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PR3124 > Community Acquired Pneumonia (CAP) > Flashcards

Community Acquired Pneumonia (CAP) Flashcards

1
Q

Mechanism of acquiring pneumonia

A
  1. Aspiration of oropharyngeal secretions
  2. Inhalation of infected aerosol
  3. Hematogeneous (extra-pulmonary infection)
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2
Q

Tests to diagnose pneumonia (5)

A
  1. Laboratory findings
    - CRP
    - Procalcitonin
    - not rlly done cos it is non-specific
  2. Sputum culture
    - high contamination
    - valid only if >10 neutrophils & <25 WBC per low power field
  3. Lower respiratory tract culture
    - Bronchoalveolar Lavage (BAL)
    - need to sedate patient and insert tube to use fluids to pick up pathogens
    - invasive
  4. Blood culture
    - rule out bacteremia
  5. Urinary antigen test
    - Streptococcus pneumoniae & Legionella pneumophilia
    - indicate exposure to pathogen only
    - not rlly used cos positive result even after effective antibiotics for days to weeks
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3
Q

Classifications of pneumonia

A
  1. Community Acquired Pneumonia (CAP)
    - in community
    - <48h after hospitalisation
  2. Hospital Acquired Pneumonia (HAP)
    - >=48h after hospitalisation
  3. Ventilator Associated Pneumonia (VAP)
    - >=48h after on mechanical ventilator
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4
Q

Risk factors for CAP

A
  1. > = 65y/o
  2. Prev hospitalisation for CAP
  3. Smoking
  4. Comorbidities (COPD, HF, DM, cancer & immunosuppresion)
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5
Q

Prevention of CAP

A
  1. Avoid smoking

2. Vaccination (pneumoccocal & influenza)

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6
Q

Pathogens of pneumonia in Outpatient, healthy patients

A
  1. Streptococcus pneumoniae
  2. Haemophilus influenzae
  3. Atypicals (not rlly)
    - Mycoplasma pneumoniae
    - Chlamydophilia pneumoniae
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7
Q

Pathogens of pneumonia in outpatient w comorbidities patients

A
  1. Streptococcus pneumoniae
  2. Haemophilus influenzae
  3. Atypicals
    - Mycoplasma pneumoniae
    - Chlamydophilia pneumoniae
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8
Q

Pathogens of pneumonia in in-patient, non-severe patients

A
  1. Streptococcus pneumoniae
  2. Haemophilus influenzae
  3. Atypicals
    - Mycoplasma pneumoniae
    - Chlamydophilia pneumoniae
    - Legionella pneumophilia
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9
Q

Pathogens of pneumonia in in-patient, severe patients

A
  1. Streptococcus pneumoniae
  2. Haemophilus influenzae
  3. Atypicals
    - Mycoplasma pneumoniae
    - Chlamydophilia pneumoniae
    - Legionella pneumophilia
  4. Staphylococcus aureus
  5. Gram -ve
    - Klebsiella pneumoniae
    - Burkholderia pseudomallei
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10
Q

Infection of Burkholderia pseudomallei

A

Melioidosis

- pneumonia is a common presentation of this group of infection

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11
Q

What are used to judge severity of CAP? (risk stratification)

A
  1. Pneumonia Severity Index (PSI)
    - 20 factors into 5 classes
    - not rlly used
  2. CURB-65
    - 5 factors into 3 classes
    - readily available parameters
  3. IDSA-ATS
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12
Q

IDSA-ATS Criteria for severe CAP

A

Major (2)

  1. Mechanical ventilation required
  2. Severe hypotension requiring vasoactive medications

Minor (8)

  1. RR >= 30bpm
  2. PaO2/FiO2 =< 250
  3. Uremia >7mmol/L
  4. Hypothermia <36dc
  5. Multilobar infiltrates
  6. Confusion/disorientation
  7. Leukopenia WBC<4x10^9 /L
  8. Hypotension requiring aggressive fluid rescucitation

Severe CAP if :
>=1 major
>= 3 minors

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13
Q

Standard empiric therapy for outpatient, healthy

A
  1. PO Amoxicillin
  2. PO Respiratory fluoroquinolones
    (Levofloxacin, Moxifloxacin)
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14
Q

Standard empiric therapy for outpatient w comorbidities

A
  1. PO Amoxicillin/Clavulanate or PO Cefuroxime
    + PO Azithromycin/Clarithromycin/Doxycycline

or

  1. PO Respiratory fluoroquinolones
    (Levofloxacin, Moxifloxacin)
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15
Q

Standard empiric therapy for inpatient, non-severe

A
  1. IV Amoxicillin/Clavulanate or IV Ceftriaxone
    + PO/IV Azithromycin/Clarithromycin/Doxycycline

or

  1. PO/IV Respiratory fluoroquinolones
    (Levofloxacin, Moxifloxacin)
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16
Q

Standard empiric therapy for inpatient, severe

A
  1. IV Amoxicillin/Clavulanate
    + IV Ceftazidime (Burkholderia pseudomallei)
    + PO/IV Azithromycin/Clarithromycin/Doxycycline

or

  1. PO/IV Respiratory fluoroquinolones
    (Levofloxacin, Moxifloxacin)
    + IV Ceftazidime (Burkholderia pseudomallei)
17
Q

What if patient has penicillin allergy & inpatient, severe pneumonia?

A

Only can use PO/IV Respiratory fluoroquinolones w/o Ceftazidime

18
Q

When is anaerobic coverage for CAP required?

A
  1. Lung abscess

2. Empyema

19
Q

Common anaerobic pathogens (4)

A
  1. Bacteriodes fragilis
  2. Prevotella spp
  3. Porphyromonas spp
  4. Fusobacterium spp
20
Q

Antibiotics used for CAP anaerobes

A
  1. PO/IV Clindamycin
  2. PO/IV Metronidazole
  3. Amoxicillin/Clav
  4. Moxifloxacin
  5. Piperacillin/Tazobactam

Add above to treat anaerobes

21
Q

When is MRSA coverage for CAP required?

A
  1. Positive respiratory cultures of MRSA within 1 year

2. Hospitalisation and IV antibiotics used within 90 days, (or locally validated risk factors) (IF SEVERE CAP ONLY)

22
Q

Antibiotics used for CAP MRSA

A
  1. IV Vancomycin
  2. PO/IV Linezolid

Add above to treat MRSA

23
Q

When is Pseudomonas aeruginosa coverage for CAP required?

A
  1. Positive respiratory cultures of Pseudomonas aeruginosa within 1 year

SEVERE CAP alr got Ceftazidime which can cover Pseudomonas (for Burkholderia)

24
Q

Why is Daptomycin not used to cover MRSA?

A

It can penetrate lungs but it is deactivated by lung surfactant

25
Q

Antibiotics used for CAP Pseudomona aeruginosa

A
  1. IV Piperacillin/Tazobactam
  2. IV Ceftazidime
  3. IV Cefepime
  4. IV Meropenem (save for ESBL)
  5. PO/IV Levofloxacin

Modify treatment to include above

26
Q

Duration of treatment

A

5 days

MRSA/Pseudomonas - 7 days
Burkholderia - 3-6 months

27
Q

Is adjunctive corticosteroids used?

A

No as the risk for hyperglycemia is higher than the benefits

28
Q

Monitoring of therapy

A
  • patient should improve within 48-72h
  • should not escalate antibiotic therapy in the first 72h, wait for AST and culture results (time needed for antibiotics to work)
  • do not use radiological findings as improvements lag behind (4-6 weeks)
29
Q

Step down therapy not necessary for these pathogens (IV to PO)

A
  1. MRSA
  2. Pseudomona aeruginosa
  3. Burkholderia pseudomallei
30
Q

Comorbidities in out-patient CAP

A
  1. Heart, lungs, liver and kidney failure
  2. DM
  3. Alcoholism
  4. Malignancy
  5. Asplenia

PR3124 (6 decks)

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