#8: Pulmonary Infx Flashcards
A CAP dx occurs within 48 hours of admission to the hospital, in a patient who has not: (3)
- Been hospitalized >2 days in the last 90 days
- Had significant health care contact, including HD, wound care, chemo or IV ABX
- Has not resided >14 days in an extended care facility (ECF, SNF)
PNA and MC’s on death: (3)
- 6 leading cause of death in the US
- 2 MC cause of hospital acquired infx
- 1 cause of nosocomial infx death
PNA classification system: (4)
1- causative pathogenic organism
2- anatomic/radiologic location
3- process of acquisition
4- by setting in which they occur
The major reason to classify pneumonias is:
to direct antibiotic therapy- and specifically to determine the risk of exposure to MDR organisms
Risk of MDR Pathogens: (6) RIFF95
RIFF95
1- RF’s for HCAP
2- IS (dz/tx)
3- Family member w/ MDR pathogen
4- Frequency of abx resistance increasing in community
5- in last 90 days, pt recieved abx for infx
6- >/=5 days: current hospitalization
Atypical organisms of CAP include: (5)
1- Mycoplasma pneumoniae
2- Legionella species
3- Chlamydophila psittaci aka parrot fever
4- Chlamydophila pneumoniae aka walking PNA
4- Chlamydophilia trachomatis: STI and PNA in infants
Typical Gram Positive Pathogens: (2)
1- Streptococcal pneumoniae
2- S. aureus
Typical Gram Negative Pathogens: (4 major and 4 minor)
1- H. influenzae 2- Moraxella catarrhalis 3- Klebsiella pneumoniae 4- Pseudomonas aeruginosa 5- Gram-negative bacilli: uncommon *EEPS -- e.coli -- enterobacter spp. -- proteus spp. -- serratia spp.
Uncommon CAP etiologies: (4)
1- Francisella tularemia: Rabbit fever
2- Coxiella burnetti: Q fever
3- Bacillus anthracis (anthrax)
4- Yersinia pestis (plague)
List and compare the two forms of Legionella Dz:
1- Pontiac fever: virus-like presentation with malaise, fevers and HA; relatively benign
2- Frank Legionella PNA: very aggressive w/ high mortality rate
Describe the classic CAP presentation associated w/ PCP:
- sudden onset of rigors w/ pleuritic CP in young pts
Describe the classic CAP sxs presentation associated w/ Legionella PNA: (4)
1- AMS
2- hyponatremia
3- diarrhea
4- other GI symptoms
Turkeys, chickens, ducks, and birds are vectors for this pathogen:
Chlamydophilia psittaci (Parrot fever)
Rabbits and rodents are vectors for this pathogen:
Francisella tularemia (Rabbit fever) and Yersinia pestis (Bubonic plague)
Cats, cattle, sheep, and goats are vectors for this pathogen:
Bacillus anthracis (anthrax) and Coxiella burnetti (Q fever)
Associated w/ exposures to overcrowded conditions such as jails, homeless shelters, dormitories: (4)
1- S. pneumoniae
2- Chlamydiophilia species
2- Mycoplasma species
4- Mycobacterium (TB)
Associated w/ exposures to contaminated air conditioning or water systems: (1)
Legionella species
Red “current jelly” sputum associated w/: (1)
Klebsiella pneumoniae PNA
Rust colored sputum associated w/: (1)
S. pneumoniae PNA
Green sputum associated w/: (3)
1- H. influenzae
2- Pseudomonas aeruginosa
3- S. pneumoniae PNA
Foul smelling or bad-tasting sputum associated w/: (1)
anaerobic infx
List the different factors that will influence the decision to hospitalize w/ CAP tx:
- Comorbidities: (4)
- PE findings: (6)
- Labs: (4)
- Imaging: (2)
Comorbidities: (4) 1- immunocompromised state 2- hx of CHF 3- hx of CAD 4- hx of CVA PE findings: (6) 1- HoTN 2- tachycardia 3- tachypnea 4- AMS 5- fever 6- hypothermia Labs: (4) 1- uncontrolled diabetes 2- hypoxia 3- dehydration 4- hyponatremia Imaging: (2) 1- pleural effusion 2- extent of lung involvement
Describe CURB-65 and it’s scoring system in making the Decision to Hospitalize:
- Confusion (based upon a specific mental test or disorientation to person, place, time)
- Urea (blood urea nitrogen >20 mg/dL)
- Respiratory rate >30 breaths/minute
- Blood pressure [BP] (systolic <90 mmHg or diastolic <60 mmHg) aka severe HoTN
- Age >65years
- *1= outpatient, 2-3=inpt ward, 3+= inpt, ICU
What is a PORT/ PSI score?
- pneumonia severity index
- a more comprehensive scoring system than CURB-65 that allows clinicians to risk stratify pts needing hospitalization
IDSA/ATS Minor Criteria for Severe CAP: (11)
1- Respirations > 30/ min
2- Hypoxia
3- Need for non-invasive ventilatory support (BiPAP or CPAP)
4- Multilobar infiltrates
5- Uremia (BUN>20mg/dL)
6- Leukopenia (<4K)
7- Thrombocytopenia (<100K)
8- Hypothermia
9- HoTN rq. aggressive fluid resuscitation
10- Confusion/disorientation
11- Major criteria are septic shock and mechanical ventilation
Empiric outpt. tx of CAP in healthy pts without a prior ABX exposure in the last 90 days: (1+2 or 1)
1- Macrolide- preferred - Azithromycin (Zithromax) - Clarithromycin (Biaxin) OR 2- Doxycycline
Significant comorbidities prompting quinolone OR beta lactam/macrolide use in empiric tx for CAP: (9)
1- alcoholism 2- CKD 3- Chronic lung dz 4- CHD 5- Chronic liver dz 6- uncontrolled DM 7- malignancy 8- recent macrolide use in previous 90 days 9- immunocompromised pts.
CAP tx for pts w/ a chronic dz (lung, heart, liver, or kidneys), poorly controlled DM, immunosuppression, malignancy, alcoholism, or pts who have used a macrolide in the last 90 days: (1+2 or 2+5+3)
1- fluoroquinolone:
- Levofloxacin (Levaquin)
- Moxifloxacin (Avelox)
2- beta lactam AND a macrolide: ---1) high dose amoxicillin ---2) amox-clav (augmentin)**preferred ---3)ceftriaxone ---4) cefuroxime ---5) cefpodoxime AND - Azithromycin (Zithromax) - Clarithromycin (Biaxin) OR - Doxycycline
Inpt. CAP tx for general medical ward/telemetry and ICU pts. w/o Pseudomonas or Legionella RF’s: (1+2 or 1+2)
1- Beta lactam with a macrolide (preferred)
—1) Ceftriaxone (Rocephin) 1-2 gram daily IVPB
—2) Cefotaxime (Claforan) 1-2 gm IVPB q 8
with Azithromycin (Zithromax) 500mg IVPB daily
OR
2- fluoroquinolone:
—1) Moxifloxicin (Avelox) 500mg IV daily
—2) Levofloxacin (Levaquin) 750mg dose IV daily
Inpt. CAP tx for ICU pts. w/ Pseudomonas or Legionella RF’s: (7)
1- Piperacillin-tazobactam (Zosyn) 4.5gm IV q6 2- Imipenem (Primaxin) 500mg IV q 6hrs 3- Meropenem (Merrem) 1gm IV q 8hrs 4- Cefepime (Maxipeme) 2gms IV q 8hrs 5- Ceftazidime (Fortaz) 2 gm IV q 8hrs *PLUS, if double coverage needed: 6- Ciprofloxacin 400mg IV or 500mg po q 8 hrs 7- Levofloxacin 750mg IV or po QD
Empiric tx for CAP-MRSA with Vancomycin should be given to hospital pts with severe CAP, defined as: (5 major and 6 minor)
1- Admission to the ICU for septic shock or mechanical ventilation 2- Necrotizing or cavitary infiltrates 3- Empyema 4- GPC in clusters on sputum gram stain 5- Risk factors for cap-MRSA: --- 1- ESRD --- 2- IVDA --- 3- MSM --- 4- prisoners --- 5- recent influenza-like illness --- 6- recent ABX therapy (particularly with quinalone) in last 3 months
Vaccines recommended in prevention of CAP: (4)
1- Seasonal influenza vaccine - IM: killed virus - Nasal spray: attenuated virus 2- PCP 3- Pneumococcal conjugate vaccine 4- Pneumococcal polysaccharide vaccine
Tx of HAP/VAP w/ early and less severe infx can be tx empirically with the following: (3)
1- 3rd gen cephalosporins
2- Beta lactam/BLI
3- Respiratory fluoroquinalone
Tx of HAP/VAP w/ early and less severe infx likely does not cover these organisms:
- pseudomonas
- mrsa
Tx of HAP/VAP w/ more severe HAP or VAP rqs. broader abx coverage for 7 days, which includes: (2+3)
*An aminoglycoside or fluoroquinolone, plus one of the following:
1- An anti-pseudomonal penicillin (Zosyn)
2- An anti-pseudomonal cephalosporin (Cefepime)
3- A carbapenem
Parenteral tx for aspiration PNA: (1)
ampicillin-sulbactam (unasyn)
Tx for aspiration PNA in a pt who is not severely ill: (3)
1- amox-clav (augmentin)
2- metronidazole AND PCN G
3- metronidazole AND amoxicillin
Tx for aspiration PNA in a pt who is allergic to PCN:
1- metronidazole AND cefotaxime (preferred)
2- metronidazole AND ceftriaxone (preferred)
3- clindamycin: may cause C. diff
Lung abscess tx: (4)
* likely rq. IV abx initially and abx continued for 3+ wks- and ID consult 1- ampicillin-sulbactam (unasyn) 2- meropenem (merrem) 3- carbapenem-imipenem (primaxin) 4- PO augmentin
