|-|-|-|-|!|-|-|-|'| | | | | | | | |}}
{{familytree | | | | | | N01 | | | | | | | | | | | | | | | | | |N01=<div style="float: left; text-align: left">Withdrawal symptoms not relieved:<br>Manage withdrawal symptoms symptomatically<br>
 
:❑ [[Clonidine]] 0.2 mg every 4 hours, tapered after day 3,<ref name="O'Connor-1995">{{Cite journal  | last1 = O'Connor | first1 = PG. | last2 = Waugh | first2 = ME. | last3 = Carroll | first3 = KM. | last4 = Rounsaville | first4 = BJ. | last5 = Diagkogiannis | first5 = IA. | last6 = Schottenfeld | first6 = RS. | title = Primary care-based ambulatory opioid detoxification: the results of a clinical trial. | journal = J Gen Intern Med | volume = 10 | issue = 5 | pages = 255-60 | month = May | year = 1995 | doi =  | PMID = 7616334 }}</ref><br>'''or'''<br>
{{familytree | | | | | | | | H01 | | | | | | | | |H01=<div style="float: left; text-align: left; width: 20em; padding:1em;">; If culture results are available then treat accordingly <br>; If no response to treatment or<br> suspicion of any complication <br>then consider</div>}}
:❑ [[Lofexidine]] 0.2 mg BD daily, titrated to 1.2 mg BD daily <ref name="Strang-1999">{{Cite journal  | last1 = Strang | first1 = J. | last2 = Bearn | first2 = J. | last3 = Gossop | first3 = M. | title = Lofexidine for opiate detoxification: review of recent randomised and open controlled trials. | journal = Am J Addict | volume = 8 | issue = 4 | pages = 337-48 | month =  | year = 1999 | doi =  | PMID = 10598217 }}</ref><br>
 
:❑ Chlordiazepoxide as needed<BR>
{{familytree | | | |,|-|-|-|-|^|-|-|-|-|.| | | | | | | | | | | | | | | | }}
❑ On subsequent induction days, if the patient returns experiencing withdrawal symptoms, continue increasing dose (up to a maximum of buprenorphine 32 mg/day & naloxone 8 mg/day</div> }}
 
{{familytree | | | | | | |!| | | | | | | | | | | | | | | | }}
{{familytree | | | I01 | | | | | | | | I02 | |I01=Pleural Effusion |I02=Empyema}}
{{familytree | | | | | | O01 | | | | | | | | | | | | | | |O01=<div style="float: left; text-align: left">'''Stabilization phase (1-2 months):''' <br> ❑ Transition when patient has:
 
:❑ No withdrawal symptoms <br>
{{familytree | | | |!| | | | | | | | | |!| | | }}
:❑ Minimal or no side effects <br>
 
:❑ No uncontrollable craving for opioid agonists <br>
{{familytree | | | J01 | | | | | | | | J02 | |J01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Perform [[thoracocentesis]]''' and analyse <br>; [[pH]] <br>; [[Cell count]] <br>; [[Gram stain]] <br>; [[Bacterial culture]]<br>; Protein <br>; [[Lactate dehydrogenase]]|J02=Drain the empyema</div>}}
❑ Begin with buprenorphine/naloxone combination, increasing dose by 2/0.5-4/1 mg per week till stabilization is achieved, most stabilizing at 16/4-24/6 mg <br> ❑ As patient stabilizes, transition to alternate day or every third day regimen by doubling and tripling daily doses respectively </div> }}
 
{{familytree | | | | | | |!| | | | | | | | | | | }}
{{familytree | | | | | | P01 | | | | | | | | | |P01=<div style="float: left; text-align: left">'''Maintenance phase:''' <br>
❑ Maintain at same dose as daily stabilization dose <br> ❑ Decide total treatment duration based on: <br>
:❑ Stable housing & income <br>
:❑ Patients motivation, doctors comfort in tapering <br>
:❑ Presence of psychosocial support
:❑ Absence of legal support
:❑ Other drugs & alcohol abuse </div> }}
{{familytree/end}}
{{familytree/end}}

Revision as of 00:44, 21 February 2014

 
 
 
 
 
 
 
 
Characterize the symptoms & signs:
; Fever
 ; Cough with sputum
 ;Dyspnea
; Pleuritic chest pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:
 ; Fever and/or
 ; Tachypnea and/or
 ; Rales and/or
 ; Increased TVF
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
; Order CBC
; Perform Sputum gram stain
; Sputum culture
; Blood culture
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
; Order a chest X-ray
; Evaluate for severity of illness
; Comorbid factors if any
; Start oxygenation if needed
 
 
; If suspecting atypical pneumonia then obtain
 ; Urine legionella antigen
; Enyzme Immunoassay (EIA)
; Immunoflorescence
; PCR
; Fibre optic bronchoscopy
; Biopsy for Histopathology
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Start empiric therapy for
Community acquired pneumonia
while awaiting culture results
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Outpatients
with no recent antibiotic exposure
and no comorbidities
 
Outpatients
with recent antibiotic exposure
and no comorbidities
 
 
 
 
 
Hospitalized patient
 
Critically ill patients
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
; Azithromycin 500 mg PO single dose
followed by 250 mg PO daily for 4 more days
OR
; Doxycycline 100 mg PO for 5 days
 
; Respiratory fluoroquinolone ( Moxifloxacin )
OR
 ; Macrolide (Azithromycin or clarithromycin)
With or Without
; Amoxicillin 1 g PO for atleast 5 days
 
 
 
 
 
; Ceftriaxone 1g IV daily
OR
; Cefotaxime 1g IV q8h
PLUS
 ; Azithromycin or Clarithromycin
OR
 ; Respiratory fluoroquinolone ( Moxifloxacin )
 
; Add Azithromycin or a Respiratory fluoroquinolone ( Moxifloxacin )to B-Lactam for L.pneumophila
; Add Vancomycin for MRSA coverage
; Add IV penicillin G to cover S.Pneumoniae
; Add antipseudomonal B-Lactam to antipseudomonal fluoroquinolone
; ( Ciprofloxacin / Levofloxacin )
to cover Pseudomonas aeruginosa
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
; If culture results are available then treat accordingly
; If no response to treatment or
suspicion of any complication
then consider
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pleural Effusion
 
 
 
 
 
 
 
Empyema
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Drain the empyema
 
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