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Clinical 2 - Antibiotics > 9 - Lower RTI > Flashcards

9 - Lower RTI Flashcards

1
Q

Clinical signs and symptoms of pneumonia ?

A
  • cough, sputum production, crackles, consolidation, tachypnea > 24, dyspnea, hypoxia, hemoptysis, pleural pain
  • fever, chills, tachycardia, leukocytosis
  • elderly can present without cough, sputum or leukocytosis and fever in only 30%
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2
Q

Most likely pathogen for pneumonia ?

A
  • Streptococcus pneumoniae

- Mycoplasma pneumoniae

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3
Q

What types of viral infections often precede, predispose to secondary bacterial pneumonia?

A
  • influenza
  • parainfluenza
  • adenovirus
  • coronavirus
  • rhinovirus
  • RSV
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4
Q

S. pneumoniae is more common in ??

A
  • COPD
  • CV or renal disease
  • asplenic
  • diabetes
  • immunocompromised
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5
Q

M. pneumoniae or Chlamydophila pneumoniae is more common in ?

A
  • adolescents

- young and elderly adults

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6
Q

S. aureus common in ?

A

immunocompromised

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7
Q

H. influenza, Moraxella catarrhalis common in ?

A

COPD, smokers

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8
Q

Klebsiella pneumonia, E. coli, Enterobacter species in ?

A

COPD, smoking, diabetes, alcoholism

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9
Q

P. aueroginosa common in ?

A
  • cystic fibrosis
  • COPD
  • corticosteroids
  • immunocompromised
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10
Q

Anaerobes common in ?

A
  • aspiration
  • cerebrovascular/neurological disease
  • alcoholism
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11
Q

How is CAP (community acquired pneumonia) diagnosed ?

A
  • clinical signs and symptoms
  • lung infiltrate on X-ray
  • low culture yield in sputum due to poor quality sampling and fastidious or slow-growing pathogens, improved yield in endothelial lining fluid obtained by bronchoaveolar lavage
  • positive blood culture in < 25% of cases
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12
Q

Describe the characteristics of Mycoplasma pneumoniae

A
  • peak incidence older children, young adults and elderly
  • incubation 2-3 weeks, associated with pharyngitis, tracheobronchitis and pneumonia
  • gradual onset fever, headache, GI symptoms, malaise, arthralgia, myalgia, rash for 1-2 weeks, followed by non-productive cough for 3-4 weeks
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13
Q

Describe the characteristics of Chlamydophila pneumoniae

A
  • young adults

- mild respiratory symptoms, fever, headache

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14
Q

Describe the characteristics of Legionella pneumophilia

A
  • ubiquitous in water and soil, outbreaks and sporadic cases with peak in summer and fall, associated with air ventilation systems
  • rapidly progressive pneumonia with multi-system involvement including fever, malaise, arthralgia, pleuritic pain, CNS and GI symptoms
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15
Q

What antimicrobial classes are active against these infections (mycoplasma pneumoniae, chlamoydophila pneumoniae, legionella pneumophilia)

A
  • Fluoroquinolones
  • Macrolides
  • Tetracyclines
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16
Q

What is the treatment for Ambulatory patient ,mild-moderate infection ?
(PO)

*no risk factors for resistance or poor outcomes

A 
-Amox (+/- Macro or Doxy) - for moderate illness or if not improving within 3 day of Amox therapy
OR
-Macro
OR
-Doxy
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17
Q

What is the treatment for Ambulatory patient with risk factors for resistance or poor outcomes? (PO)

A 
-Amox-clav + (Macro or Doxy)
OR
-Cefproz/Cefurox + (Macro or Doxy)
OR
-Levo/Moxi (restrict use to more serious illness, treatment failure, serious B lactam allergy)
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18
Q

What is the treatment for a severe infection, requiring hospitalization? (IV)

A 
Levo/Moxi
OR
(Cefotax / Ceftriax) + Azithro
OR
(Cefotax / Ceftriax) + (Levo/Moxi)
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19
Q

What is the typical response for mild-moderate CAP in adults ?

A

Clinical improvement within 2-3 days, complete resolution in weeks

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20
Q

Duration of therapy for mild-moderate CAP in adults ?

A

5-7 days, based on clinical response and resolution

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21
Q

List risk factors for lower RTI’s

A
  • elderly
  • COPD
  • congestive heart failure
  • end-stage renal disease
  • diabetes
  • smoking
  • alcoholism
  • cerebrovascular or neurological disease
  • immunocompromised
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22
Q

What is PSI ?

A

Pneumonia severity index

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23
Q

What is CURB-65 (BTS)

A

new onset, confusion, plasma urea > 7.1, RR > 30, BP <90/<60 or age > 65 years

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24
Q

Describe the predicted mortality with CURB-65 (BTS) ?

A

< 3% with 0 or 1 point
9.2% with 2 points
15% with 3 points
>40% with 4-5 points

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25
Q

Monitoring:

Cough

A

Continuous monitoring, targeting absent or improved cough for 2-3/7+ days

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26
Q

Monitoring:

HR, RR, temp

A

BID monitoring, targeting normal, for 2-3 days

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27
Q

Monitoring:

WBC

A

Monitor every other day, targeting normal for 5-7 days

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28
Q

Monitoring:

Chest X-ray

A

Repeat if deterioration, targeting normal, for more than 6 weeks

29
Q

What is a plan for step-down antimicrobial therapy

A

1) clinical improvement, hemodynamically stable
2) afebrile x 24-48 hours
3) agent with appropriate spectrum, reliable bioavailability, adequate concentrations and good tolerability

30
Q

PO treatment for S. pneumoniae (Pen-S)

A

Amoxicillin

31
Q

Alternatives for PO treatment for S. pneumoniae (Pen-S)

A

Levo/moxi

Linezolid

32
Q

IV treatment for S. pneumoniae (Pen-S)

33
Q

Alternatives for IV treatment for S. pneumoniae (Pen-S)

A

Cefotax/Ceftriax
Vanco
Linezolid

34
Q

PO treatment for S. pneumoniae (Pen-IR)

35
Q

Alternatives for PO treatment for S. pneumoniae (Pen-IR)

36
Q

IV treatment for S. pneumoniae (Pen-IR)

A

HD Pen G 24 MU/d given q24h
OR
Cefotax/Ceftriax

37
Q

Alternatives for IV treatment for S. pneumoniae (Pen-IR)

A

Vanco

Linezolid

38
Q

PO treatment for S. pneumoniae (Pen-R)

39
Q

Alternatives for PO treatment for S. pneumoniae (Pen-R)

40
Q

IV treatment for S. pneumoniae (Pen-R)

A

Cefotax/Ceftriax

41
Q

Alternatives for IV treatment for S. pneumoniae (Pen-R)

A

Vanco

Linezolid

42
Q

PO treatment for H. influenza

A

Amox
or
Amox-clav

43
Q

Alternatives for PO treatment for H. influenza

A

Cefproz / Cefurox

FQs (Levo, Moxi, Cipro)

44
Q

IV treatment for H. influenza

A

Cefurox
or
Cefotax / Ceftriax

45
Q

Alternatives for IV treatment for H. influenza

A

FQs (Levo, Moxi, Cipro)

46
Q

Incidence of CAP in infants and children ?

A
  • 3-4 cases per 100 children < 5 years in developed countries
  • viral in 80% of preschool children (RSV, rhinovirus, human metapneumovirus, influenza)
  • S. pneumonia is most likely if bacterial in children of all age
  • reduced risk with routine immunization for S. pneumonia, H. flu, pertussis, and influenza
47
Q

1st line for treating CAP in infants and preschool children

A

Amox 90mg/kg/day given q8-12h

*uncertain need for high-dose in Canada

48
Q

Alternative for treating CAP in infants and preschool children in the case of a failure or had a previous B lactam in the last month (where you think there will be resistance)

49
Q

1st line for treating CAP in school age children and adolescents

A

Amox 90 mg/kg/day given q12h +/- Macro (for M. pneumoniae coverage)

50
Q

Alternatives for treating CAP in school age children and adolescents

A

Cefprozil / Cefuroxime axetil
Clindamycin 30-40 mg/kg/day given q8hr
Linezolid (PRSP coverage)

51
Q

Typical response of CAP in children

A

clinical improvement within 2-3 days

52
Q

Duration of therapy of CAP in children

A

10 days (most studied), although shorter course may be as effective

53
Q

To minimize resistance, use antimicrobials when ?

A
  • only when necessary and beneficial, targeted at known or suspected pathogen
  • in appropriate doses which optimize efficacy and minimize resistance
  • for shortest effective duration
54
Q

When should antiviral therapy be considered for treating CAP in infants and children ?

A
  • moderate-severe, particularly worsening disease consistent with influenza infection during widespread circulation
  • Amantadine has poor activity against influenza B and increasing resistance in influenza A
  • If indicated, neuraminidase inhibitors including Oseltamivir (Tamiflu) for children > 1 year old or Zanaminivir inhaler (Relenza) for children > 7 years old
  • Maximum benefit when initiated within 48 hours of onset of illness
  • Adverse effects include precaution for neuropsychiatric disturbances particularly in children
55
Q

HAP (hospital acquired pneumonia):

List the additional risk factors (to those for CAP) for HAP

A
  • hospitalization > 2 days particularly surgical and ICU patients, or hospitalization within previous 3 months
  • resident of long-term care facility
  • patients in dialysis or other hospital-based programs
  • aspiration due to immobility, supine position, ventilation (VAP), nasogastric tube
  • antacids or gastric acid suppression (ex. H2 blockers, PPI’s)
56
Q

HAP (hospital acquired pneumonia):

What are the most likely pathogens ?

A
  • S. pneumonia particularly if within 3 days of admission
  • S. aureus including MRSA
  • enteric GNB
  • non-enteric GNB
57
Q

Treatment for HAP that is early onset within 3 days of admission ?

A

Ceftriax / Cefotax

58
Q

Treatment for HAP > 3 days of admission or risk factors for resistant pathogens

A

Ceftaz + Vanco

Pip-tazo +/- Vancomycin (MRSA coverage)

Mero +/- Vanco (MRSA coverage)

59
Q

Alternatives for serious beta lactam allergy ?

A

Cipro/Levo + Vanco

AG + Vanco

60
Q

Alternatives for FQ-R ?

A

AG + Vanco

61
Q

What are some issues regarding antimicrobial activity in the lungs ?

A
  • blood-bronchus barrier penetration ex. physiochemical properties, protein binding
  • site of infection ex. inflammatory cells and other debris, low pH
  • optimal dosing based on PK-PD principles to optimize efficacy, minimize adverse effects and prevent resistance
62
Q

Treatment of HAP:

MSSA

A

Clox
or
Cefazolin

63
Q

Treatment of HAP:
MSSA

Alternative ?

A

Vancomycin or Linezolid

NOT DAPTO

64
Q

Treatment of HAP:

MRSA

A

Vancomycin

65
Q

Treatment of HAP:
MRSA

Alternative ?

66
Q

Treatment of HAP:

Enterobacteria (K. pneumonia, E. coli, Enterobacter species)

A

Cefotax / Ceftriax
or
Cipro / Levo / Moxi

67
Q

Treatment of HAP:
Enterobacteria (K. pneumonia, E. coli, Enterobacter species)

Alternative ?

A

Pip-tazo or Mero / Ertapenem

68
Q

Treatment of HAP:

P. aeruginosa

A

Ceftaz or pip-tazo or Meropenem

+/- Gent/Tobra or Cipro/Levo

69
Q

Duration of therapy for HAP

A

7 days based on patient, clinical status, pathogen and response to therapy

Clinical 2 - Antibiotics (14 decks)

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