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PR3124 CA3 > CAP > Flashcards

CAP Flashcards

1
Q

what is the pathogenensis of pneumonia? (3 mechs)

A
  • aspiration of oropharyngeal secretions
  • inhalation of aerosols (containing bac)
  • hematogenous spreading (bac inside blood, carry to lungs–> bac replicate in lungs–> pneumonia, bacteremia from extra pulmn source)
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2
Q

s/sx of pneumonia

A
  • cough, chest pain
  • SOB, hypoxia
  • fever >38C, chills, fatigue, anorexia
  • tachypnea, tachcardia, hypotension
  • leukocytosis
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3
Q

what physical examination is done to assess pneumonia

A
  • diminished breath sounds over affected area

- inspiratory crackles during lung expansion

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4
Q

pneumonia lab findings

A

eg. C reactive protein, procalcitonin
- non specific
- limited discriminatory potential
- not rec for routine use

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5
Q

what resp cultures are taken ? (2)

A
  1. sputum culture
    - low yield (may not be able to identify bac that is causing pneumonia), freq contamination by oropharyngeal secretion
    - quality sample: >10 neutrophils (indicate infection) AND <25 epithelial cells (less contam by motuh flora) per low power field
  2. lower resp tract sample
    - less contamination
    - invasive sampling
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6
Q

Why are blood cultures taken for pneumonia

A

to eliminate bacteremia

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7
Q

what org does urine antigen test identify?

A
  • strep pneumoniae

- legionella pneumophilia

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8
Q

limitations of urien antigen test?

A
  • indicate exposure to respective pathogen (pt exposed to pathogen but doesnt mean it caused the pneumonia)
  • remain positive for days-weeks despite ab tx

not routinely used

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9
Q

define hospital acquired ppneumonia HAP

A

onset >=48 h after hospital admin

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10
Q

define ventilator assc pneumonia

A

onset >48h after mechinical ventilation

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11
Q

define community acquired pneumonia CAP

A

onset in community or <48h after hospital admin

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12
Q

what are the 3 classificatiosn of pneumonia

A

hospital acquired
ventilator assc
community acquried

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13
Q

risk factors for CAP

A

age>65
previosu hospitalisation for CAP
smoking
COPD, DM, HF, cancer, immunosup

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14
Q

how to prevent CAP

A

smoking cessation, immunisation (influenza, pneumococcal)

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15
Q

how does severity of CAP determine tx (4)

A
  • location of tx
  • org that need to be covered
  • empiric ab selection
  • ROA of ab
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16
Q

criterion for CAP risk stratification (CURB-65)

A
  • confusion
  • urea > 7mmol/L
  • RR >39 breaths/min
  • Blood pressure (sbp<90, dbp<60)
  • age >65

if the total score is 0 or 1: outpat
score 2: inpatient
score >=3: inpt, consider ICU

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17
Q

what are teh moajor criterias for severe CAP

A
  • mech ventilation

- septic shock vasoactive medications

18
Q

minor criterias for severe cap?

A
  • RR>30
  • hypoxia, paO2>250
  • multilobar infiltrates
  • confusion
  • uremia (urea>7mmol/L)
  • leukopenia (WBC<4x10^9
  • hypothermia (core tmpe<36)
  • hypotension req aggressive fluid resuscitation
19
Q

what is criterias do we need to diagnose for severe CAP?

A

> =1 major
or
=3 minor

20
Q

what are the potential org to cover for OUTpt

A
  • strep pneumo
  • haemophilus influenzae
  • atypical org
21
Q

what is the empiric therapy for generally healthy outpt

A
  • beta lactam (amoxicillin)
    or
    resp FQ eg. levo or moxifloxacin`
22
Q

what is the empiric therapy for pt pop with chronic heart, lung, liver renal disease, DM.. outpt

A

need to cover atypical as well

1. beta lactam (amox/clav) pr cefuroxime
PLUS macrolide (clarithromycin or azithromycin) or resp FQ (levo/moxi)
23
Q

what is the standard regimen for inpatient non severe

A
  1. beta lactam (amox/clav or ceftriazone) PLUS macroldie (clarithromycin or azithromycin)
    or resp FQ (levo/moxi)
24
Q

ROA of inpt non severe?

A

beta lac and FQ admin IV- step down to PO when pt imrpoves

macrolide and doxycycline PO

25
Q

what is the regimen for inpatient severe?

A 
1. beta lactam (pen G or amox/clav PLUS ceftrazidime)
plus 2. macrolide or doxycycline 
OR
resp FQ (levo/moxi)
PLUS ceftazidime (to cover burkholderia)
26
Q

what organisms to cover for inpt severe?

A
  • strep pneumo
  • H flu
  • atypical org
  • s aureus
  • other gram neg bacilli
27
Q

when to cover anaerobic? what indications? (2)

A
  • lung abscesss

- empyema (abscess in lung pleural space)

28
Q

what ab to add when standard regimen has no anaerobic cov?

A

clindamycin IV/PO

metronidazole IV/PO

29
Q

what indications to cover for MRSA? (2)

A
  • prior respiratory isolation of MRSA in last 1 year
  • severe CAP only, hospitalisation and received IB ab within last 90 days and locally validated risk factors (look at antibiogram to check which MRSA is common)
30
Q

what ab to add wto cover MRSA? (2)

A

vancomycin IV

linezolid IV/PO

31
Q

what indicatiosn to cover for pseudomonas?

A

prior resp isolation of ps. aeruginosa in last 1 year

32
Q

how to modify standard regimen to cover ps/

A 
include pip/tazo IV, or
ceftazidime IV or 
cefepime IV
or meropenem IV or
levofloxacin IV/PO
33
Q

Why dont we use resp FQ as first line for CAP

A
  • many adverse effects eg. tendonitis, tendon rupture, neuropathy, qtc prolongation, cns disturbances, hypoglycemia
  • dev of resistance with overuse
  • preserve activity for other gram neg infections– its the only PO option to cover pseudomonas, dw to anyhow use
  • delay diagnosis of tb
34
Q

why is adjunctive coritcosteroid therapy considered for soem pt?

A
  • less inflammation in the lungs
  • variable drug and dosing regimens
  • may reduce length of stay and tiem to clinical stability
  • NOT ROUTINELY REC
35
Q

how to monitor safety of therapy?

A
  • adverse effects eg. diarrhea, rash

- renal func

36
Q

hwo to monitor efficacy of therapy?

A
  • clinical improvemnt expecte din 48-72h
  • less cough, chest pain, SOB, fever, wbc
  • elderly pt or those with multiple co-morbs may take longer
  • should not escalate ab therapy in the first 72h (unless culture directed or significant clinical deterioration)
  • rediographic improvement lags behind (4-6 weeks for reso)- repeat only if clnical deterioration eg. chest xray
37
Q

when to stop empiric cov for MRSA or ps. aeruginosa?

A
  • may be stopped in 48h if no mRSA or ps is foun din culture AND pt is improving
38
Q

when can IV ab be stepped down to PO?

A
  • hemodynamically stable
  • clinically improved
  • aferbile >24 h
  • able to ingest PO med
  • normally functioning GIT
39
Q

what are the general benefits of IV to PO? (5)

-

A
  • higher pt comfort and mobility
  • less risk of nosocomial axquired bloodtream infection
  • less phlebitis
  • decreased prep and admin time
  • lower cost
  • facilitates discharge
40
Q

what is the tx duration ?

A

until clinical stability is achieved and for at elast 5 days
- most achieve clinical stab in 48-72h

exceptions

  • MRSA, ps: 7 days
  • burkholderia: 3-6months
41
Q

what is considered clincal stable?

A
  • afebrile, able to maintain oral intake, normal vital signs, o2 saturation and mental status

PR3124 CA3 (6 decks)

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