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PSBIM Harrison 21st Edition > CAP guidelines 2020 > Flashcards

CAP guidelines 2020 Flashcards

1
Q

Sputum GS is highly specific for identifying the following: ____

A
  1. S. pneumoniae
  2. H. influenzae
  3. S. aureus
  4. Gram negative bacilli infection
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2
Q

Sputum GSCS

A

Not recommended for LR
Recommended for MR & HR & Risk factor for MDR pathogen

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3
Q

Predictors of Bacteremia

A

Systolic BP <90
Temp <35 or ≥ 40
PR ≥ 125
Liver disease
BUN ≥ 30
Serum Na <130
WBC <5,000 or >20,000

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4
Q

4 variables significantly associated with positive blood culture

A

WBC <4,500
Serum creatinine >106 umol/L
Serum glucose <6.1 mmol/L
Temp >38.0 C

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5
Q

Benefit of Blood CS is for __ (2)

A

Prognostication
Antimicrobial surveillance

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6
Q

Blood CS

A

Moderate Risk CAP
High Risk CAP

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7
Q

Indications for Influenza testing in patients with CAP

A
  1. During periods of high influenza activity (July to January)
  2. Age >60
  3. Pregnant
  4. Asthmatic
  5. with Comorbidities
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8
Q

Indications to get Urinary antigen test for Legionella

A

ICU admission
failure of outpatient therapy
Active alcohol abuse
Recent travel
Pleural effusion

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9
Q

Legionella Urine Antigen test

A

May be considered for High Risk CAP

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10
Q

Multiplex PCR

A

Not recommended

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11
Q

Serious adverse effect of Azithromycin

A

Fatal arrhythmia

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12
Q

Serious adverse effect of Fluoroquinolone

A

Tendonitis
Tendon rupture
CNS effects
Peripheral neuropathy
Myasthenia gravis exacerbation
QT prolongation
Torsades de pointes
Phototoxicity
Hypersensitivity

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13
Q

CAP-LOW RISK: Management
No comorbidities

A

Amoxicillin 1g TID

OR

Clarithromycin 500 mg BId

OR

Azithromycin 500 mg OD

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14
Q

CAP-LOW RISK: Management
with STABLE comorbidities

A

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

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15
Q

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.

A

Doxycycline
Levofloxacin

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16
Q

Patients with MODERATE RISK CAP without MDRO infection

A

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

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17
Q

Patients with HIGH RISK CAP without
MDRO infection

FIRST-LINE

A

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

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18
Q

Patients with HIGH RISK CAP without
MDRO infection

ALTERNATIVE TREATMENT

A

Non-pseudomonal Beta-lactam antibiotic

PLUS

Respiratory fluoroquinolone
Levofloxacin 750 mg PO/IV daily

OR

Moxifloxacin 400 mg PO/IV daily

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19
Q

Routine anaerobic coverage for suspected aspiration pneumonia is NOT
recommended, unless _____

A

lung abscess or empyema is suspected

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20
Q

The most strongly and consistently associated risk factors for CAP due to MRSA
were _____

A
  1. Previous MRSA colonization or infection, especially of the respiratory tract, within 1 year
  2. Intravenous antibiotic therapy within 90 days
21
Q

Independent risk factors for
CAP due to P. aeruginosa

A
  1. Previous P. aeruginosa colonization or infection of the respiratory tract
  2. Severe bronchopulmonary disease
  3. Bronchiectasis
  4. Prior tracheostomy
22
Q

Independent risk factor for drug-resistant P. aeruginosa CAP

A

Intravenous antibiotic therapy within 90 days

23
Q

Risk factor for MDR Enterobacteriaceae

A

Prior colonization or infection with extended-spectrum beta-lactamase (ESBL)
producing organisms

24
Q

Risk for Methicillin Resistant Staphylococcus aureus (MRSA)

A
  1. Prior colonization or infection with MRSA
    within 1 year
  2. Intravenous antibiotic therapy within 90 days
25
Q

TREATMENT FOR CAP-MRSA

A

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

26
Q

Risk for ESBL

A

Prior colonization or infection with ESBL-producing organisms within 1 year

27
Q

TREATMENT FOR ESBL POSITIVE

A

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

28
Q

Risk for Pseudomonas aeruginosa

A
  1. Prior colonization or infection with P
    aeruginosa within 1 year
  2. Severe bronchopulmonary disease (severe
    COPD, bronchiectasis, prior tracheostomy)
29
Q

Treatment for Pseudomas aeruginosa

A

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*

30
Q

Definition of Clinical Failure

A
  1. Failure to reach clinical improvement within 7 days
  2. Transfer to the intensive care unit after 24 hours in a ward
  3. Need for re-hospitalization within 30 days
31
Q

Antiviral therapy recommended on the following patients:

A
  1. Aged 60 years and above
  2. Pregnant
  3. Asthmatic
  4. Other co-morbidities

who tests positive on Influenza virus test

32
Q

Time of the first antimicrobial dose from arrival at the emergency department (ED) to the intravenous infusion of the antimicrobial should be within ____

A

within 4 hours of admission

33
Q

Definition of Clinically stable patient

A
  1. Afebrile within 48 hours
  2. Able to eat
  3. Normal blood pressure
  4. Normal heart rate
  5. Normal respiratory rate
  6. Normal oxygen saturation
  7. Return to baseline sensorium
34
Q

Duration of treatment for Clinically Stable patients

A

5 days

35
Q

When to extend antibiotic therapy (>5 days)?

A

(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

36
Q

When is it recommended to get post-treatment chest xray

A

After a minimum of 6 to 8 weeks
among patients with CAP to establish baseline and to exclude other conditions

37
Q

C-Reactive Protein

A

Not recommended

38
Q

Use of Procalcitonin to monitor treatment response among patients with CAP

A

Not recommended

39
Q

Use of Procalcitonin to guide antibiotic discontinuation among patients with
moderate or high risk CAP

A

Conditional recommendation. May be used.

40
Q

________may cause slow resolution of pneumonia in the elderly

A

S. pneumoniae
L. pneumophila

41
Q

Reasons for Non-improvement of condition after 72H of treatment

A

1.Incorrect diagnosis or presence of a complicating noninfectious condition

  1. 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

42
Q

What should be done for patients who are not improving after 72 hours of empiric
antibiotic therapy?

A
  1. Repeat Chest Xray
  2. Obtain additional specimen for microbiological testing
43
Q

Criteria for De-escalation

A
  1. Resolution of fever for more than 24 hours
  2. Improvement of cough and WBC
    counts
  3. No respiratory distress
  4. No bacteremia
  5. No signs of unstable comorbid condition or any life threatening complication
  6. No signs of organ dysfunction
  7. Able to take oral fluids and oral medication with no malabsorption and etiologic agent is not a high risk pathogen.
44
Q

CAP symptoms and resolution

Fever

A

1 week

45
Q

CAP symptoms and resolution

Chest pain and Sputum production

A

4 weeks

46
Q

CAP symptoms and resolution

Cough and Breathlessness

A

6 weeks

47
Q

CAP symptoms and resolution

Most symptoms should have resolved, but fatigue may still be present

A

3 months

48
Q

CAP symptoms and resolution

Back to normal

A

6 months

PSBIM Harrison 21st Edition (15 decks)

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