Community Acquired Pneumonia Flashcards
What are common bacterial respiratory diseases associated with HIV?
Sinusitis, bronchitis, otitis, pneumonia
These diseases occur with increased frequency at all CD4 counts.
What is the focus of the chapter on community-acquired pneumonia (CAP) in people with HIV?
Diagnosis, prevention, and management of bacterial CAP
Viral pneumonias like influenza and SARS-CoV-2 are outside the scope of these guidelines.
What is considered an AIDS-defining condition regarding pneumonia?
Recurrent pneumonia (two or more episodes within a 1-year period)
Bacterial pneumonia is a common cause of HIV-associated morbidity.
How has the incidence of bacterial pneumonia in individuals with HIV changed with ART?
Decreased from 22.7 to 9.1 episodes per 100 person-years
This decline occurred after the introduction of ART.
What are the main risk factors for bacterial pneumonia in individuals with HIV?
- CD4 count <100 cells/mm3
- Lack of ART
- Chronic viral hepatitis
- Tobacco and alcohol use
- Injection drug use
- Chronic obstructive pulmonary disease (COPD)
- Malignancy
- Renal insufficiency
- Congestive heart failure
- Obesity
These factors contribute to the higher risk of pneumonia despite ART.
What are the most frequently identified bacterial causes of CAP in individuals with HIV?
- Streptococcus pneumoniae
- Haemophilus species
- Staphylococcus aureus
Atypical pathogens like Legionella pneumophila and Mycoplasma pneumoniae are less common.
What should be considered when diagnosing pneumonia in individuals with HIV?
Tuberculosis (TB) diagnosis
High incidence areas should always consider TB as a potential diagnosis.
What is the significance of Pseudomonas aeruginosa and Methicillin-Resistant Staphylococcus aureus (MRSA) in individuals with HIV?
Higher frequency as community-acquired pathogens
Risk factors include advanced HIV disease, corticosteroid use, and recent hospitalization.
What clinical symptoms are characteristic of bacterial pneumonia in individuals with HIV?
- Fever
- Chills
- Chest pain
- Cough with purulent sputum
- Dyspnea
These symptoms typically have an acute onset over 3 to 5 days.
What is the relationship between CD4 count and bacteremia in individuals with HIV?
Increased incidence of bacteremia with lower CD4 counts
Particularly significant with counts <100 cells/mm3.
What factors are associated with increased mortality in individuals with HIV and pneumonia?
- CD4 count <100 cells/mm3
- Radiographic progression of disease
- Presence of shock
These factors are independent predictors of increased mortality.
What is the recommended diagnostic evaluation for CAP in hospitalized patients with HIV?
- Gram stain of sputum
- Two blood cultures
Especially for those with severe pneumonia or low CD4 counts.
True or False: The use of Procalcitonin (PCT) testing is recommended for guiding treatment decisions in HIV-associated bacterial pneumonia.
False
Specific PCT thresholds for HIV-associated pneumonia have not been established.
Fill in the blank: The clinical diagnosis of bacterial pneumonia requires a demonstrable infiltrate by _______ or other imaging technique.
chest radiograph
This should be in conjunction with compatible clinical symptoms.
What are the potential long-term outcomes associated with pneumonia in individuals with HIV?
- Greater long-term mortality
- Impaired lung function
- Increased risk of subsequent lung cancer
Hospitalization for pneumonia has been linked to increased mortality up to one year later.
What is the recommendation for routine diagnostic tests in outpatients with HIV and CAP?
Optional, especially if microbiologic studies cannot be performed promptly.
What diagnostic tests are recommended for hospitalized patients with HIV and severe CAP?
Gram stain of sputum and two blood cultures.
When should specimens for diagnostic tests be ideally obtained in patients with HIV?
Before initiation of antibiotics or within 12 to 18 hours after initiation.
What urinary antigen tests are recommended in hospitalized patients with severe CAP?
- L. pneumophila
- S. pneumoniae
What additional testing should be performed for adults with severe CAP?
Culture for Legionella on selective media or nucleic acid amplification testing.
When should rapid MRSA nasal testing be performed?
In patients with risk factors for MRSA or in a high prevalence setting.
What is the yield of sputum cultures in patients with HIV?
Identifies bacterial etiology in up to 30-40% of good quality specimens.
What should be done in patients with pleural effusion and concern for empyema?
Diagnostic thoracentesis should be performed.
What is the importance of pneumococcal vaccination in people with HIV?
Prevents bacterial pneumonia and invasive pneumococcal disease.
What is the recommendation for PPSV23 in patients with CD4 counts <200 cells/mm3?
Preferably deferred until CD4 count increases to >200 cells/mm3 while on ART.
What should be administered to all people with HIV during influenza season?
Immunization against influenza with inactivated, standard dose or recombinant vaccine.
What modifiable factors are associated with an increased risk of bacterial pneumonia?
- Smoking cigarettes
- Using injection drugs
- Consuming alcohol
What is the general approach to antibiotic treatment of CAP in patients with HIV?
Same basic principles as for patients without HIV.
What factors guide the decision for outpatient treatment versus hospitalization for CAP?
Severity of illness, ability to take oral medications, adherence, and confounding factors.
What scoring systems can guide decisions regarding treatment location for CAP in people with HIV?
- Pneumonia Severity Index (PSI)
- CURB-65
- ATS/IDSA severity criteria
What should be considered when selecting empiric antibiotic therapy for patients with HIV?
Local resistance patterns, MRSA testing results, and individual patient risk factors.
What are the preferred antibiotics for outpatient CAP treatment in individuals with HIV?
- Oral beta-lactam plus a macrolide
- Respiratory fluoroquinolone
What is the preferred beta-lactam for outpatient CAP treatment?
High-dose amoxicillin or amoxicillin-clavulanate.
What is the role of TMP-SMX in preventing bacterial respiratory infections in HIV patients?
Should not be prescribed solely to prevent bacterial respiratory infection.
What factors are associated with decreased risk of bacterial pneumonia in HIV patients?
- Use of ART
- TMP-SMX for PCP prophylaxis
What are the considerations for using respiratory fluoroquinolones in patients with suspected TB?
Use with caution as it may delay proper TB diagnosis and treatment.
What clinical trial demonstrated the efficacy of PCV against vaccine-type IPD in adults with HIV?
A trial on 7-valent PCV (PCV7) in Malawi showed 74% efficacy.
What is the significance of CD4 count in the management of patients with HIV and CAP?
CD4 count <200 cells/mm3 is associated with increased risk of death.
What additional vaccines are recommended for people with HIV?
COVID-19 vaccination and H. influenzae type vaccine if indicated.
What are the preferred beta-lactams for outpatient CAP?
High-dose amoxicillin or amoxicillin-clavulanate
Alternatives include cefpodoxime or cefuroxime.
What are the preferred macrolides for outpatient CAP?
Azithromycin or clarithromycin
What should be used as an alternative to beta-lactam for patients allergic to penicillin?
A respiratory fluoroquinolone (moxifloxacin or levofloxacin)
What should be given to patients with contraindications to a macrolide or fluoroquinolone?
Doxycycline in addition to a beta-lactam
Why is empirical monotherapy with a macrolide not recommended for outpatient CAP in patients with HIV?
Due to increasing rates of pneumococcal resistance and potential treatment failure
What is the recommendation for non-severe CAP inpatient treatment?
IV beta-lactam plus a macrolide or respiratory fluoroquinolone
What has been found regarding beta-lactam monotherapy versus beta-lactam/macrolide combination therapy?
Beta-lactam monotherapy was not found to be non-inferior to combination therapy
What are the preferred beta-lactams for inpatient treatment of non-severe CAP?
Ceftriaxone, cefotaxime, or ampicillin-sulbactam
What should be used in patients who are allergic to penicillin?
A respiratory fluoroquinolone (moxifloxacin or levofloxacin)
What is the treatment recommendation for severe CAP?
IV beta-lactam plus azithromycin or a respiratory fluoroquinolone
What are the preferred beta-lactams for severe CAP treatment?
Ceftriaxone, cefotaxime, or ampicillin-sulbactam
What should be added for patients with risk factors for Pseudomonas infection?
An antipneumococcal, antipseudomonal beta-lactam plus ciprofloxacin or levofloxacin
What is the recommendation for empiric coverage for MRSA in patients with risk factors?
Vancomycin or linezolid should be added to the regimen
What should be done when the etiology of pneumonia is identified?
Antimicrobial therapy should be modified and directed at the identified pathogen
When should a switch to oral therapy be considered?
In patients with CAP on IV therapy who have improved clinically and can tolerate oral medications
When should ART be initiated in patients with bacterial pneumonia not already on treatment?
Promptly within 2 weeks of initiating therapy for pneumonia
What is a predictor for longer time to clinical stability in CAP patients with HIV?
Advanced HIV infection and CD4 count <100 cells/mm3
What is the recommendation regarding pneumococcal and influenza vaccines for patients with HIV?
Patients should receive both vaccines as recommended
What should be avoided to prevent recurrences of bacterial respiratory infections?
Antibiotic chemoprophylaxis
What is the recommendation regarding smoking cessation for patients with pneumonia?
Patients should be encouraged to quit smoking
What macrolide is recommended for use during pregnancy?
Azithromycin
What is the recommendation for using quinolones during pregnancy?
Use only when a safer alternative is not available
Why is doxycycline not recommended during pregnancy?
Due to increased hepatotoxicity and staining of fetal teeth and bones
What is the risk of birth defects or musculoskeletal abnormalities associated with quinolone use in pregnant women?
No increased risk found
Studies evaluating quinolone use in pregnant women did not find an increased risk of birth defects or musculoskeletal abnormalities.
What antibiotic is not recommended for use during pregnancy due to hepatotoxicity and fetal teeth staining?
Doxycycline
Doxycycline is associated with increased hepatotoxicity and staining of fetal teeth and bones.
What are the beta-lactam antibiotics associated with in pregnancy?
No teratogenicity or increased toxicity
Beta-lactam antibiotics have not been associated with teratogenicity or increased toxicity in pregnancy.
What is the theoretical risk associated with aminoglycosides during pregnancy?
Fetal renal or eighth nerve damage
A theoretical risk exists, but documented cases in humans are limited.
What should be avoided during the first trimester of pregnancy if alternate agents are available?
Telavancin
Use of telavancin should be avoided in the first trimester if alternate agents with more experience in use in pregnancy are available.
What is a potential consequence of pneumonia during pregnancy?
Increased rates of preterm labor and delivery
Pneumonia during pregnancy is associated with increased rates of preterm labor and delivery.
When should pregnant women with pneumonia be monitored for evidence of contractions?
After 20 weeks’ gestation
Pregnant women with pneumonia after 20 weeks’ gestation should be monitored for evidence of contractions.
What pneumococcal vaccines were found to be safe and immunogenic in pregnant women with HIV?
PCV10 and PPSV23
A study found that PCV10 and PPSV23 were equally safe and immunogenic in pregnant women with HIV.
What vaccine is recommended for all pregnant women during influenza season?
Inactivated influenza vaccine
The inactivated influenza vaccine is recommended for all pregnant women during influenza season.
What should be administered to pregnant women with HIV to minimize increases in plasma HIV RNA levels?
Vaccination after ART has been initiated
Vaccination of pregnant women is recommended after ART has been initiated to minimize increases in plasma HIV RNA levels.
What should be administered to all people with HIV regardless of CD4 count?
Pneumococcal vaccination
All people with HIV regardless of CD4 count should receive pneumococcal vaccination.
What should be administered at least 8 weeks after PCV15 for those without previous pneumococcal vaccination?
PPSV23
If PCV15 is used, a dose of PPSV23 should be administered at least 8 weeks later.
What is the recommendation for adults age ≥65 regarding influenza vaccination?
High-dose IIV or adjuvanted IIV
Adults age ≥65 years are recommended to receive high-dose IIV or adjuvanted IIV over standard-dose unadjuvanted vaccine.
What is the preferred outpatient therapy for community-acquired pneumonia?
An oral beta-lactam + a macrolide
Preferred therapy is an oral beta-lactam plus a macrolide (azithromycin or clarithromycin).
What is the preferred therapy for hospitalized patients with non-severe community-acquired pneumonia?
An IV beta-lactam + a macrolide
The preferred therapy is an IV beta-lactam plus a macrolide (azithromycin or clarithromycin).
What is the duration of therapy for most patients with community-acquired pneumonia?
5–7 days
The patient should be afebrile for 48–72 hours and clinically stable before discontinuation of therapy.
What should be considered for patients who have improved and can tolerate oral medications?
Switch from IV to PO therapy
A switch should be considered for patients who have improved clinically, can swallow and tolerate oral medications.
What is the recommendation regarding empiric therapy with a macrolide alone?
Not routinely recommended
Empiric therapy with a macrolide alone is not routinely recommended because of increasing pneumococcal resistance.
