CAP

Question 1

systemic symptoms of pneumonia

Answer 1

fever, chills, malaise, myalgias, leukocytosis (high WBC count)

Question 2

pulmonary symptoms of pneumonia

Answer 2

cough, purulent sputum, pleuritic chest pain, SOB/dyspnea

Question 3

physical exam findings of pneumonia

Answer 3

tachypnea, tachycardia, decreased or coarse breath sounds, crackles on inspiration

Question 4

most common gram + bacterial pathogens that cause CAP

Answer 4

strep. pneumoniae, staph. aureus

Question 5

most common gram - bacterial pathogens that cause CAP

Answer 5

h. influenzae, m. catarrhalis

Question 6

most common atypical bacterial pathogens that cause CAP

Answer 6

legionella, chlamyophilia pneumoniae, mycoplasma pneumoniae

Question 7

what are the typical culprits of “typical” bacterial pneumonia

Answer 7

strep. pneumoniae, H influenzae, staph. aureus, M. catharrhalis, legionella

Question 8

signs that favor typical bacterial pneumonia

Answer 8

abrupt onset, lack of upper respiratory symptoms, WBC>15,000 or <6,000 w/ inc. bands, procalcitonin >0.25

Question 9

what are the typical culprits of “atypical” walking pneumonia

Answer 9

mycoplasma pneumoniae, chlamydophilia pneumoniae

Question 10

signs that favor atypical walking pneumonia

Answer 10

slower onset, milder symptoms, dry cough (lasting a long time), headache, sore throat, normal or mildly elevated WBC, procalcitonin >0.1

Question 11

what are the typical culprits of viral pneumonia

Answer 11

influenza a and b, RSV, parainfluenza, COVID

Question 12

signs that favor viral pneumonia

Answer 12

upper respiratory symptoms, patchy pulmonary infiltrates, normal or slightly elevated WBC, procalcitonin <0.1, systemic symptoms

Question 13

what are the clinical criteria for the diagnosis of pneumonia

Answer 13

signs and symptoms such as fever, leukocytosis or leukopenia, purulent sputum, decline in oxygenation (O2 sat <92%) or need for supplemental O2. PLUS radiographic findings: new lung infiltrates on chest xray or CT scan

Question 14

recommended outpatient antibiotic regimens for CAP with no comorbidities

Answer 14

amoxicillin OR doxycycline OR macrolide (only if local resistance <25%)

Question 15

recommended outpatient antibiotic regimens for CAP with comorbidities

Answer 15

combination therapy with:
1. amox/clav OR cephalosporin
AND
2. macrolide OR doxycycline
OR: monotherapy with respiratory quinolone

Question 16

what are the “comorbidities” mentioned for CAP

Answer 16

chronic heart, lung, liver, renal disease, diabetes mellitus, alcoholism, malignancy, asplenia

Question 17

what are the respiratory quinolones

Answer 17

levofloxacin, moxifloxacin, gemifloxacin

Question 18

what quinolone is NOT a respiratory quinolone and WHY

Answer 18

ciprofloxacin because it lacks adequate coverage for strep. pneumoniae. even tho it has adequate penetration into the lungs.

Question 19

what does “respiratory quinolone” terminology really mean

Answer 19

the coverage of organisms common to respiratory infections AKA STREP PNEUMONIAE. does not have anything to do with penetration into lungs. and cipro is not respiratory bc it doesn’t cover strep pneumoniae

Question 20

why is macrolide monotherapy usually not appropriate

Answer 20

> 30% resistance rate in the US leading to treatment failure and a further increase in resistance.

Question 21

what are 3 (general) options for INPATIENT treatment of non-severe CAP

Answer 21

1. combo therapy with IV beta lactam + IV/PO macrolide.
2. monotherapy with a respiratory quinolone.
3. alternative if 1 or 2 is a contraindication: combo therapy with a beta lactam and doxycycline

Question 22

describe the options for COMBO therapy for inpatient treatment of non-severe CAP

Answer 22

beta lactam: ampicillin/sulfbactam 1.5-3g q6h, cefotaxime 1-2g q8h, ceftriaxone 1-2g daily, ceftalorine 600 mg q12h. PLUS a macrolide: azithromycin 500 mg daily or clarithromycin 500 mg BID

Question 23

describe the options for respiratory quinolone monotherapy for inpatient treatment of non-severe CAP

Answer 23

levofloxacin 750 mg daily, moxifloxacin 400 mg daily

Question 24

describe the alternate treatment for inpatient treatment of non-severe CAP if there is a contraindication to macrolides or quinolones

Answer 24

doxycycline 100 mg BID + beta lactam: ampicillin/sulbactam, cefotaxime, ceftalorine, ceftriaxone

Question 25

when to add MRSA or pseudomonal coverage?

Answer 25

1. prior respiratory isolation of MRSA or pseudomonas
2. severe infxn with recent hospitalization receiving parenteral abx and locally validated ris for MRSA/pseudomonas

Question 26

when to withhold MRSA or pseudomonal coverage?

Answer 26

non-severe infxn with recent hospitalization receiving parenteral abx and locally validated risk for MRSA or pseudomonas

Question 27

what to do if (-) nasal PCR swab for MRSA

Answer 27

discontinue MRSA coverage (negative predictive value 99%)

Question 28

what to do if (+) nasal PCR swab for MRSA

Answer 28

add/continue MRSA coverage (positive predictive value 35%)

Question 29

what are the MRSA treatment options

Answer 29

vancomycin 15-20 mg/kg q12h, linezolid 600 mg q12h

Question 30

what are the pseudomonas treatment options

Answer 30

zosyn 4.5 g q6h, cefepime 2 g q8h, ceftazidime 2 g q8h, aztreonam 2 g q8h, meropenem 1 g q8h, imipenem 500 mg q6h

Question 31

inpatient options for severe CAP

Answer 31

beta lactam + macrolide or beta lactam + fluoroquinolone

Question 32

what’s the recommendation for a patient with CAP who tests positive for flu

Answer 32

oseltamivir within 48h of symptom onset

Question 33

stability criteria as established in Dinh study for stopping antibiotics at 3 days in patients with CAP

Answer 33

temp <37.8 C (100 F), HR <100 bpm, RR <24, SBP >90 mmHg, O2 sat 90% or pO2 >60 mmHg, ability to maintain oral intake, normal mental status

Question 34

who should receive a 3 day duration?

Answer 34

non-severe, uncomplicated CAP, improving and clinically stable by day 3