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Pharmacotherapy > Community Acquired Pneumonia > Flashcards

Community Acquired Pneumonia Flashcards

1
Q

What is the patient population that presents with fungal pneumonia ?

A

Very immunocompromised pts (blood cancers/organ transplant)

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2
Q

What is the pathogenesis of pneumonia?

A

Inhalation of aerosols
Aspiration of oropharyngeal secretions
Hematogenous spread

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3
Q

What are some common signs and symptoms of pneumonia? (local and systemic)

A 
Local:
– Cough, chest pain
– Shortness of breath, hypoxia
Systemic:
– Fever > 38C, chills, fatigue, anorexia, nausea
– Tachypnea, tachycardia, hypotension
– Leukocytosis
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4
Q

What are some results we can expect from physical examinations for a pneumonia patient?

A

– Diminished breath sounds over the affected area

– Inspiratory crackles during lung expansion

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5
Q

What are some radiographic findings to expect from a pneumonia patient?

A

– New or progressive infiltrates

– Dense consolidations

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6
Q

What is the difference between how we use chest x-ray (frontal) and an axial CT scan?

A
  • Chest X-rays are 1st line when the pt has respiratory symptoms
  • CT scans are reserved for non-responsive pt (despite appropriate abx tx) for closer investigation
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7
Q

What are the expected lab findings for a pneumonia patient?

A

A rise in acute phase reactants
– Non-specific with Limited discriminatory potential*
– Not recommended for routine use to guide antibiotic initiation or discontinuation

*i.e. acute phase reactants typical of any other infection

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8
Q

What are the respiratory cultures to take for Pneumonia?

A

Sputum and lower respiratory tract samples

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9
Q

What are things to note for sputum cultures?

A

Low yield*

  • Frequent contamination by oropharyngeal secretions
  • Easily obtained

*may not be able to identify a bacteria that caused pt’s pneumonia

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10
Q

What is a quality sputum sample?

A

Quality sample: > 10 neutrophils and < 25 epithelial cells per low-power field

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11
Q

What are things to note for lower respiratory cultures?

A
  • Less contamination

* Invasive sampling, e.g. bronchoalveolar lavage (BAL)

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12
Q

What is the purpose of taking blood cultures for pneumonia?

A

To rule out hematogenous spread

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13
Q

What is the urinary antigen testing for in pneumonia?

A

Antigens secreted by:
– Streptococcus pneumoniae
– Legionella pneumophilia (serogroup 1 only)

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14
Q

What are the limitations of urinary antigen testing in pneumonia?

A
  • Indicate exposure to the respective pathogens
  • Remain positive for days-weeks despite antibiotic treatment
  • exposure does not mean causative agent
  • Not routinely used
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15
Q

According to pneumonia classification, how can we classify Hospital acquired pneumonia (HAP)?

A

Onset > 48 hours after hospital admission

*also considered nosocomial pneumonia

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16
Q

According to pneumonia classification, how can we classify Ventilator-Associated pneumonia (VAP)?

A

Onset > 48 hours after mechanical ventilation

*also considered nosocomial pneumonia

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17
Q

According to pneumonia classification, how do we classify Community-Acquired Pneumonia (CAP)?

A

Onset in the community or < 48 hours after hospital admission

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18
Q

Does frequent exposure to the healthcare setting (dialysis/chemotherapy) increase risk for resistant organisms?

A

No, Evidence does not support

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19
Q

What are the risk factors for CAP?

A

– Age > 65 years
– Previous hospitalization for CAP
– Smoking
– COPD, DM, HF, cancer, immunosuppression

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20
Q

How can we advise on the prevention of CAP?

A

Smoking cessation, immunizations (influenza, pneumococcal)

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21
Q

What are the organisms associated for bacterial CAP in the OUTPATIENT setting?

A
  • Streptococcus Pneumoniae
  • Haemophilus Influenzae
  • Atypical organisms, e.g. Mycoplasma pneumoniae, Chlamydophila pneumoniae
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22
Q

What are the organisms associated for bacterial CAP in the INPATIENT (NON-severe) setting?

A
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Atypical organisms, e.g. Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella pneumophilia
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23
Q

Difference between outpatient and inpatient (non-severe) bacterial CAP microbiology?

A

Legionella pneumophilia usually causes severe pneumonia that warrants hospitalization
- Not considered (despite being an atypical) in outpatient CAP as pt is doing well

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24
Q

What are the organisms associated for bacterial CAP in the INPATIENT (SEVERE) setting?

A
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Atypical organisms, e.g. Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella pneumophilia
  • Staphylococcus aureus*
  • Other Gram-negative bacilli*, e.g. Klebsiella pneumonia, Burkholderia pseudomallei
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25
Q

What are some things to note for Burkholderia pseudomallei in pneumonia?

A

Normally found in contaminated soil/water

  • High local prevalence
  • Causes Melioidosis
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26
Q

Qn: Which ONE of the following antibiotics is an effective treatment for CAP? (OP setting)

  • Ciprofloxacin
  • Levofloxacin
  • Ceftriaxone
  • Azithromycin
  • Ceftazidime + azithromycin
A

Levofloxacin.

  • Cipro (not resp FQ as it has poor activity against S.pneumoniae)
  • Ceftriaxone (no atypical cover)
  • Azithromycin (atypical cover but does not cover strep pneumoniae due to high local resistance)
  • Ceftazidime + azithromycin (no reliable cover of strep pneumoniae –> poor gram pos cover for ceftazidime + high local resistance for azithromycin)
  • only FQs (cipro, levo), Macrolides, tetracyclines (commonly doxycycline) provide atypical cover
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27
Q

How can we apply the CURB-65 for patient risk stratification?

A

Score 0 or 1: outpatient
Score 2: inpatient
Score ≥ 3: inpatient, consider ICU

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28
Q

What are the (2) major criteria for severe CAP?

A

Mechanical ventilation

Septic shock requiring vasoactive medications

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29
Q

What are the (8) minor criteria for severe CAP?

A 
RR ≥ 30 breaths/min
PaO2/FiO2 ≤ 250
Multilobar infiltrates
Confusion/disorientation
Uremia (urea > 7 mmol/L)
Leukopenia (WBC < 4 x 10^9/L)
Hypothermia (core temperature < 36C)
Hypotension requiring aggressive fluid resuscitation
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30
Q

What is the IDSA criteria for severe CAP?

A

At least 1 major criterion OR at least 3 minor criteria

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31
Q

What is empiric treatment framework like for CAP patients?

A
  1. Standard regimen for ALL (minimum cover based on location of treatment and risk stratification)
  2. Anaerobe/MRSA/Pseudomonas cover for INPATIENTs only (if indicated)
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32
Q

What is the standard empiric regimen for OUTPATIENT CAP for patients who are generally healthy?

Potential organisms:

  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Atypical organisms
A

PO abx only
Preferred: Beta-lactam (amoxicillin)

OR
Penicillin allergy: Respiratory FQ (levofloxacin OR moxifloxacin)

No atypical cover as patients are healthy

33
Q

What are some co-morbidities of concern when treating a OP CAP patient?

A

Chronic heart, lung, liver or renal diseases, diabetes mellitus, alcoholism, malignancy, asplenia

34
Q

What is the standard empiric regimen for OUTPATIENT CAP for a patient who has diabetes?

Potential organisms:

  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Atypical organisms
A

PO abx only
Beta-lactam (Augmentin OR cefuroxime) –> BL H flu cover
+ Macrolide (clarithromycin OR azithromycin) OR Doxycycline –> atypical cover

OR
Penicillin allergy: Respiratory FQ (levofloxacin OR moxifloxacin)

35
Q

If an outpatient presenting with CAP has a past hx of respiratory MRSA, is there a need to provide MRSA cover?

A

Patients classified under outpatient = doing well (not as severe) = no need MRSA cover
- MRSA cover considered for INpatients only

36
Q

What is the standard empiric regimen for INPATIENT (NON-severe) CAP?

Potential organisms:

  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Atypical organisms (now with legionella)
A

IV Beta-lactam (Augmentin OR ceftriaxone) –> BL H flu cover
+
PO Macrolide (clarithromycin OR azithromycin) OR PO Doxycycline –> atypicals

OR
Penicillin allergy: IV Respiratory FQ (levofloxacin OR moxifloxacin)

*Step down to PO abx when pt improves

37
Q

Why is cefuroxime not used in Inpatient Non-severe CAP despite having an IV option?

A 
Clinical data (evidence) for IP CAP tx mostly use ceftriaxone 
- IP usually give beta lactams IV -> cefuroxime is IV ok -> but not a standard IV drug used in SG hospital setting
38
Q

What is the standard empiric regimen for INPATIENT (severe) CAP?

Potential organisms:

  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Atypical organisms (now with legionella)
  • Staphylococcus aureus*
  • Other Gram-negative bacilli* (e.g. K. pneumoniae, Burkholderia pseudomallei)
A

2 IV Beta lactams (Penicillin G OR Augmentin + ceftazidime) + PO Macrolide (clarithromycin OR azithromycin) OR PO Doxycycline

OR
Mild penicillin allergy*: IV Respiratory FQ (levofloxacin OR moxifloxacin) + IV Ceftazidime

  • low cross reactivity with cephalosporin, challenge possible with mild allergy i.e. mild rash
  • *Step down to PO when pt improves
39
Q

Why is there a need to use 2 beta lactams in the cover of INPATIENT (severe) CAP? Isnt there overlap in cover?

A
  • Poor gram pos cover of ceftazidime (1st line to tx burkholderia)
  • High local strep pneumoniae resistance to macrolides/tetracyclines
  • Additional beta lactam needed to cover gram pos strep pneumoniae (augmentin/penicillin G)

*Augmentin preferred > penicillin G due to addition BL H flu cover

40
Q

What should we do when a patient with severe penicillin allergy (angioedema) presents with INPATIENT (severe) CAP?

A

Treat as a CAP w/o burkholderia coverage (using FQs only) and wait for culture growth -> if pt culture grows burkholderia -> use sensitive abx that pt can tolerate (culture directed tx)
- If not we have to desensitize the pt

41
Q

What is the indication for anaerobe cover in CAP?

A
  1. Inpatient

2. Any one of the following (Lung abscess or Empyema) –> Diagnosed using CT/X-rays

42
Q

What is the anaerobe that drives anaerobe cover in a CAP pt with lung abscess?

A

Gram Negative Bacteroides fragilis

Other common anaerobes*: Fusobacterium spp., Prevotella spp. (oropharyngeal anaerobes), Porphyromonas spp.

43
Q

Which ONE of the following antibiotics in the standard regimen covers Bacteroides fragilis?

  • Amoxicillin
  • Augmentin
  • Levofloxacin
  • Ceftriaxone
  • Ceftazidime
A

Augmentin

- Bacteroides fragilis also BL producing agent + gram neg + anaerobe

44
Q

An Inpatient (non-severe) CAP patient was prescribed IV Levofloxacin due to penicillin allergy. 2 days later, the patient’s condition worsened and a lung abscess was found upon further investigation. What needs to be changed for the antibiotic cover?

A

Provide additional anaerobe cover: Clindamycin IV/PO OR Metronidazole IV/PO

*Depends on whether pt can tolerate PO abx

45
Q

An Inpatient (non-severe) CAP patient was prescribed IV Augmentin + IV Azithromycin. 2hrs later, the CT scan showed presence of a lung abscess. The doctor asks you if there is any need to add on coverage.

A

The standard regimen already covers for anaerobes. No further cover needed

46
Q

What is the indication for MRSA cover in CAP?

A
  1. Inpatient
  2. Any one of the following: Prior respiratory isolation of MRSA in last 1 year OR Severe CAP only: hospitalization and received IV antibiotics within last 90 days
47
Q

A patient presents in the ER with core temperature < 36C, Hypotension and confusion. He was quickly started on IV Augmentin + IV ceftazidime + IV Azithromycin. As the pharmacist reviewing the drug order, you realize the patient was recently hospitalized 2months ago for CAP that was successfully treated with IV Augmentin + IV azithromycin.

Are there any necessary changes to the order?

A

MRSA cover is indicated (Severe CAP only: hospitalization and received IV antibiotics within last 90 days)
- Add on Vancomycin IV; OR Linezolid IV/PO*

*Prefer IV as patient likely has difficulty swallowing in his current state

48
Q

A patient was recently warded for CAP and started on IV Augmentin + PO Azithromycin. Today while reviewing the patient’s case, you notice that she had a prior history of MRSA isolation from her cellulitis infection 7months ago.

Are there any necessary changes to the order?

A

No. MRSA cover indicated for respiratory isolations of MRSA, not skin isolation. (i.e. sputum/BAL sample)

49
Q

A patient presents to the ER in septic shock and was promptly placed on ventilator support. After diagnosis and testing, the patient was deemed to have severe CAP and started on IV Augmentin + IV Ceftazidime + IV Azithromycin as per guidelines. When reviewing her case notes the next day, you realize the patient had been hospitalized 9months ago for an episode of CAP with pseudomonas aeruginosa isolation from her sputum culture.

Are there any necessary changes to the order?

A

All severe CAP already has IV ceftazidime to cover burkholderia (intent was not to cover pseudomonas but pseudomonas is covered unintentionally)
- No change needed

50
Q

A patient present to ER with hypoxia, fever, tachycardia and hypothermia. Upon lung X-ray, multi-lobar infiltrates were detected. The patient was subsequently hospitalized for CAP tx. His case note revealed he had been hospitalized for CAP 5 months ago with Pseudomonas isolation.

What is the appropriate empiric abx selction for the patient?

A

IV Pip-tazo + IV/PO azithromycin

*Change Augmentin to Pip-tazo for expanded Pseudomonas cover

51
Q

A patient present to ER with hypoxia, fever, tachycardia and hypothermia. Upon lung X-ray, multi-lobar infiltrates were detected. The patient was subsequently hospitalized for CAP tx. His case note revealed he had been hospitalized for CAP 5 months ago with Pseudomonas isolation. You also note Penicillin allergy (angioedema) and G6PD Deficiency for the patient.

What is the appropriate empiric abx selection for the patient?

A

Levofloxacin IV

  • Atypical cover, Pseudomonas cover, Gram pos and Gram neg cover
52
Q

What are the common abx that cover for pseudomonas?

A

Piperacillin/tazobactam IV, Ceftazidime IV, Cefepime IV, Meropenem IV, Levofloxacin IV/PO

53
Q

Can moxifloxacin (respiratory FQ) be used to cover for pseudomonas?

A

No. Moxi does not cover pseudomonas despite being a respiratory FQ

54
Q

Why are FQs not preferred in the tx of CAP?

A
  • Adverse effects**
  • Resistance development (with overuse)
  • Preserve PO FQs for other gram neg infections*
  • Delays TB diagnosis

*Alternative Pseudomonas coverage with severe penicillin allergies
*Only PO options covering Pseudomonas aeruginosa
**(e.g. tendonitis, tendon rupture, neuropathy, QTc
prolongation, CNS disturbances, hypoglycemia, etc.)

55
Q

What is the place in therapy of corticosteroids in CAP?

A

Not recommended
– May ↓ length of stay and time to clinical stability
– Any impact is small and likely outweighed by ↑ hyperglycemia

56
Q

What the safety parameters we monitor for in CAP?

A 
Adverse effects of  abx
Renal function (affects abx CL)
57
Q

What do we monitor for efficacy in CAP?

A

– Clinical improvements expected in 48-72h
• ↓ Cough, chest pain, shortness of breath, fever, WBC, tachypnea, etc.
• Elderly patients and/or those with multiple co-morbidities may take longer

58
Q

What are the circumstances where we escalate abx therapy in the 1st 72h?

A
  • When culture results return
  • When there is significant clinical deterioration

*usually dont escalate within 1st 72h, give the abx time to work

59
Q

Can radiological results (X-ray/CT) be used to show clinical improvement of a CAP patient?

A

No. Radiographic improvement lags behind, up to 4-6weeks needed before resolution occurs

  • Repeat only if clinical deterioration (i.e. when pt clinical condition worsens, want to make sure nothing missed out)
  • For diagnostic purposes only
60
Q

What is the duration of empiric MRSA/Pseudomonas Cover if the patient responds to empiric tx?

A

May be stopped in 48h (i.e. de-escalate pip-tazo or stop IV vanco)

*can also stop if no MRSA/Pseudomonas found in culture

61
Q

What are the 5 criteria for stepping down IV abx to PO abx?

A 
ALL criteria needs to be met
• Hemodynamically stable
• Clinically improved/improving
• Afebrile ≥ 24 hours
• Able to ingest PO medications
• Normally functioning gastrointestinal tract
62
Q

Why do we want to step patients down to PO tx?

A

– ↑ patient comfort and mobility
– ↓ risk of nosocomial-acquired bloodstream infections
– ↓ phlebitis
– ↓ preparation and administration time
– ↓ costs (e.g. drug, IV tubing, syringes, time)
– Facilitates discharge

63
Q

A patient was found to be eligible for step down therapy with her culture report has returning positive (for certain organisms) today.
What is the step down plan for the patient?

A

Use susceptibility results to guide selection of PO antibiotic(s)
- if no PO abx alternative, keep the IV abx on

64
Q

A patient was found to be eligible for step down therapy after 2 days of empiric tx. Cultures result are negative (no organism grew).
What is the step down plan for the patient?

A

No positive cultures* for MRSA/Pseudomonas/Burkholderia = stop coverage –> step down to standard regimen
– Use either the same antibiotic or another antibiotic from the same class

*If positive culture, provide the respective culture directed tx

65
Q

Assume patient is on ceftriaxone IV + azithromycin IV, which ONE of the following is the MOST appropriate PO step-down regimen?

  • Cefuroxime PO
  • Augmentin PO + azithromycin PO
  • Ceftriaxone PO + azithromycin PO
  • Levofloxacin PO
A

Ans: Augmentin PO + azithromycin PO

  • Augmentin and ceftriaxone is similar in cover
  • no PO ceftriaxone
66
Q

QN: if pt has positive pseudomonas cultures sensitive to pip-tazo and FQs and is eligible for step down
- would we prefer IV pip-tazo or step it down to PO FQs?

A

Ans:

  • depends on what we want to do
  • if pt want to discharge and go home -> PO FQs (good FQ use as there is a documented pseudomonas infection)
  • if pt staying in hospital -> prefer IV pip-tazo (avoid collateral dmg and side effects of FQs)
67
Q

What is the treatment duration for CAP?

A
  • Treat until clinical stability* for at least 5 days
  • IF MRSA/Pseudomonas: 7days
  • IF Burkholderia: 3-6 months

*Afebrile, able to maintain oral intake, normal vital signs, oxygen saturation and mental status

68
Q

A patient shows clinical improvement after 2 days of empiric abx tx. After appropriate step down therapy, what is the next step in care plan for the patient?

A

Monitor for another day before discharging pt home (preferred but not a must, can step down and discharge w/o monitoring)
- Give pt the rest of abx course to complete PO after clinical improvement (at least 5 days)

69
Q

CAP tx: Provide the ROA, Dose of: Amoxicillin

A

1g PO TDS*

*High dose Amoxicillin

70
Q

CAP tx: Provide the ROA, Dose of: Augmentin

A

625mg PO TDS or 2g PO BD

1.2g IV q8h

71
Q

CAP tx: Provide the ROA, Dose of: Ceftriaxone

A

1-2g IV Q24H

72
Q

CAP tx: Provide the ROA, Dose of: Cefuroxime

A

500mg PO BD

73
Q

CAP tx: Provide the ROA, Dose of: Ceftazidime

A

2g IV q8h

74
Q

CAP tx: Provide the ROA, Dose of: Penicillin G

A

4 million units IV q6h

75
Q

CAP tx: Provide the ROA, Dose of: Azithromycin

A

500mg PO OD

500mg IV Q24H

76
Q

CAP tx: Provide the ROA, Dose of: Clarithromycin

A

500mg PO BD

500mg IV Q12H

77
Q

CAP tx: Provide the ROA, Dose of: Doxycycline

A

100mg PO BD

78
Q

CAP tx: Provide the ROA, Dose of: Levofloxacin

A

750mg PO OD

750mg IV Q24H

Pharmacotherapy (10 decks)

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