9 - Lower RTI Flashcards by Sam Myers

Clinical signs and symptoms of pneumonia ?

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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Most likely pathogen for pneumonia ?

Streptococcus pneumoniae

- Mycoplasma pneumoniae

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

influenza
parainfluenza
adenovirus
coronavirus
rhinovirus
RSV

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S. pneumoniae is more common in ??

COPD
CV or renal disease
asplenic
diabetes
immunocompromised

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M. pneumoniae or Chlamydophila pneumoniae is more common in ?

adolescents

- young and elderly adults

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S. aureus common in ?

immunocompromised

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H. influenza, Moraxella catarrhalis common in ?

COPD, smokers

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Klebsiella pneumonia, E. coli, Enterobacter species in ?

COPD, smoking, diabetes, alcoholism

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P. aueroginosa common in ?

cystic fibrosis
COPD
corticosteroids
immunocompromised

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Anaerobes common in ?

aspiration
cerebrovascular/neurological disease
alcoholism

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How is CAP (community acquired pneumonia) diagnosed ?

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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Describe the characteristics of Mycoplasma pneumoniae

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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Describe the characteristics of Chlamydophila pneumoniae

young adults

- mild respiratory symptoms, fever, headache

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Describe the characteristics of Legionella pneumophilia

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

Fluoroquinolones
Macrolides
Tetracyclines

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

*no risk factors for resistance or poor outcomes

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

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

Levo/Moxi
OR
(Cefotax / Ceftriax) + Azithro
OR
(Cefotax / Ceftriax) + (Levo/Moxi)

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

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

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Duration of therapy for mild-moderate CAP in adults ?

5-7 days, based on clinical response and resolution

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List risk factors for lower RTI’s

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

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What is PSI ?

Pneumonia severity index

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What is CURB-65 (BTS)

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

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

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

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Monitoring: | Cough

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

Monitoring: | HR, RR, temp

BID monitoring, targeting normal, for 2-3 days

Monitoring: | WBC

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

Monitoring: | Chest X-ray

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

What is a plan for step-down antimicrobial therapy

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

PO treatment for S. pneumoniae (Pen-S)

Amoxicillin

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

Levo/moxi | Linezolid

IV treatment for S. pneumoniae (Pen-S)

Pen G

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

Cefotax/Ceftriax Vanco Linezolid

PO treatment for S. pneumoniae (Pen-IR)

Levo/Moxi

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

Linezolid

IV treatment for S. pneumoniae (Pen-IR)

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

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

Vanco | Linezolid

PO treatment for S. pneumoniae (Pen-R)

Levo/Moxi

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

Linezolid

IV treatment for S. pneumoniae (Pen-R)

Cefotax/Ceftriax

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

Vanco | Linezolid

PO treatment for H. influenza

Amox or Amox-clav

Alternatives for PO treatment for H. influenza

Cefproz / Cefurox | FQs (Levo, Moxi, Cipro)

IV treatment for H. influenza

Cefurox or Cefotax / Ceftriax

Alternatives for IV treatment for H. influenza

FQs (Levo, Moxi, Cipro)

Incidence of CAP in infants and children ?

- 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

1st line for treating CAP in infants and preschool children

Amox 90mg/kg/day given q8-12h *uncertain need for high-dose in Canada

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)

Amox-clav

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

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

Alternatives for treating CAP in school age children and adolescents

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

Typical response of CAP in children

clinical improvement within 2-3 days

Duration of therapy of CAP in children

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

To minimize resistance, use antimicrobials when ?

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

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

- 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

HAP (hospital acquired pneumonia): | List the additional risk factors (to those for CAP) for HAP

- 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)

HAP (hospital acquired pneumonia): | What are the most likely pathogens ?

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

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

Ceftriax / Cefotax

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

Ceftaz + Vanco Pip-tazo +/- Vancomycin (MRSA coverage) Mero +/- Vanco (MRSA coverage)

Alternatives for serious beta lactam allergy ?

Cipro/Levo + Vanco AG + Vanco

Alternatives for FQ-R ?

AG + Vanco

What are some issues regarding antimicrobial activity in the lungs ?

- 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

Treatment of HAP: | MSSA

Clox or Cefazolin

Treatment of HAP: MSSA Alternative ?

Vancomycin or Linezolid NOT DAPTO

Treatment of HAP: | MRSA

Vancomycin

Treatment of HAP: MRSA Alternative ?

Linezolid

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

Cefotax / Ceftriax or Cipro / Levo / Moxi

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

Pip-tazo or Mero / Ertapenem

Treatment of HAP: | P. aeruginosa

Ceftaz or pip-tazo or Meropenem +/- Gent/Tobra or Cipro/Levo

Duration of therapy for HAP

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