Drugs for respiratory infections Flashcards
CURB-65
confusion
uremia (BUN>19)
respiratory rate (>=30)
BP low (systolic =65
CURB-65 scale
0-1 treat outpatient
2-admit
3-ICU
minor criteria of admission
WBC100,000
temp <36
absolute indications for ICU admission
mechanical ventilation
septic shock
CAP CXR
infiltates required for Dx
if neg but CAP strongly suspected start antibiotics and repeat CXR in 24-48hrs
CAP culutre
need to know what microbe to Tx to decrease mortality
CAP UA
legionella
pneumococcal
atypical bacteria
mycoplasma penumoniae
chlamydophilia pneumoniae
legionella
common infecting organisms for outpatient
S. penumoniae M. pneumoniae H. influenza Chlamydophilia pneumoniae respiratory viruses
in-patient non ICU organisms
S. penumoniae M. pneumoniae Chlamydophilia pneumoniae H. influenza legionella aspiration respiratory viruses
ICU organisms
S. penumoniae S. aureus legionella gram - bacilli H. influenza
underlying bronchopulmonary disease
H. influenza
M. catarrhalis
S. aureus
chronic oral steriods, severe underlying bronchopulmonary disease, alcoholism, frequent antibiotic use
enterobacteriaceae
pseudomonas aeruginosa
anaerboes
classic aspirations in alcohol/drug overdose
seizures w/gingical disease
esophageal motility disorders
common CAP viruses
influenza
RSV
adenovirus
parainfluenza
other CAP viruses
human metapnumonvirus
HSV
varicella-zoster
SARS associated coronavirus
2-3% incidence
M. tuberculossis chlamydophilia psittaci coxiella burnetti F. tularensis B. pertusis endemic fungi
drug resistant S. penumoniae (DRSP)
65 B-lactam use w/in previous 3 yrs alcoholics immunosupressed exposure to child at day care
outpatient in previous healthy
macrolide- azithromycin
doxycycline
both PO
outpatient at risk for DRSP
respiratory fluoroquinolone- levofloxacin
B-lactam- amoxicllin +macrolide
all PO
inpatient non ICU
respiratory fluoroquinolone- levofloxacin (PO or IV)
B-lactam- ceftriaxone + macrolide IV
ICU
respiratory fluoroquinolone- levofloxacin
B-lactam- ceftriaxone + macrolide IV
pseudomonas risks
structural lung disease
repeated COPD exacerbations with frequent corticosteroid and/or antibiotic use
prior antibiotic therapy
Tx for psudomonas
anti-psuudomonal B-lactam IV (piperacillin-taxobactam, cefepime) + either cipro or levofloxacin
or
beta lactam + gentamicin and azithromycin
or beta lactam + gentamycin +anti-psudomondal fluoroquinolone
CA-MRSA risk
end stage renal disease
injection drug abuse
prior influenza
prior antibiotic use
CA-MRSA Tx
add vancomycin or linezolid IV
panton-valentine leucocidin necrotizing pneumonia
add clindamycin or use linezolid
IV -> PO
hemodynamically stable normal temp and HR RR 90 SAO2 >90% normal mental status tolerating oral meds normal fnx of GI
duration of therapy
min 5 days, usually 7-10
must be afrebile for 48-72hours
no more then 1 CAP associated sign of clinical insatbility
duration of psudomonas therapy
15 days to prevent relapse
HAP
occurs 48hrs or more after admission
2nd most nosocomial infection in US
increases hospitalization 7-9days
VAP
arises in 48-72 hours after endotracheal intubation
occurs in 9-27%
HCAP
associated w/Hx of hospitalization or exposure to healthcare setting
HAP, VAP, HCAP onset
early onset <4days
late onset 5+ days
HAP, VAP, HCAP aerobic gram neg
P. aeruginosa
E. coli
K. pneumoniae
Acinetobacter
HAP, VAP, HCAP gram pos cocci
MRSA
more common in DM, head trauma, and ICU
HAP, VAP, HCAP oralpharyngeal pathogens
viridans group strep
coagulatse neg staph
neisseria
corynebacterium
Multi-drug resistant pathogens (MDR)
psudomonas aeruginosa klebsiella enterobacter serratia MRSA DRSP
psudomonas aeruginosa
resistance caused by multiple efflux pumps decreased expression of outer membrane porin Ch increasing resistance to piperacllin ceftazidime cefepime imipenem meropenem aminoglycosides fluroquinolones
klebsiella
intrinsically resistant to ampicillin and can acquire resistance to cephalosporins and aztreonma -> ESBL production
enterobacter
high frequency of developing resistance to cephalosporins during Tx
klebsiella, enterobacter, serratis
carry plasmid mediated AmpC-type enzymes (ESBL) which are carbapenem susceptible, but concerned about reisitance
MRSA
> 50% of ICU infection
PBPs w/reduced affinity for B-lactams
concern for linezolid resistance, but still rare
DRSP
altered PBP
all MDR strains in US currently susceptible to vancomycin and linezolid
empiric therapy early onset
ceftiaxone or FQ or ampicillin/sublactam or ertapenem
empiric therapy early onset pathogens
S. pneumoniae
H. influenza
MSSA
sensitive gram neg E. coli, Klebsiella, enterobacter, proteus, serratia
empiric therapy late onset pathogens
P. aeruginosa
Klebsiella
acinetobacter
MRSA
empiric therapy late onset
antipseudomonal cephalosporin or antipsudomonal carbapenem or beta lactam/bata lactamase inhibitor \+ antipseudomonal FQ or aminoglycoside \+ linezolid or vancomycin
VAP duration of therapy
7 days, unless P. aeruginosa -> 15
non resistant S. pneumoniae
Penicillin G
amoxicillin
resistant S. pneumoniae
cefotaxime ceftriaxone levofloxacin moxifloxacin vancomycin linezolid
H. influenza
non-B-lactamaase producing: amoxicillin
B-lactamase producing: 2nd or 3rd generation cephalosproin and amoxicillin
M. pneumoniae
macrolide
tetracycline
C. pneumoniae
macrolide
tetrocycline
C. Psittaci
doxycylcine
legionella
fluoroquinolone
azithromycin
doxycycline
enterobacteriaecease
3rd or 4th genreation cephalosproin
carbapenem
Psudomonas
antipseudomonal B-lactam + ciprofloxacin, levofloxacin, or an aminoglycoside
S. aureus methicillin-sensative
antistaphylococcal penicillins
nafcillin
oxacillin
dicloxacillin
MRSA
vancomycin or linezoid
pneumocystis jiroveci
trimethoprim/sulfamethoxazole
Bordetella pertussis
azithromycin
clarithromycin
influenza virus
osteltamivir
zanamivir
coccioidioides
no treatment necessary if otherwise healthy
if needed itraconazole, fluconazole
histoplasmosis and blastomycosis
itraconazole
B-lactams MOA
stuctural analongs of D-Ala-D-lAla
covelently bind benicillin-binding proteins (PBPs)
inhibit cell wall synthesis
resistance B-lactams
structural difference in PBPs
decreased PBP affinity for B-lactam
inability for drug to reach site of action
active efflux pumps
drug destruction and inactivation by B-lactamases
pencillins adverse effects
allergic rxn anaphylaxis interstitial nephritis (rare) GI pseudomembranous colitis
cephalosporins adverse rxn
1% risk of cross-rxn to penicillins
diarrhea
intolerance to alcohol
carbapenems adverse effects
nausea/vomiting
seizures
hypersensitivity
vancomycin MOA
inhibits cell wall synthesis
vancomycin resistance
alteration of D-Ala-D-Ala target
which bind glycopeptides poorly
vancomycin adverse effects
macular skill rash chills fever rash red man syndrome (histamine) hypotnesion tachycardic ototoxicity and nephrotoxicity
fluoroquinolones MOA
concentration dependent
targets bacterial DNA gyrase and topoisomerase IV
active transport out of cell
fluoroquinolones adverse effects
GI
CNS
rash, photosensitivity
achilles tendon rupture
fluoroquinolones contraindications
kids
30s inhibitors
aminoglycosides
tertracycline
aminoglycosides advere efects
ototoxicity
nephrotoxicity
neuromuscular blockade
tetracycline adverse effects
GI
superinfections w/C. difficile
photosensitivity
teeth discoloration
50s inhbitiors
macrolides
clindamycin
streptogamins
linezolid
macrolides adverse effects
GI
hepatoxicity
arrythmias
clindamycin adverse effects
Diarrhea
C. dif
skin rash
streptogramins adverse rxns
infusion pain and phelbitis
linezolid adverse rxns
myelosupression
HA
rash
neurominidase inhibitors
oseltamivir
anamivir
neurominidase inhibitors MOA
analogs of sialic acid
interfere w/release of progeny influenza virus from infected host cell
oseltamivir adverse effects
nausea, vomiting, abdominal pain
HA, fever, diarrhea, neuropsychiatric effects
children >1yr
zanamirvir adverse effects
cough bronchospasm decrease in pulmonary fnx nasal/throat discomfort not recommended in underlying airway disease children >7
neurominidase resistance
point mutation in viral hemagglutinin (HA) or neuroaminidase (NA)
all influenza A and B susceptible
H1N1 resistant ot oseltamivir
uses of neuroamindase
influenza prophylaxis
influenza Tx
M2Ch Blockers
amantadine
rimantadine
M2Ch blocker MOA
block M2 proton ion Ch of virus inhibiting uncoating of viral RNA w/in host cell
only works against influenza A
M2Ch blocker adverse effects
GI CNS severe behavioral changes delirium agitation seizures
other anti-virals
acyclovir
valacylovir
ganciclovir
valgancyclovir
acyclovir and valacylovir MOA
inhibits DNA synthesis
acyclovir and valacylovir uses
genital herepes varicella HSV encephalitis neonatal HSV
acyclovir and valacylovi adverse effects
nausea
diarrhea
HA
ganciclovir and valgancyclovir MOA
termination of DNA elongation
ganciclovir and valgancyclovir uses
CMV retinitis
CMV prophylaxis
ganciclovir and valgancyclovir adverse effects
myelosuppression nausea diarrhea fever peripheral neuropathy
antifungal uses
candida albicans histoplama cryptococcus neoformans coccidioides adpergillus blastomyces
Azole antifungals MOA
inhibits fungal cytochrome P450 reducing production of ergosterol
Azole antifungals uses
candida blastomycosis coccidiodomycosis histoplasmosis aspergillus
Azole antifungals adverse effects
minor GI
abnormal liver enzymes
drug interactions
amphotericin B
polyene macrolide antibiotic
amphotericin B MOA
binds ergosterol and changes permeabilty of cell by forming pores in cell membrane
amphotericin B uses
broadest spectrum of activity
useful in life threatening situations, but very toxic
amphotericin B uses
infusion related fever chills HA vomiting cumulative toxicity ->renal damage
echinocandins
caspofungin
micafungin
anidulafungin
all IV
echinocandins MOA
inhibits synthesis of B-glucan
disrupts fungal cell wall -> cell death
echinocandins uses
candida
aspergillus
echinocandins adverse effects
minor GI
flushing
