CAP guidelines 2020 Flashcards
Sputum GS is highly specific for identifying the following: ____
- S. pneumoniae
- H. influenzae
- S. aureus
- Gram negative bacilli infection
Sputum GSCS
Not recommended for LR
Recommended for MR & HR & Risk factor for MDR pathogen
Predictors of Bacteremia
Systolic BP <90
Temp <35 or ≥ 40
PR ≥ 125
Liver disease
BUN ≥ 30
Serum Na <130
WBC <5,000 or >20,000
4 variables significantly associated with positive blood culture
WBC <4,500
Serum creatinine >106 umol/L
Serum glucose <6.1 mmol/L
Temp >38.0 C
Benefit of Blood CS is for __ (2)
Prognostication
Antimicrobial surveillance
Blood CS
Moderate Risk CAP
High Risk CAP
Indications for Influenza testing in patients with CAP
- During periods of high influenza activity (July to January)
- Age >60
- Pregnant
- Asthmatic
- with Comorbidities
Indications to get Urinary antigen test for Legionella
ICU admission
failure of outpatient therapy
Active alcohol abuse
Recent travel
Pleural effusion
Legionella Urine Antigen test
May be considered for High Risk CAP
Multiplex PCR
Not recommended
Serious adverse effect of Azithromycin
Fatal arrhythmia
Serious adverse effect of Fluoroquinolone
Tendonitis
Tendon rupture
CNS effects
Peripheral neuropathy
Myasthenia gravis exacerbation
QT prolongation
Torsades de pointes
Phototoxicity
Hypersensitivity
CAP-LOW RISK: Management
No comorbidities
Amoxicillin 1g TID
OR
Clarithromycin 500 mg BId
OR
Azithromycin 500 mg OD
CAP-LOW RISK: Management
with STABLE comorbidities
Co-Amoxiclav 625 mg TID or 1g BID
OR
Cefuroxime 500 mg BID
PLUS OR MINUS
Clarithromycin 500 mg BId
OR
Azithromycin 500 mg OD
OR
Doxycycline 100 mg BID
The consensus panel voted against Monotherapy of ______ and _______, for treatment of CAP-LR, due to inferiority in coverage for S. pneumoniae and prevalence of Tuberculosis in the country, respectively.
Doxycycline
Levofloxacin
Patients with MODERATE RISK CAP without MDRO infection
Non-pseudomonal Beta-lactam antibiotic
Ampicillin-sulbactam 1.5–3 g every 6 h
OR
Cefotaxime 1–2 g every 8 h
OR
Ceftriaxone 1–2 g daily
PLUS
Macrolide
Azithromycin 500 mg daily
OR
Clarithromycin 500 mg twice daily
Patients with HIGH RISK CAP without
MDRO infection
FIRST-LINE
Non-pseudomonal Beta-lactam antibiotic
Ampicillin-sulbactam 1.5–3 g IV every 6 h
OR
Cefotaxime 1–2 g IV every 8 h
OR
Ceftriaxone 1–2 g IV daily
PLUS
Macrolide
Azithromycin 500 mg PO/IV daily
OR
Erythromycin 500 mg PO every 6 hours
OR
Clarithromycin 500 mg PO twice daily
Patients with HIGH RISK CAP without
MDRO infection
ALTERNATIVE TREATMENT
Non-pseudomonal Beta-lactam antibiotic
PLUS
Respiratory fluoroquinolone
Levofloxacin 750 mg PO/IV daily
OR
Moxifloxacin 400 mg PO/IV daily
Routine anaerobic coverage for suspected aspiration pneumonia is NOT
recommended, unless _____
lung abscess or empyema is suspected
The most strongly and consistently associated risk factors for CAP due to MRSA
were _____
- Previous MRSA colonization or infection, especially of the respiratory tract, within 1 year
- Intravenous antibiotic therapy within 90 days
Independent risk factors for
CAP due to P. aeruginosa
- Previous P. aeruginosa colonization or infection of the respiratory tract
- Severe bronchopulmonary disease
- Bronchiectasis
- Prior tracheostomy
Independent risk factor for drug-resistant P. aeruginosa CAP
Intravenous antibiotic therapy within 90 days
Risk factor for MDR Enterobacteriaceae
Prior colonization or infection with extended-spectrum beta-lactamase (ESBL)
producing organisms
Risk for Methicillin Resistant Staphylococcus aureus (MRSA)
- Prior colonization or infection with MRSA
within 1 year - Intravenous antibiotic therapy within 90 days
TREATMENT FOR CAP-MRSA
Non-pseudomonal Beta lactam antibiotic
PLUS
Macrolide
OR
Respiratory fluoroquinolone
PLUS
Vancomycin 15 mg/kg IV every 12 hours
OR
Linezolid 600 mg IV every 12 hours
OR
Clindamycin 600 mg IV every 8 hours
Risk for ESBL
Prior colonization or infection with ESBL-producing organisms within 1 year
TREATMENT FOR ESBL POSITIVE
Ertapenem 1g IV every 24 hours
OR
Meropenem 1 g IV every 8 hours (if Ertapenem is not available)
PLUS
Macrolide
OR
Respiratory fluoroquinolone
PLUS
Vancomycin 15 mg/kg IV every 12 hours
OR
Linezolid 600 mg IV every 12 hours
OR
Clindamycin 600 mg IV every 8 hours
Risk for Pseudomonas aeruginosa
- Prior colonization or infection with P
aeruginosa within 1 year - Severe bronchopulmonary disease (severe
COPD, bronchiectasis, prior tracheostomy)
Treatment for Pseudomas aeruginosa
Piperacillin-Tazobactam 4.5g IV every 6 hours
OR
Cefepime 2 g IV every 8 hours
OR
Ceftazidime 2 g IV every 8 hours
OR
Aztreonam 2 g IV every 8 hours
OR
Meropenem 1 g IV every 8 hours (especially if with ESBL risk)
PLUS
Macrolide
OR
respiratory fluoroquinolone*
Definition of Clinical Failure
- Failure to reach clinical improvement within 7 days
- Transfer to the intensive care unit after 24 hours in a ward
- Need for re-hospitalization within 30 days
Antiviral therapy recommended on the following patients:
- Aged 60 years and above
- Pregnant
- Asthmatic
- Other co-morbidities
who tests positive on Influenza virus test
Time of the first antimicrobial dose from arrival at the emergency department (ED) to the intravenous infusion of the antimicrobial should be within ____
within 4 hours of admission
Definition of Clinically stable patient
- Afebrile within 48 hours
- Able to eat
- Normal blood pressure
- Normal heart rate
- Normal respiratory rate
- Normal oxygen saturation
- Return to baseline sensorium
Duration of treatment for Clinically Stable patients
5 days
When to extend antibiotic therapy (>5 days)?
(1) pneumonia is not resolving
(2) pneumonia complicated by sepsis, meningitis, endocarditis and other deep-seated infection
(3) infection with less common pathogens
(i.e. Burkholderia pseudomallei, Mycobacterium tuberculosis, endemic fungi, etc)
(4) infection with a drug resistant pathogen
When is it recommended to get post-treatment chest xray
After a minimum of 6 to 8 weeks
among patients with CAP to establish baseline and to exclude other conditions
C-Reactive Protein
Not recommended
Use of Procalcitonin to monitor treatment response among patients with CAP
Not recommended
Use of Procalcitonin to guide antibiotic discontinuation among patients with
moderate or high risk CAP
Conditional recommendation. May be used.
________may cause slow resolution of pneumonia in the elderly
S. pneumoniae
L. pneumophila
Reasons for Non-improvement of condition after 72H of treatment
1.Incorrect diagnosis or presence of a complicating noninfectious condition
- A resistant microorganism or an unexpected pathogen that is not covered by the antibiotic choice
3.Antibiotic is ineffective or causing an allergic reaction
4.Impaired local or systemic host defenses
5.Local or distant complications of pneumonia
6.Overwhelming infection
7.Slow response in the elderly patient
8.Exacerbation of comorbid illnesses
9.Nosocomial superinfection
What should be done for patients who are not improving after 72 hours of empiric
antibiotic therapy?
- Repeat Chest Xray
- Obtain additional specimen for microbiological testing
Criteria for De-escalation
- Resolution of fever for more than 24 hours
- Improvement of cough and WBC
counts - No respiratory distress
- No bacteremia
- No signs of unstable comorbid condition or any life threatening complication
- No signs of organ dysfunction
- Able to take oral fluids and oral medication with no malabsorption and etiologic agent is not a high risk pathogen.
CAP symptoms and resolution
Fever
1 week
CAP symptoms and resolution
Chest pain and Sputum production
4 weeks
CAP symptoms and resolution
Cough and Breathlessness
6 weeks
CAP symptoms and resolution
Most symptoms should have resolved, but fatigue may still be present
3 months
CAP symptoms and resolution
Back to normal
6 months
