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835 > CAP > Flashcards

CAP Flashcards

1
Q

CAP

A
  • Community-acquired pneumonia

- Acute infection of pulmonary parenchyma and has been acquired in the community

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2
Q

Pneumonia

A
  • Leading cause of death by infection
  • Affects the very young and elderly
  • Challenges: diagnoses, wide microbe etiology, resistance
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3
Q

Pathogenesis - Entry

A
  • Inhalation
  • Direct spread from upper respiratory tract
  • Aspiration
  • Hematogenous seeding (less likely)
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4
Q

Pathogenesis - Other

A
  • Impaired defense mechs contribute to risk: smoking, alcohol, stroke
  • Altered host function: age, COPD, AIDS, imumunosuppressive agents, malnutrition
  • Prior viral infection (flu)
  • Site of care varies by microbe infecting patient
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5
Q

Smoking Risks

A
  • Impairs ciliary function

- Contributes to CAP risk

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6
Q

Alcohol/Smoke Risks

A
  • Impairs cough and epiglottic reflex

- Contributes to CAP risk

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7
Q

Risk Factors + Pathogens

A
  • COPD - H. influenzae, M. catarrhalis (B-lactamase producers)
  • Alcoholism: S. pneumoniae, aspiration
  • Injection drug use: S. aureus
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8
Q

S. Pneumoniae

A
  • Most common pathogen in CAP
  • Colonizes upper respiratory tract in ~10% of healthy adults
  • Polysaccharide capsules: >90 serotypes, target for vaccines
  • Resistance is an issue
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9
Q

S. Pneumoniae Abx Resistance

A

Resistance to following:

  • PCN
  • Macrolides
  • Fluoroquinolones
  • Cephalosporins
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10
Q

Risk for S. Pneumoniae

A
  • Age >= 65 years old
  • Comorbidities: asthma, diabetes, COPD, malignancy, chronic heart/lung/liver/kidney disease
  • Alcoholism
  • Immunosuppression
  • Exposure to child in daycare
  • Beta-lactam, macrolide, or fluoroquinolone use in last 3 months
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11
Q

H. Influenzae

A
  • Gram “-“ coccobacillus
  • Colonizer of URT
  • Indistinguishable clinical features from S. pneumoniae
  • ~30% produce beta-lactamases
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12
Q

Atypical Bacteria

A
  • M. pneumoniae, C. pneumoniae, Legionella spp
  • Symtoms: non-productive cough, absence of leukocytes
  • Abnormal X-ray
  • Hard to identify/isolate in lab
  • Abx options: FQN, azithromycin, doxy
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13
Q

M. Pneumoniae

A
  • Mycoplasma pneumoniae
  • Short rod-shaped bacteria w/o cell wall
  • Not detectable on gram stain
  • Responsible for ~10-20% of cases
  • Transmission high in close congregate settings (dorms)
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14
Q

C. pneumoniae

A
  • Chlamydophilia pneumoniae
  • Gram “-“ obligate intracellular bacteria
  • Responsible for ~5-10% of cases
  • Mild symptoms, usually worse in elderly
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15
Q

L. pneumophila

A
  • Legionella pneumophila
  • Naturally occurring aquatic bacteria (intracellular)
  • Accounts for 1-5% of CAP, rare
  • Causes severe disease
  • Increased risk: recent travel (2 weeks), contaminated water, elderly, smoking, immunocompromised
  • Urine antigen test available
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16
Q

Clinical Symptoms

A
  • Cough
  • Sputum production
  • Fever
  • Chills
  • Dyspnea
  • Pleuritic chest pain
  • N/V
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17
Q

Physical Exam Findings

A
  • Tachycardia
  • Tachypnea
  • Diminished breath sounds
  • Egophony
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18
Q

Diagnosis

A
  • Chest X-ray showing infiltrate is “gold standard” and should always be obtained when pneumonia is suspected
  • Additional diagnostic testing is optional in outpatient and recommended in some hospitalized patients
19
Q

CAP Risk Assessment

A
  • Treat either outpatient, inpatient medical floor, or ICU
  • Treatment depends on severity and mortality risks
  • Risks are determined from vital signs/stability, physical exam, lab tests, and need for IV therapy
20
Q

CAP Scoring Systems

A
  • PSI (Pneumonia severity index) is preferred, larger proportion assessed for OP treatment
  • Assessess risk for mortality (hospitalization required)
  • Not designed to select level of care needed for hospitalized patients
21
Q

PSI Risk Class I

A
  • Absence of risk factors
  • 0.4% 30 day mortality risk
  • Recommended Tx Site: Outpatient
22
Q

PSI Risk Class II

A
  • =<70 points
  • 0.7% 30 day mortality risk
  • Recommended Tx Site: Outpatient
23
Q

PSI Risk Class III

A
  • 71-90 points
  • 2.8% 30 day mortality risk
  • Recommended Tx Site: Outpatient or brief inpatient
24
Q

PSI Risk Class IV

A
  • 91-130 points
  • 8.5% 30 day mortality risk
  • Recommended Tx Site: Inpatient
25
Q

PSI Risk Class V

A
  • > 130 points
  • 31.1% 30 day mortality risk
  • Recommended Tx Site: Inpatient
26
Q

CURB-65

A
  • Requires no labratory data

- Doesn’t consider outpatient treatment as much as PSI

27
Q

Admitting CAP to ICU

A
  • Major criterion: need for vasopressors, need for mechanical ventilation
  • At least 3 of the minor criteria for severe CAP
28
Q

Minor Criteria

A
  • RR >= 30 breaths/min
  • Multilobar infiltrates
  • Confusion/disorientation
  • Uremia
  • Leukopenia
  • Thrombocytopenia
  • Hypothermia
  • Hypotension
  • PaO2/FiO2 ratio =< 250
29
Q

Etiology Identification

A
  • Organism identified in only ~30% of CAP cases

- Start empiric abx from procalcitonin diagnostic tests AND additional tests/labs

30
Q

Additional Tests/Labs for Empiric Treatment

A
  • Pretreatment sputum/bronchoalveolar lavage gram stain and culture
  • Pretreatment blood gram stain and culture
  • Urine legionella antigen test
  • Urine pneumococcal antigen test
31
Q

Empiric Outpatient Therapy + NO Comorbidities/Risk Factors for Drug-Resistance

A

-Strong Recommendation: Amoxicillin 1g PO TID

Conditional Recommendations:
-Doxy 100 mg PO BID
Macrolide (If resistance <25%):
-Azith 500 mg PO day 1, then 250 mg PO daily x 4days
-Clarithromycin 1000 mg ER PO QD or 500 mg BID

Don’t use FQN

32
Q

Empiric Outpatient Therapy + Comorbidities/Risk Factors for Drug-Resistance

A

B-Lactam + Macrolide

  • Augmentin 875/125 or 2000/125 PO BID
  • Cefpodoxime 200 mg PO BID
  • Cefuroxime 500 mg PO BID
OR 
Respiratory FQN
-Moxifloxacin 400 mg PO QD
-Levofloxacin 750 mg PO QD
-Gemifloxacin 320 mg PO QD
33
Q

Empiric Inpatient Therapy + Non-ICU

A 
B-Lactam
-Ceftriaxone 2g IV q24h
-Cefotaxime 2g IV q8h
-Unasyn 3g IV q6h
-Ceftaroline 600 mg IV q12h
PLUS Macrolide
-Azithromycin 500 mg IV/PO QD
-Clarithromycin 500 mg PO daily

OR
Respiratory FQN:
-Moxifloxacin 500 mg IV/PO q24h
-Levofloxacin 750 mg IV/PO q24h

DON’T use corticosteroids

34
Q

MRSA + CAP

A
  • Low prevalence
  • Results in severe disease
  • Empiric coverage recommended for patients with history of respiratory isolation within year, severe CAP with history of hospitalization or locally validated risk factors
  • Treatment: Vanco 15 mg/kg IV q12h OR Linezolid 600 mg IV/PO q12h
  • De-escalate treatment if PCR is negative or doesn’t grow in culture
35
Q

P. aeruginosa + CAP

A
  • Low prevalence
  • Risk factors: lung disease, immunosuppression, ventilation
  • Empiric coverage recommended for patients with history of respiratory isolation within year, severe CAP with history of hospitalization or locally validated risk factors
  • De-escalate treatment if doesn’t grow in cultures
36
Q

-P. aeruginosa + Treatment Options

A
  • Zosyn: 4.5g IV q6h
  • Cefepime 2g IV q8h
  • Ceftazidime 2g IV q8h
  • Primaxin: 500 mg IV q6h
  • Meropenem 1g IV q8h
  • Aztreonam 2g IV q8h
37
Q

Aspiration

A
  • May result in pneumonitis
  • Many patients have symptom resolution in 24-48 hours without treatment
  • Anaerobic bacteria don’t play a major role
  • Anaerobic coverage rarely indicated unless lung abscess or empyema suspected
38
Q

Empiric Inpatient Treatment + ICU

A
  • B-Lactam PLUS Macrolide or Respiratory FQN

- Can also add empiric coverage for P. aeruginosa and MRSA if necessary

39
Q

Duration of Therapy

A
  • Continue treatment until patient is stable, minimal 5 days of Tx
  • Hemodynamically stable and improving clinically with PE
  • Cavitary or extrapulmonary disease may require longer therapy
  • Other considerations: narrow therapy if possible, consider switching IV=>PO if able to and normal GI tract
40
Q

Viral Influenza

A
  • Symptoms: fever, chills, cough, sore throat, runny nose, muscle aches, HA, fatigue, N/V, diarrhea
  • Rapid testing recommended during influenza season
41
Q

Severe Viral Influenza Risks

A
  • <5 y.o. or >= 65 y.o.
  • Preggo or postpartum (2 wks post-delivery)
  • Patients with certain comorbidities
  • American Indian or Alaskan natives
  • Long-term aspirin therapy
  • Patients in long-term care facilities
42
Q

Influenza Treatment Indications/Benefits

A
  • Indicated for patients at risk of serious complications and positive PCV/symptoms, hospitalized or severely ill patients with positive PCR/symptoms
  • Best benefits when starting within 48 hours
  • Shown to decrease severity of symptoms and time of illness by 1-2 days
43
Q

Influenza Treatment Options

A
  • Oseltamivir (Tamiflu): 75 mg PO BID x5d
  • Zanamavir (Relenza): two 5mg inhalations BID x5d
  • Peramivir (Rapivab): 600mg IV once
  • Baloxavir marboxil (Xofluza): 40 mg PO once
44
Q

General Prevention

A
  • Vaccine for 6+ mo
  • Pneumococcal vaccines for 65+ y.o. and high-risk comorbidities
  • Smoking cessation

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