Bacterial Infections of the Lung- Sweatman

Question 1

Most important factor in successful treatment of pneumonia?

Answer 1

Early intervention

Question 2

What are you thinking in a patient with pneumonia symptoms and an unproductive cough?

Answer 2

Mycoplasma or viral pneumonia

Question 3

What are the respiratory quinolones?

Answer 3

Levofloxacin, ciprofloxacin, and moxifloxacin

Question 4

Macrolides commonly used in respiratory infections?

Answer 4

Erythromycin, Azithromycin

Question 5

Risk factors for contracting Leginonnaires Disease?

Answer 5

1) Male sex and >50 years of age
2) Smokers or those with chronic lung disease
3) Immunocompromised

Question 6

Possible abx for HAP (6)?

Answer 6

1) Imipenem/Cilistatin
2) Meropenem (alternate for Imipenem)
3) Aztreonam
4) Piperacillin/Tazobactam (alt)
5) Ceftazidime
6) Cefepime (alt)

all these offer coverage against Gram(-) anaerboes; most likely Pseudomonas or Haemophilus

Question 7

When is vancomycin used to treat HAP?

Answer 7

MRSA

Question 8

Antibiotics recommended for aspirational pneumonia?

Answer 8

Clindamycin or Ampicillin/Sulbactam; coverage for gram negative anaerobes

Question 9

Unique toxicities of Azithromycin?

Answer 9

Cholestatic jaundice; QT prolongation

Question 10

Unique toxicities of Doxycycline?

Answer 10

Teeth discoloration; photosensitivity; retards bone growth

Question 11

Unique toxicities of Erythromycin?

Answer 11

CYP3A4/Pgp Inhibitor; cholestatic jaundice; QT prolongation

Question 12

Unique toxicities of Gentamicin?

Answer 12

Nephrotoxic and ototoxic; neuromuscular paralysis

Question 13

Unique toxicity of Imipenem?

Answer 13

Seizures

Question 14

Unique toxicities of Levofloxacin?

Answer 14

Tendon rupture (adults); cartilage damage (children)

Question 15

Unique toxicities of Linezolid?

Answer 15

Bone marrow suppression; non-specific MAO inhibitor

Question 16

Unique toxicities of Vancomycin?

Answer 16

Nephrotoxicity and ototoxicity; Red Man’s Syndrome (erythematous rash over face, neck, and upper torso after infusion –> mast cell degranulation)

Question 17

Daptomycin is not used to treat pneumonia despite having great activity against Gram(+), better than vanc. Why?

Answer 17

Because it is directly inactivated by pulmonary surfactant

Question 18

Indicated treatment of bronchitis (no resistance)?

Answer 18

Amoxicillin+Clavulanic Acid; Azithromycin; Clarithromycin; Doxycycline

Question 19

Indicated treatment for bronchitis with resistance?

Answer 19

Ciprofloxacin

Question 20

Indicated treatment for Lung Abscesses?

Answer 20

Clindamycin (covers PCN-resistant bacteriodes); Metronidazole + Ceftriaxone (Nosocomial infections); metronidazole should not be used alone due to incomplete coverage

Question 21

What is the most common cause of CAP pneumonia in pts age 40+

Answer 21

Strep pneumo

Question 22

what is the most common cause of CAP pneumonia in adolescents

Answer 22

Mycoplasma p

Question 23

what is the most common cause of CAP pneumonia in pts 0-6 weeks old

Answer 23

Group B streptococci

Question 24

What are the most likely organisms involved in nosocomial pneumonia

Answer 24

S. aureus, P. aeuruginosa

Question 25

If you see an alcoholic or a diabetic, what kind of pneumonia are you thinking?

Answer 25

Klebsiella

Question 26

why are chronic alcohol users at risk for severe CAP?

Answer 26

they have decreased saliva production, an important component of mucosal defense

Question 27

why do diabetics face a higher risk for influenza and its complications?

Answer 27

possibly b/c diabetes neutralizes the effects of protective proteins on the surface of the lungs

Question 28

what is the only drug on label for the treatment of legionella?

Answer 28

erythromycin - 1st gen macrolide

Question 29

what are the Abx most commonly used by physicians for the tx of Legionella (the technically not labeled ones)

Answer 29

a newer macrolide - azithromycin (3rd gen) | "respiratory" quinolones - levofloxacin, cirpofloxacin, moxifloxacin

Question 30

what is the advantage of using newer macrolides or respiratory quinolones in the tx of Legionellas?

Answer 30

these drugs have good dosing characteristics and the advantage of easily achieving good concentrations in pulmonary tissues

Question 31

for a severly ill pt w/ Legionellas, what drug can you add in in combination? what is a potential problem?

Answer 31

Rifampin | potential for drug-drug interactions (CYP) of rifampin and macrolide w/ pt concurrent drugs is constant problem

Question 32

decision tree for drug selection in the tx of CAP - if you have an outpatient with no modifying factors - what drugs?

Answer 32

macrolide or doxycyline

Question 33

decision tree for drug selection in the tx of CAP - if you have an outpatient with COPD, what drug history do you need to obtain before proceeding with treatment?

Answer 33

steroid or Abx in the past 3 months

Question 34

decision tree for drug selection in the tx of CAP - outpt w/ COPD who has not been on steroid or Abx in past 3 months - what drugs can you use?

Answer 34

2nd gen macrolide (clarithromycin) or doxycycline

Question 35

decision tree for drug selection in the tx of CAP - outpt w/ COPD who has a history of steroid or abx in past 3 months - what drugs

Answer 35

Fluoroquinolone; amox/clav; 2nd gen macrolide +- cephalosporin

Question 36

decision tree for drug selection in the tx of CAP - if you are treating a nursing home pt, what drugs?

Answer 36

Fluoroquinolone; amox/clav; 2nd gen macrolide +- cephalosporin

Question 37

decision tree for drug selection in the tx of CAP - treating a pt on the hospital ward - what drugs

Answer 37

Fluoroquinolone; amox/clav; 2nd or 3rd generation macrolide +- cephalosporin

Question 38

decision tree for drug selection in the tx of CAP - pt in the ICU - what drugs

Answer 38

3rd gen Cephalosporin +- macrolide; piperacillin/tazobactam; fluoroquinolone

Question 39

decision tree for drug selection in the tx of CAP - pt in the ICU that is at risk of P aeruginosa - what drugs

Answer 39

1) antipseudomonal fluoroquinolone (cipro) + B-lactam (ceftazadime, meropenem, or piperacillin/tazobactam) 2) macrolide + 2 antipseudomonal agents (aminoglycosides + ceftazadime, cefepime, meropenem, or pip/taz) aminoglycoside = gentamicin

Question 40

What are the 1st, 2nd, and 3rd gen macrolides?

Answer 40

1st - erythromycin 2nd - clarithromycin 3rd - azithromycin (go in descending order alphabetically)

Question 41

what is the MOA of macrolides?

Answer 41

50s ribosomal inhibitor blocking translocation

Question 42

what is an example of a tetracyline and their MOA?

Answer 42

Doxycyline | 30s ribosomal inhibitor blocking protein synthesis

Question 43

what is the most commonly used Fluoroquinolone and the MOA?

Answer 43

Levofloxacin | DNA gyrase inhibitor preventing DNA replication

Question 44

what are the two most commonly used Penicillins and the MOA?

Answer 44

Amoxicillin+ Clav Pip/Taz block cell wall cross-linking

Question 45

what is the most commonly used carbopenem and the MOA

Answer 45

Meropenem | blocks cell wall cross-linking

Question 46

what are the 1st, 2nd, 3rd gen cephalosporins most commonly used? what are the 3rd gen cephs w/ antipseudomonal activity?

Answer 46

1st - cefazolin 2nd - cefuroxime 3rd - ceftriaxone (tri) 3rd w/ antipsuedo - ceftazadime or cefepime

Question 47

MOA of cephalosporins?

Answer 47

inhibition of cell wall cross-linking

Question 48

the most common aminoglycoside and MOA

Answer 48

Gentamicin | 30s ribosomal inhibitor

Question 49

what is the mechanism of resistance to macrolides?

Answer 49

ribosomal methylation and mutation of 23S rRNA | active efflux

Question 50

what is the mechanism of resistance to tetracyclines

Answer 50

decreased entry into and increased efflux from | target insensitivity

Question 51

what is the mech of resistance to fluoroquinolones

Answer 51

mutation of DNA gyrase | active efflux

Question 52

what is the mech of resistance to penicillins?

Answer 52

``` drug inactivation (B-lactamase) altered PBPs (target insensitivity) ```

Question 53

what is the mech of resistance to cephalosporins?

Answer 53

decreased permeability of gram -ve outer membrane (altered porins) active efflux

Question 54

what is the mech of resistance to aminoglycosides?

Answer 54

drug inactivation (aminoglycoside modifying enzyme) decreased permeability of gram -ve outer membrane active efflux ribosomal methylation

Question 55

what is the MOA of clindamycin

Answer 55

50S ribosomal inhibitor blocking translocation

Question 56

what is the mech of resistance towards clindamycin?

Answer 56

methylation of binding site, enzymatic inactivation

Question 57

what is the MOA of vancomycin?

Answer 57

binds D-alanyl-D-alanine terminus of the peptide precursor units, inhibiting peptidoglycan polymerase and transpeptidation reactions

Question 58

what is the mech of resistance towards vanc?

Answer 58

replacement of D-ala by D-lactate

Question 59

why is cefepime considered to be a 4th generation cephalosporin?

Answer 59

it retains activity against some microbes that demonstrate resistance to ceftazidime

Question 60

what are the 6 abx that do not need a dose adjustment for the renally impaired? in other words, what 6 Abx are not excreted solely by the renal route?

Answer 60

``` Azithromycin Ceftriaxone Clindamycin Doxycyline Erythromycin Linezolid ```

Question 61

if a pt shows a prior allergic rxn to penicillin, what other drug classes should you be weary of? why?

Answer 61

cephalosporins carbapenems they all contain a B lactam ring - cross reactivity

Question 62

What 4 abx do you need to use caution/avoid in a breastfeeding mother?

Answer 62

Piperacillin Metronidazole (avoid) Clarithromycin Linezolid "Pregnant Mothers Cannot Lactate" or some other shitty mnemonic that helps you remember this fucking shit

Question 63

What are the 4 combination drug products for abx? | what is the rationale?

Answer 63

1) Amox/Clav 2) Pip/Tazobactam 3) Ampicillin/Sulbactam 4) Imipenem/Cilastin none of the additives possesses any antimicrobial activity, rather these are metabolic inhibitors that preserve the lifespan of the drug and therefore its activity

Question 64

what 2 drugs are an appropriate 1st choice for CAP? what is another option?

Answer 64

1) macrolide (azithromycin) 2) respiratory quinolone (levofloxacin) 3) Amox/clav

Question 65

what should treatment for abscess and spiration pneumonia cover?

Answer 65

oral anaerobes