Bugs/Drugs Flashcards
Name as many signs/sx of CAP as you can.
Fever/hypothermia Tachypnea Cough +/- sputum dyspnea chest discomfort sweats and or rigors tachypnea tachycardia O2 desaturation pleurisy hemoptysis fatigue Headache anorexia abdomen pain
Possible physical exam findings for CAP
Bronchial breath sounds, inspiratory crackles, dullness to percussion.
CXR findings for CAP
any of the following are possible:
Parenchymal opacity
patchy airspace opacities
lobar consolidation with air bronchograms
diffuse alveolar and interstitial opacities
CXR or CT required to establish diagnosis!
What is the best way to treat CAP
EMPIRICALLY - don’t wait for labs to come back, promptly initiate a drug, ideally one that the bug is susceptible to
When is diagnostic testing indicated?
Generally not, unless there is something funky in the history to make you suspect an atypical pneumonia or some other cause.
Diagnostic tests include sputum gram stain, urinary antigen tests (for S. pneumonia and legionella), and rapid antigen (influenza).
Patients who require hospitalization will require 2+ blood draws for culture from at least two sites.
How big a problem is CAP?
4-5 million cases per year, 25% of which require hospitalization.
Most deadly infectious disease, 8th leading cause of death!
What are the risk factors for CAP?
Advanced age Alcoholism Tobacco Use Comorbid Medical Conditions Immunosupression
Where/when does CAP occur?
Outside of the hospital/health care setting, or within 48 hours of admission.
What are two preventative measures for CAP?
Pneumococcal vaccine, flu shot
Empiric treatment for an outpatient CAP without recent antibiotic use?
Macrolide or doxy
Empiric treatment for an outpatient CAP with comorbid condition or recent antibiotic use?
Respiratory floroquinolone or macrolide + beta-lactam
Empiric therapy for an inpatient CAP who is NOT in the ICU
respiratory floroquinolone or macrolide+B-lactam
Empiric therapy for an inpatient CAP who IS in the ICU
Azithromycin or respiratory fluroquinolong +
antipneumococcal beta-lactam
Empiric therapy for an inpatient CAP who is in the ICU and at risk for pseudomonas?
Azithromycin or respiratory fluroquinolone
+antipneumococcal
+antipseudomal beta-lactam
+aminoglycoside
Empiric therapy for an inpatient CAP pt who is at risk for MRSA
Azithromycin or respiratory fluroquinolone
+vancomycin
How does HAP differ from CAP?
- Different infectious causes
- Different antibiotic susceptibility and increased resistance
- Patient’s underlying health status puts them more at risk
Risk factors for nosocomial pneumonia
malnutrition, advanced age, altered consciousness, swallowing disorder, underlying disease
When does HAP occur?
48 hours after admission to the hospital or other health care facility, excludes any infection present at the time of admission.
When does HCAP occur?
It occurs in community members whose extensive contact with healthcare has changed their risk for organisms.
What must be present for a diagnosis of nosocomial pneumonia?
1) At least two of the following:
- fever
- leukocytosis
- purulent sputum
2) New or progressive opacity on CXR
How common in nosocomial pneumonia?
Very common in patients requireing ICU or ventiliation.
HAP=2nd most common cause of infection and leading cause of death due to infection, with a 20-50% mortality rate
How is nosocomial pneumonia treated?
EMPIRICALLY. You can always decelerate when the labs come back if necessary!
What labs should be done for a person with suspected nosocomial pneumonia?
- Blood cultures from 2 different sites
- ABG to determine severity and need for ventilator
- thoracentesis if a pleural effusion is present
- sputum gram stain
What is the treatment for nosocomial pneumonia when there is a low risk of resistance?
One of the following:
- Ceftriaxone
- Respiratory floroquinolone
- Ampicillin-sulbactam
- Piperacillin-tazobactam
- Ertapenem
What is the treatment for nosocomial pneumonia when there is a high risk of resistance?
ONE OF EACH:
1) Antipseudomonal (Cefipine, piperacillin)
2) 2nd antipseudomonal (levofloxacin, gentamicin)
3) Coverage for MRSA (vanco, linezolid)
Most common causes of CAP in outpatient setting?
- S. pneumoniae (2/3!) –> Macrolide or doxy
- M. pneumoniae –> macrolide or doxy
- C. pneumoniae –> macrolide or doxy
What are the most common causes of CAP in an ICU setting?
- S. pneumo
- Legionella
- H. flu
- Enterobacae
- S. aureus
- Pseudomonas
treat with azithromycin and a respiratory fluroquinolone
What are the most common causes of CAP in a hospitalized patient?
- S. pneumoniae (respiratory fluoroquinolone -or- macrolide+beta lactam
- M. Pneumoniae (respiratory fluoroquinolone -or- macrolide+beta lactam
- C. pneumoniae ((respiratory fluoroquinolone -or- macrolide+beta lactam)
- H. flue (respiratory fluoroquinolone -or- macrolide+beta lactam
- Legionella (respiratory fluoroquinolone -or- macrolide+beta lactam
What are the main causes of HAP?
- S. aureus (MSSA and MRSA)
- P. aeruginosa
- Gram - rods
What are the main causes of VAP
- Much like HAP! Staph, pseudomonas, gram - rods
- Acinetobacer
- stentophomas maltophila
What are the main causes of HCAP?
- Strep penumo
- H. flu
- Similar to HAP (staph, pseudomonas, gram - rods)
What are the atypical pneumonas and how are they treated?
M. pneumonia (clarithromycin, azithromycin, doxy)
C. pneumonia (doxy)
P. jiroveci (TMP-SMX)
Legionella (?)
Typical or atypical? Treatment? S. pneumoniae
Typical - amoxicillin, PCN, or cephalosporin
Typical or atypical? Treatment? H. influenza
Typical - TMP-SMX
Typical or atypical? Treatment? S. aureus
Typical. MSSA=nafcillin, MRSA = vanco
K. pneumonia - Typical or atypical? Treatment?
Typical. Cephalosporin.
E. coli - Typical or atypical? Treatment?
Typical. Cefotaxime, ceftriaxone
P. aeruginosa - Typical or atypical? Treatment?
Typical. Piperacillin-tazobactam or ceftazidime or cefepime, imipenem or meropenem or doripenem +/- aminoglycosides
M. catarrhalis - Typical or atypical? Treatment?
Typical. cefuroxime, fluroquinolone
common macrolides
clarithromycin, azithromycin
common beta-lactam
cefotaxime, ceftriaxone, ampicilli
