Bacterial Infections of the Lung Flashcards
What is the most important aspect of treatment of someone with suspected pneumonia?
Treat EARLY - do NOT wait on blood/sputum cultures to come back before you start treating the patient
How should you begin treating someone’s pneumonia?
• BROAD empiric agents are important
What classifies Community Acquired Pneumonia?
- Less than 60 y/o
- Over 60 y/o without coexisting illness
- Severe or Rapidly progressing nursing home patient
T or F: nosocomial pneumonia can be ventilator of non-ventilator associated.
True
If someone with diabetes gets pneumonia, what category does their case fall into?
Pneumonia in immunocompromised Host
• This is the same category as people with HIV/AIDS, Hypogammaglubulinemia, transplant pts, Chemotherapy pts.
What are the most common causes of pneumonia for someone 0-6 wks?
• 6 wks - 18y/o?
0-6 wks
• Group B streptococci
• E. Coli
6 wks - 18 y/o • Viruses (Flu, RSV, Adeno, Rhino • Myoplasma Pneumoniae • Chlamydia Pneumoniae • Steptococcus Pneumoniae
What are the most common causes of pneumonia for someone 18-40 y/o?
• 45-65 y/o?
18-40 y/o:
• Mycoplasma Pneumoniae
• Streptococcus Pneumoniae
40-65 y/o: • Steptococcus Pneumoniae • H. Influenzae • Anaerobes • Viruses (Flu, RSV, Adeno, Rhino • Mycoplasma pneumoniae
What are the most common causes of pneumonia for someone over 65 y/o?
over 65 y/o: • Steptococcus pneumoniae • Viruses (Flu, RSV, Adeno, Rhino) • Anaerobes • H. Influenzae • Gram + rods
What are the most common causes of nosocomial pneumonia?
S. Aureus
P. Aeruginosa
What kind of pneumonia is most common in diabetics?
• what other group is subject to getting this?
• why are these people more susceptible to getting pneumonia?
Klebsiella pneumoniae
Diabetics:
• Neutralization of protective proteins on the surface of the lungs
Alcoholics:
• EtOH inhibits mucous production that is needed to prevent infection
What are some opportunistic pathogens that cause pneumonia in the immunocompromised?
- CMV
- Aspergillus
- Pneumocystis
- Norcardia asteroides
What is the protocol for protecting people with diabetes against pneumonia?
- Pneumococcal Vaccines
* Flu Vaccination
Legionella • gram staining characteristics? • environment? • Who do we see this in? • How do we treat it? • What about severely ill pts?
- Gram -
- aerobe
Legionella:
• Most common in men, usually over 50
• Smokers or chronic lung disease
• Immunocompromised patients
Treatment:
Macrolides - Azithromycin or Clarithromycin
Repiratory Quinolones - Levofloxacin, Ciprofloxacin or Moxifloxacin
Severe Tx:
• Add rifampin, but watch out for CYP interactions with Rif + Macrolides
What are the 7 most commonly used drugs in the treatment of Community Aquired Pneumonia?
- Macrolides (MYCINs)
- Tetracyclines (CYCLINEs)
- Fluroquinolones (FLOXACINs)
- Penicillins (CILLINs)
- Carbopenem
- Cephalosporins (CEFs or CEPHs)
- Aminoglycosides (mIcins)
FOR REVIEW OF ANTIMICROBIALS LOOK AT CMOD PHARM BLOCK 1 DECK.
FOR REVIEW OF ANTIMICROBIALS LOOK AT CMOD PHARM BLOCK 1 DECK.
An outpatient with COPD comes in complaining of sudden onset fever and persistent productive cough. On physical exam you notice increased tactile fremitus and dullness to percussion. You note on his chart that he visited 2 months prior with a similar presentation and was given an antibiotic prescription.
- How should you initiate treatment?
- Explain why you chose this Tx.
- what other patient would be treated identically?
• Patient Likely has CAP
Factors Complicating Tx:
- Has been treated for with ABX in the last 3 months (could have also been corticosteroids that complicated the case)
- COPD
Tx:
•Fluroquinolones (FLOXACIN) OR…
• Amox/Clav OR…
• 2nd gen Macrolide (MYCIN) (clarithromycin) ± Cephalolsporin (CEFs or CEPHs)
Other:
• NURSING HOME PATIENTS would be treated the same way as this person
You are seeing a 50 year old woman as an in patient at Regional One who has acquired pneumonia during her hospital stay.
- How should you initiate treatment?
- Explain why you chose this Tx.
- what other patient would be treated identically?
Factors Complicating Tx:
• Hospital Ward
Tx:
•Fluroquinolones (FLOXACIN) OR…
• Amox/Clav OR…
• 3rd gen Macrolide (MYCIN) (Azithromycin) ± Cephalolsporin (CEFs or CEPHs)
Other:
same as COPD + ABX or Steroids and as Nursing Home except you use 3rd Gen. Macrolides
An otherwise healthy 25 year old male visits your outpatient clinic. He complains of sudden onset fever, cough, difficulty breathing, and Egophany is heard on pulmonary exam.
- How should you initiate treatment?
- Explain why you chose this Tx.
- what other patient would be treated identically?
Factors Complicating Tx:
• Nothing
Tx:
• Macrolide (Erythromycin, Clarithromycin, Azithromycin) OR…
•Doxycycline
Other:
• Similar to outpatient with COPD and no other complicating factors except with COPD you need to use a 2nd generation macrolide (MYCIN)
A patient has been intubated for 3 days in the ICU and now has a fruity smelling blue-green flim coming from his lungs. The attending suspects that the patient has pneumonia.
- What pathogen should you suspect?
- How should you initiate Treatment?
- Explain why you chose this Tx.
Factors Complicating Tx:
• ICU
• P. aeruginosa suspected
Tx:
• Antipseudomonal Fluroquinolone (like Cipro) + ß-lactam (Ceftazidine, meropenum, Pip/Tazo) OR..
• Macrolide + 2 antipseudomonal agents (aminoglycocide + ceftazidine, Cefepine, meropenum, or Pip/Tazo)
A patient in the ICU has a suspected case of pneumonia.
- How should you initiate Treatment?
- Explain why you chose this Tx.
Factors Complicating Tx:
• ICU
• No reason to suspect pseudomonas yet..
Tx:
•3rd Generation cephalosporin ± Macrolide OR…
• Pip/Tazo OR…
• Fluroquinolone
A woman in a nursing home comes to your office with a a suspected case of pneumonia.
- How should you initiate Tx?
- Explain.
Factors Complicating Tx:
• Nursing Home
Tx:
• 2nd Generation Macrolide (clarithromycin) ± Cephalosporin
Other:
•COPD pts. that have had ABX or steroids in last 3 months should be treated the same way
What are the 2 main species you want to protect against when you are looking to treat a nosocomial pneumonia?
• staining characterisitics?
• why are these the bugs usually seen in nosocomial pneumonia?
Species:
• H. influenzae
• Pseudomonas aeruginosa
WHY THESE?
• Loss of Fibronectin shifts the pathogen profile to include gram - bacilli
A patient acquires what appears to be a pneumonia while at a prolongued stay in the hospital, however no etiologic agent can be established.
• what is the problem here?
Problem:
• No Etiologic agent can be established in 50% of cases of nosocomial pneumonia
What at the 1st line drugs in cases of nosocomial pneumonia?
• what are their alternatives?
Imipenem/Cilastin = Alt => Meropenum
Aztreonam = Alt => Piperacillin/Tazobactam
Ceftazidime = Alt => Cefepime
Vancomycin —> MRSA
An alcoholic comes in with a case of pneumonia.
• why do they have pneumonia?
• How do you treat it? Alternative?
How:
• this is Aspiration pneuomonia
Tx:
• Clindamycin = Alt => Ampicilin/sulbactam
Why is it easy to move a patient from parenteral fluroquinolones to oral fluroquinolones?
• The FLOXACINS have high oral bioavailability
What are some reasons to not give a patient oral drugs for their pneumonia in spite of the infection being mild?
- HYPOTENSION - blood will be directed away from the GI tract
- Chelating agents or Food in GI tract
- Lack of Adherance
In what drugs is the time spend above the MIC the most important?
• what does this mean for the dosing interval?
ß-lactams
• Penicillins
• Cephalosporins
• Carbapenems
=> You’ll want small dosing intervals to keep serum concentrations above the MIC
In what drugs is the 24 hour area over the curve/MIC the most important?
- Aminoglycosides
- Fluoroquinolones
- Tetracyclines
- Vancomycin
- Macrolides
- Clindamycin
=> You can do wide dosing intervals
In what drugs is Peak concentration/MIC the most important?
• what does this mean for your dosing interval?
- Aminoglycosides
- Fluroquinolones
=> if these drugs are toxic this reduces the time that toxic levels are achieved in the serum while reducing the bacterial load
Name 6 drugs that would be acceptable to use in a patient with reduced renal function that have pneumonia.
• how are each of these drugs eliminated?
Macrolides:
• Azithromycin - Biliary
• Clindamycin - Renal/Biliary
• Erthromycin - Biliary
ß-lactamase:
• Ceftriaxone - Renal/Biliary
Tetracycline:
• Doxycycline - Biliary
Other:
• Linezolid - Metabolism
A 12 year old patient presents with bronchitis. What antibiotic is most appropriate?
NO antibiotic would be likely to work because younger patients usually contract VIRAL bronchitis
A 68 year old man who smokes 2 packs a day presents with bronchitis. What is the most likely etiology?
• what are your treatment options?
• What drugs would you want to use if the infection progressed in severity?
H. Influenzae
Tx: • Amoxi/Clav = alt => Ciprofloxacin • Azithromycin • Clarithromycin • Doxycycline
• Doxyclyline and Ciprofloxacin are your go-to’s if the infection continues to progress
What are the most likely causes of bronchitis in elderly patients?
Elderly Bronchitis: • Mycoplasma pneumoniae • Streptococcus pneumoniae • Haemophilus Influenzae • Moraxella Catarrhalis • Bordetella Pertussis
A patient develops a lung abscess after a 2 week hospital stay. What type of bacteria is likely the cause?
• how would you treat it?
Nosocomial
• probably a GRAM - bacilli - anaerobe
Tx:
• Metronidazole + Ceftriaxone
How would you treat a community acquired lung abscess?
Community Aquired
• Probably a gram + cocci - anaerobe
Tx:
• Clindamycin (better than penicillin for bacteroides species)
T or F: anerobes are typically responsible for lung abscesses
True - these organisms clearly don’t need air to live
*Treatment for aspiration and abscess should always include coverage for anaerobes
