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pharmacotherapy 4270 > 8. Lower Respiratory Tract Infections MT2 > Flashcards

8. Lower Respiratory Tract Infections MT2 Flashcards

1
Q

this refers to an acute infection of the pulmonary parenchyma acquired outside of the hospital

A

community-acquired pneumonia (CAP)

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2
Q

this refers to an acute infection of the pulmonary parenchyma acquired in the hospital settings and includes both hospital acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP)

A

nosocomial pneumonia

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3
Q

this type of nosocomial pneumonia refers to pneumonia acquired >48 hours after hospital admission

A

HAP

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4
Q

this type of nosocomial pneumonia refers to pneumonia acquired > 48 hours after endotracheal intubation

A

VAP

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5
Q

this is caused by “atypical” bacteria pathogens including Legionella spp., M. pneumoniae, Chlamydia pneumoniae, Chlamydia psittaci and Coxiella burnetii

A

atypical pneumonia

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6
Q

this results from entry of gastric or oropharyngeal fluid, which may contain bacteria and/or be of low pH, or exogenous substances (e.g. ingested food particles or liquids, mineral oil, salt or fresh water) into the lower airways

A

aspiration pneumonia

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7
Q

this is the aspiration of substances (e.g. acidic gastric fluid) that causes an inflammatory reaction in the lower airways, independent of bacterial infection

A

chemical pneumonitis

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8
Q

this is an active infection caused by inoculation of large amounts of bacteria into the lungs via orogastric contents

A

bacterial aspiration pneumonia

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9
Q

this is an infection of the pleural space, usually involving anaerobes, S. aureus and/or GNB

A

empyema

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10
Q

this is part of the lungs that transfers oxygen and carbon dioxide between the air and the blood

A

lung parenchyma

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11
Q

what are some common symptoms of lower respiratory tract infections

A
  • fever or hypothermia
  • rigours
  • sweats
  • new cough and/or sputum production, or change in sputum color in patients with COPD
  • dyspnea, tachypnea, pleuritic chest pain, tachycardia
  • altered mental status (particularly in the elderly)
  • nonspecific: fatigue, myalgias, abdominal pain, anorexia, headache
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12
Q

what are the risk factors for community-acquired pneumonia (CAP)

A
  • > 65
  • ineffective cough
  • smoking
  • thick mucus
  • comorbities (e.g. COPD)
  • lifestyle factors (crowded living conditions, living in low-income settings, environmental toxins)
  • viral respiratory infections (e.g. influenza)
  • impaired alveolar macrophage function (e.g immunocompromised)
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13
Q

what is the most common microbe identified in CAP

A

streptococcus pneumoniae

others: H. influenzae, S. aureus, Klebsiella, and other GNB
virus: influenza, RSV, adenovirus, parainfluenza virus, COVID-19

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14
Q

true or false: bacterial pneumonia can occur around the same time as a virus, or pop up later as worsening symptoms after initial improvement of the viral infection

A

true

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15
Q

when a chest Xray is performed, is lobar/alveolar consolidation more likely with bacterial or viral pneumonia

A

bacterial

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16
Q

what are some ways to prevent CAP

A

vaccination
- annual vaccination for seasonal influenza is indicated for all patients
- covid vaccination
- pneumococcal vaccine is indicated for anyone over 65 or with risk factors (certain comorbidities including heart, lung and liver disease, immunocompromised, impaired splenic function)

smoking cessation

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17
Q

how is CAP diagnosed

A
  • mostly based on presentation and history of present illness for outpatients
  • CXR infiltrates initially, but not to confirm resolution
  • sputum culture should be ordered and interpreted cautiously
  • blood culture for admitted pts
  • PCR for viral
  • bronchoscopy may be used if pt is in ICU
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18
Q

what technique is used to decide whether or not a patient should be admitted for CAP

A

CURB-65
- confusion
- urea
- respiratory rate
- blood pressure
- age

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19
Q

when treating a patent with CAP, what microbe should always be covered

A

S. pneumoniae

20
Q

when treating a patient with CAP that has other comorbidities, should you tighten or broaden the spectrum of antibiotic

A

broaden - poor outcomes are more likely with tx failure

21
Q

if a patient with CAP has no comorbidities or risk factors for MRSA or Pseudomonas, what is the standard regimen?

A

Amoxicillin OR doxycycline or macroline

22
Q

if a patient with CAP has comorbidities, what is the standard regimen

A

combination of amoxi/clav or cephalosporin with macrolide or doxycycline OR monotherapy with a respiratory fluoroquinolone (e.g. levofloxacin, moxifloxacin, or gemifloxacin)

23
Q

what are some criteria used to determine whether someone has severe inpatient CAP

A

either one major criteria (septic shock with need for vasopressors or respiratory failure requiring mechanical ventilation) or three minor criteria (increased RR, Pa02/Fl02 ratio < 250, multiliobar infiltrates, confusion/disorientation, uremia > 20mg/dl, leukopenia, thrombocytopenia, hypothermia, hypotension requiting aggressive fluid resuscitation)

24
Q

what is the standard regimen for a nonsecure inpatient CAP

A

beta-lactam + macrolide or respiratory fluoroquinolone

25
Q

what is the standard regimen for a severe inpatient CAP

A

beta-lactam + macrolide or beta-lactam + fluoroquinolone

26
Q

what are some strong risk factors for CAP caused by MRSA

A
  • known MRSA colonization
  • prior MRSA infection
  • detection of gram-positive cocci in clusters on a good-quality sputum gram stain
27
Q

what are some strong risk factors for CAP caused by Pseudomonas

A
  • known Pseudomonas colonization
  • prior pseudomonas infection
  • detection of gram-negative rods on a good-quality sputum gram stain
  • hospitalization with receipt of IV antibiotics in the prior 3 months
28
Q

are these other risk factors for CAP caused by MRSA or Pseudomonas?
- recent hospitalization or antibiotic use
- recent influenza-like illness
- necrotizing or cavitary pneumonia
- empyema
- immunosuppression
- risk factors for colonization (ESRD, crowded living conditions, injection drug use, contact sports participation, men who have sex with men)

A

MRSA

29
Q

are these other risk factors for CAP caused by MRSA or Pseudomonas?
- recent hospitalization or stay in a long-term care facility
- recent antibiotic use of any kind
- frequent COPD exacerbations requiring glucocorticoid and/or antibiotic use
- other structural lung diseases (eg. bronchiectasis, cystic fibrosis)
- immunosuppression

A

Pseudomonas

30
Q

what is the duration of therapy for CAP

A

5-7 days. 10 days in complicated patients

31
Q

what is the most significant risk factor for HAP

A

intubation

32
Q

what are some other risk factors for HAP

A
  • older age
  • chronic lung disease
  • depressed consciousness
  • aspiration
  • chest or upper abdominal surgery
  • agents that increase gastric pH (e.g. antacids)
  • reintubation or prolonged incubation
  • mechanical ventilation for acute respiratory distress syndrome
  • frequent ventilator circuit changes
  • total opioid exposure
  • multiple trauma
  • paralysis
  • number of central venous catheter placements and surgeries
  • use of muscle relaxants or glucocorticoids
  • the presence of an intracranial monitor
  • malnutrition
  • chronic renal failure
  • anemia
  • previous hospitalization
33
Q

is HAP usually mono microbial or polymicrobial

A

polymicrobial

34
Q

what are the most common HAP bacteria

A

staphylococcus aureus (including MRSA)
Pseudomonas

35
Q

what are some other common HAP pathogens

A

aerobic GNB (klebsiella, e. coli, enterobacter, acintobacter)
gram-positive cocci (streptococcus spp.)
viruses
fungi (more common in immunocompromised patients)

36
Q
  • IV antibiotics within the past 90 days
    is a risk factor for…..
A

MDR pseudomonas, other gram-negative bacilli and MRSA (HAP)

37
Q
  • structural lung disease (e.g. brochiectasis or cystic fibrosis)\
  • a respiratory specimen gram stain with numerous and pre-dominant gram-negative bacilli
  • colonization with OR prior isolation of MDR pseudomonas or other gram-negative bacilli
    these are risk factors for…..
A

MDR pseudomonas and other gram-negative bacilli (HAP)

38
Q
  • treatment in a unit in which >20% of staphylococcus isolates are methicillin resistant
  • treatment in a unit in which the prevalence of MRSA is not known
  • colonization with OR prior isolation of MRSA
    these are risk factors for…
A

MRSA (HAP)

39
Q
  • treatment in an ICU in which > 10% of gram-negative isolates are resistant to an agent being considered for mono therapy
  • treatment in an ICU in which local antimicrobial susceptibility rates are no known
  • colonization with OR prior isolation of MDR pseudomonas or other gram-negative bacilli
    these are risk factors for..
A

MDR pseudomonas and other gram-negative bacilli (VAP)

40
Q
  • IV antibiotic use within the previous 90 days
  • septic shock at the time of VAP
  • ARDs preceding VAP
  • > 5 days of hospitlization prior to the occurrence of VAP
  • acute renal replacement therapy prior to VAP onset
    these are risk factors for….
A

MDR pathogens (VAP)

41
Q
  • treatment in a unit which > 10 to 20% of staphylococcus aureus isolates are methicillin resistant
  • treatment in a unit which the prevalence of MRSA is unknown
  • colonization with OR prior isolation of MRSA
    these are risk factors for….
A

MRSA (VAP)

42
Q

how should HAP/VAP therapy be tailored once the pathogen is identified

A

tailor therapy to susceptibility

43
Q

how should HAP/VAP therapy be tailored if the patient is clinically improving but the pathogen is not identified

A

discontinue empiric treatment for MRSA or MDR GNB if not grown in high-quality sputum culture in 48-72 hrs

44
Q

how should HAP/VAP therapy be tailored if the patient is not improving within 72 hours

A

evaluate for complications, other sites of infections and alternate diagnoses (e.g. empyema, lung abscess, untreated infections elsewhere, drug-resistant pathogens, additional cultures, expand empiric coverage)

45
Q

if considering switching a HAP/VAP patient from an IV to PO antibiotic, what are some requirements the patient must meet

A
  • hemodynamically stable
  • clinically improving
  • able to tolerate oral medications
46
Q

if considering switching a HAP/VAP patients from an IV to PO antibiotic, what are some requirements the PO medication must meet for these patients

A
  • must be based on the pathogens susceptibility pattern (if a pathogen was not identified, it should have similar antimicrobial coverage as the IV agent)
  • have good lung penetration
47
Q

what is the recommended duration of treatment for HAP/VAP

A

7 days appears to be effective

longer than 7 days may be warranted and should be individualized for patients with severe illness, bacteremia, immunocompromised, empyema, lung abscess, etc

pharmacotherapy 4270 (19 decks)

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