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Year 3 - Clinical > 9 - LRTI (Pneumonia) > Flashcards

9 - LRTI (Pneumonia) Flashcards

1
Q

What are the clinical signs and symptoms of pneumonia?

A
  • Acute respiratory and systemic signs and sx; infection and inflammation of pulmonary parenchyma
  • Cough, sputum production, crackles, consolidation, tachypnea > 24, dyspnea, hypoxia, hemoptysis, pleural pain
  • Fever, chills, tachycardia > 100, leukocytosis
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2
Q

How is community-acquired pneumonia diagnosed?

A
  • Clinical signs and sx

- Lung infiltrate on x-ray

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3
Q

Why is the culture yield of sputum poor? What can be done to improve this?

A
  • B/c of poor quality sampling and fastidious or slow-growing pathogens
  • Improved yield in endothelial lining fluid (ELF) obtained by bronchoalveolar lavage (BAL)
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4
Q

What are the most common pathogens associated w/ CAP and pathogen-specific risk factors?

A
  • Viral predisposes to secondary bacterial pneumonia
  • Strep pneumonia - COPD, CV or renal disease, asplenic, diabetes, immunocompromised
  • Mycoplasma pneumoniae - adolescents, young and elderly adults
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5
Q

What are some less common pathogens associated w/ CAP and pathogen-specific risk factors?

A
  • Gram neg bacilli (H. influenzae, moraxella catarrhalis) – COPD, smoking; (klebisella pneumoniae, E. coli, enterobacter) – COPD, smoking, diabetes, alcoholism
  • P. aeruginosa – cystic fibrosis, COPD, immunocompromised
  • Staph aureus
  • Anaerobes - aspiration, neurological disease
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6
Q

Do meropenem and amox-clav have coverage against mycoplasma?

A

No, b/c these drugs work against the cell wall, which mycoplasma don’t have; so drugs that work against ribosomes will have coverage over mycoplasma

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7
Q

What are some characteristics of pneumonia associated w/ mycoplasma pneumoniae?

A
  • Peak incidence in older children, adolescents, young adults, and elderly
  • Incubation 2-3 weeks, associated w/ pharyngitis, tracheobronchitis, pneumonia
  • Serology using IgM enzyme immunoassay; respiratory sample PCR
  • Gradual onset fever, headache, GI sx, malaise, arthralgia, myalgia, rash, cardiac syndromes for 1-2 weeks, followed by non-productive cough for 3-4 weeks
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8
Q

What are some characteristics of pneumonia associated w/ legionella pneumophila?

A
  • Ubiquitous in water and soil, outbreaks and sporadic cases w/ peak from June to Octboer, associated w/ air ventilation systems
  • Rapidly progressive pneumonia w/ multi-system involvement including fever, malaise, arthralgia, pleuritic pain, CNS & GI sx
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9
Q

What are the considerations for antimicrobial therapy in CAP?

A
  • Suspected pathogens and risk for resistance
  • Severity of illness; co-morbidities influencing likelihood of pathogen or clinical response
  • Availability, formulary, cost
  • Potential CI’s, drug interactions & adverse effects
  • Appropriate dose (weight, renal and hepatic function)
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10
Q

Antimicrobial options for empirical tx of ambulatory, mild-moderate CAP? Is it given PO or IV?

A
  • PO
  • Amox (+/- macro or doxy) for moderate illness, or if not improving w/in 3 days of amox therapy
  • Macrolide (concerns regarding resistance)
  • Doxy (less clinical data than alternatives)
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11
Q

Antimicrobial options for empirical tx of ambulatory, mild-moderate CAP w/ risk factors for resistance or poor prognosis? Is it given PO or IV?

A
  • PO
  • Amox-clav (+/- macro or doxy) - add if not improving w/in 3 days or initial therapy
  • Cefprozil/ cefuroxime (+/- macro or doxy)
  • Levo/ moxi - restrict to more severe illness, tx failure, or serious beta-lactam allergy
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12
Q

Antimicrobial options for empirical tx of severe CAP? Is it given po or IV?

A
  • IV
  • Levo/ moxi
  • Cefotaxime/ ceftriaxone + azithromycin
  • Cefotaxime/ ceftriaxone + levo/ moxi – seriously ill, ICU admission
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13
Q

Adult dosing of amoxicillin for CAP

A

1 g q8h (high dose)

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14
Q

Adult dosing of amox-clav for CAP

A

500/125 mg q8h or 875/125 mg q12h

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15
Q

Adult dosing of macrolides for CAP

A
  • Erythromycin 500 mg q6h
  • Clarithromycin 500 mg q12h or 1 g ER q24h
  • Azithromycin normal dosing
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16
Q

Adult dosing of doxycycline for CAP

A

100 mg PO q12h

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17
Q

Adult dosing of cefprozil or cefuroxime for CAP

A

500 mg q12h

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18
Q

Adult dosing of ceftriaxone or cefotaxime for CAP

A
  • Ceftriaxone = 1 g q24h

- Cefotaxime = 1-2 g q8h

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19
Q

Adult dosing of fluoroquinolones for CAP

A
  • Levo = 500-750 mg q24h

- Moxi = 400 mg q24h

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20
Q

What is the typical response for antimicrobial tx of CAP?

A
  • Clinical improvement w/in 2-3 days

- Complete resolution in 10-14 days

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21
Q

What is the duration of tx for CAP?

A

5-7 days based on clinical response and resolution

22
Q

What are some risk factors for LRTI?

A
  • Elderly
  • COPD, congestive heart failure, end-stage renal disease, diabetes
  • Smoking, alcoholism
  • Cerebrovascular or neurological disease, immunocompromised
23
Q

What are the severity scores of LRTIs?

A
  • PSI (pneumonia severity index)
  • CURB-65 – new onset confusion, plasma urea > 7.1 mmol/L, RR > 30, BP < 90/60, or age > 65 years
  • Score of 3 or higher = should be admitted to hospital and treated IV
24
Q

What are the monitoring parameters for treating pneumonia?

A
  • Cough = improved or absent w/in 2-7 days
  • HR, RR, and temp = normal w/in 2-3 days
  • WBC = normal w/in 5-7 days
  • Chest x-ray = repeat if deterioration; normal in over 6 weeks
25
Q

What should be considered for PO step-down antimicrobial therapy for pneumonia?

A
  • Clinical improvement and hemodynamically stable
  • Afebrile x 24-48 h
  • Agent w/ appropriate spectrum, reliable bioavailability, adequate concentrations, and good tolerability
26
Q

Antimicrobial options for pathogen-directed tx for S. pneumoniae CAP?

A
  • PO = amox [levo/ moxi or linezolid]
  • IV = Pen G [cefotax/ ceftriax or vanco]
  • Combination IV therapy w/ beta-lactam plus macrolide or aminoglycoside suggested for moderate-severe pneumococcal pneumonia
27
Q

Antimicrobial options for pathogen-directed tx for M. pneumoniae CAP?

A

PO/IV = macrolide, doxycycline, or levo/ moxi

28
Q

Antimicrobial options for pathogen-directed tx for H. influenzae CAP?

A
  • PO = amox or amox-clav [cefprozil/ cefuroxime or levo/ moxi/ cipro]
  • IV = cefuroxime or cefotaxime/ ceftriaxone [levo/ moxi/ cipro]
29
Q

What do macrolides inhibit?

A

CYP 3A4 and the enzyme P-gP

30
Q

Interaction of macrolides w/ statins

A

Lovastatin and simvastatin are absolutely contraindicated w/ azithro and clarithro

31
Q

Interaction of macrolides w/ cyclosporine

A
  • Interaction is variable from pt to pt
  • Tacrolimus more susceptible to interaction than cyclosporine
  • CI
32
Q

Interaction of macrolides w/ lorazepam

A
  • Not affected by clarithro
  • Medazolam or triazolam are affected by clarithro
  • CI
33
Q

Interaction of macrolides w/ diltiazem

A
  • Applies to all calcium channel blockers
  • Significant interaction w/ clarithro (increases levels of CCB => hypotension and bradycardia)
  • CI
34
Q

Interaction of macrolides w/ warfarin

A
  • Broad spectrum antibiotics get rid of gut flora which produce vitamin K, so vitamin K is reduced
  • Recommendation to monitor warfarin
35
Q

Interaction of macrolides w/ digoxin

A

Absorption can be increased by antibiotic b/c antibiotics inhibit P-gP

36
Q

Interaction of macrolides w/ colchicine

A
  • Increases absorption b/c of inhibition of CYP 3A4 and P-gP
  • Life-threatening b/c is an anti-mitotic drug, so toxicity will cause WBC to dramatically decrease
  • Azithro has about 1/4 of the effect of clarithro
  • CI
37
Q

Interaction of quinolone w/ insulin

A

Quinolones have metabolic effect on glucose, so can cause hypo or hyperglycemia

38
Q

Interaction of quinolone w/ Maalox (Al, Mg, Fe, sucralfate)?

A
  • Affects absorption
  • Most prevalent w/ cipro than levo/ moxi
  • Calcium tends to be less affected
39
Q

What effect does quinolones have on the heart?

A
  • Variable QT prolongation (moxi > levo/ cipro) => can cause Torsade de Pointes, ventricular arrhythmias, or sudden death
  • More often in px w/ pre-existing QT prolongation, underlying pro-arrhythmic conditions, class 3 anti-arrhythmics, tricyclic antidepressants, anti-psychotics, and other antibiotics
40
Q

What are some risk factors for nosocomial pneumonia (hospital acquired)?

A
  • Hospitalization > 3 days, surgery, ICU admission (mechanical ventilation)
  • Risk factors for aspiration (immobility, supine positioning, NG tubes)
  • Antacids or gastric acid suppression w/ H2 antagonists or PPIs
41
Q

What are the most likely pathogens in NP?

A
  • Strep pneumoniae (particularly w/in 3 days of admission)
  • Staph aureus including MRSA
  • K. pneumoniae, E. coli, enterobacter spp
  • P. aeruginosa, acinetobacter, stenotrophomonas maltophila
42
Q

What is the difference between nosocomial pathogens and pathogens that are community-acquired?

A
  • Nosocomial pathogens associated w/ higher rates of resistance leading to delays in appropriate therapy and worse prognosis
  • Nosocomial pathogens more common in px undergoing chronic dialysis, from long-term care facilities, or hospitalized w/in 3 months
43
Q

What are the antimicrobial options for NP that has early onset w/in 3 days of admission? Is it PO or IV?

A
  • IV
  • Ceftriaxone/ cefotaxime
  • [Levo/ moxi] – allergy
44
Q

What are the antimicrobial options for NP that occurred w/in 3 days of admission or has risk factors for resistant pathogens? Is it PO or IV?

A
  • IV
  • Ceftazadime + vanco (preferred choice b/c least broad)
  • Pip-tazo +/- vanco
  • Meropenem +/- vanco
  • [Cipro/ levo + vanco] - allergy
  • [AG + vanco] - allergy and FQ resistance
45
Q

What are the issues regarding antimicrobial activity in the lungs?

A
  • Blood-bronchus barrier penetration
  • Site of infection
  • Optimal dosing based on PK-PD to optimize efficacy, minimize adverse effects, and limit resistance
46
Q

What are the IV antimicrobial options for pathogen-directed MSSA NP?

A
  • Clox or cefazolin
  • [Vanco or linezolid]
  • Not dapto!
47
Q

What are the IV antimicrobial options for pathogen-directed MRSA NP?

A
  • Vancomycin

- [Linezolid]

48
Q

What are the IV antimicrobial options for pathogen-directed enterobacteria NP?

A
  • Cefotaxime/ ceftriaxone
  • Cipro/ levo/ moxi
  • [Pip-tazo or meropenem/ ertapenem] - as per susceptibilities
49
Q

What are the IV antimicrobial options for pathogen-directed P. aeruginosa NP?

A
  • Ceftazadime
  • Pip-tazo
  • Meropenem
  • +/- gent/ tobra or cipro/ levo
50
Q

What is the typical duration of therapy for HAP?

A

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

Year 3 - Clinical (30 decks)

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