CAP Flashcards
systemic symptoms of pneumonia
fever, chills, malaise, myalgias, leukocytosis (high WBC count)
pulmonary symptoms of pneumonia
cough, purulent sputum, pleuritic chest pain, SOB/dyspnea
physical exam findings of pneumonia
tachypnea, tachycardia, decreased or coarse breath sounds, crackles on inspiration
most common gram + bacterial pathogens that cause CAP
strep. pneumoniae, staph. aureus
most common gram - bacterial pathogens that cause CAP
h. influenzae, m. catarrhalis
most common atypical bacterial pathogens that cause CAP
legionella, chlamyophilia pneumoniae, mycoplasma pneumoniae
what are the typical culprits of “typical” bacterial pneumonia
strep. pneumoniae, H influenzae, staph. aureus, M. catharrhalis, legionella
signs that favor typical bacterial pneumonia
abrupt onset, lack of upper respiratory symptoms, WBC>15,000 or <6,000 w/ inc. bands, procalcitonin >0.25
what are the typical culprits of “atypical” walking pneumonia
mycoplasma pneumoniae, chlamydophilia pneumoniae
signs that favor atypical walking pneumonia
slower onset, milder symptoms, dry cough (lasting a long time), headache, sore throat, normal or mildly elevated WBC, procalcitonin >0.1
what are the typical culprits of viral pneumonia
influenza a and b, RSV, parainfluenza, COVID
signs that favor viral pneumonia
upper respiratory symptoms, patchy pulmonary infiltrates, normal or slightly elevated WBC, procalcitonin <0.1, systemic symptoms
what are the clinical criteria for the diagnosis of pneumonia
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
recommended outpatient antibiotic regimens for CAP with no comorbidities
amoxicillin OR doxycycline OR macrolide (only if local resistance <25%)
recommended outpatient antibiotic regimens for CAP with comorbidities
combination therapy with:
1. amox/clav OR cephalosporin
AND
2. macrolide OR doxycycline
OR: monotherapy with respiratory quinolone
what are the “comorbidities” mentioned for CAP
chronic heart, lung, liver, renal disease, diabetes mellitus, alcoholism, malignancy, asplenia
what are the respiratory quinolones
levofloxacin, moxifloxacin, gemifloxacin
what quinolone is NOT a respiratory quinolone and WHY
ciprofloxacin because it lacks adequate coverage for strep. pneumoniae. even tho it has adequate penetration into the lungs.
what does “respiratory quinolone” terminology really mean
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
why is macrolide monotherapy usually not appropriate
> 30% resistance rate in the US leading to treatment failure and a further increase in resistance.
what are 3 (general) options for INPATIENT treatment of non-severe CAP
- combo therapy with IV beta lactam + IV/PO macrolide.
- monotherapy with a respiratory quinolone.
- alternative if 1 or 2 is a contraindication: combo therapy with a beta lactam and doxycycline
describe the options for COMBO therapy for inpatient treatment of non-severe CAP
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
describe the options for respiratory quinolone monotherapy for inpatient treatment of non-severe CAP
levofloxacin 750 mg daily, moxifloxacin 400 mg daily
describe the alternate treatment for inpatient treatment of non-severe CAP if there is a contraindication to macrolides or quinolones
doxycycline 100 mg BID + beta lactam: ampicillin/sulbactam, cefotaxime, ceftalorine, ceftriaxone
when to add MRSA or pseudomonal coverage?
- prior respiratory isolation of MRSA or pseudomonas
- severe infxn with recent hospitalization receiving parenteral abx and locally validated ris for MRSA/pseudomonas
when to withhold MRSA or pseudomonal coverage?
non-severe infxn with recent hospitalization receiving parenteral abx and locally validated risk for MRSA or pseudomonas
what to do if (-) nasal PCR swab for MRSA
discontinue MRSA coverage (negative predictive value 99%)
what to do if (+) nasal PCR swab for MRSA
add/continue MRSA coverage (positive predictive value 35%)
what are the MRSA treatment options
vancomycin 15-20 mg/kg q12h, linezolid 600 mg q12h
what are the pseudomonas treatment options
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
inpatient options for severe CAP
beta lactam + macrolide or beta lactam + fluoroquinolone
what’s the recommendation for a patient with CAP who tests positive for flu
oseltamivir within 48h of symptom onset
stability criteria as established in Dinh study for stopping antibiotics at 3 days in patients with CAP
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
who should receive a 3 day duration?
non-severe, uncomplicated CAP, improving and clinically stable by day 3
