Drugs for the treatment of Resp infections (Kinder - lecture) Flashcards
what patients are excluded from the general guidelines of management of community acquired pneumonia ?
Immunocompromised patients
Solid organ, bone marrow, or stem cell transplant
Those receiving chemotherapy
Long-term high dose corticosteroids (> 30 days)
Congenital or acquired immunodeficiency
HIV with CD4 count < 350 cells/mm3
Children ≤ 18 years
what is the CURB-65 score based on? what criteria?
it is a tool to assess pneumonia severity
Confusion
Uremia (BUN > 19 mg/dL)
Respiratory rate (≥ 30 breaths/min)
Low blood pressure
SBP < 90 mmHg, DBP ≤ 60 mmHg
Age (≥ 65 Years)
CURB-65 score of 0-1
treat as outpatient
score of 2 (CURB-65)
admit to hospital
Score of >3 (CURB-65)
admit to ICU
what are the minor criteria that are included with CURB - 65 score to determine need for ICU admission (x3)
WBC < 4000 cells/mm3
PLT < 100,000 cells/mm3
Core temperature < 36 ˚C
2 absolute indications for ICU admission
mechanical ventilation
septic shock
Clinical findings of Community aquired pneumonia?
what if a CXR is negative?
cough
fever
sputum production
pleuritic chest pain
demonstratable infiltrate on CXR is required ***
If negative but CAP suspected, initiate antibiotics and repeat CXR in 24-48 hours
what are the atypical bacteria in CAP
3
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella spp
what are the most common outpatient bugs in CAP
5
Streptococcus pneumoniae (diplococci) Mycoplasma pneumoniae Haemophilus influenzae Chlamydophila pneumoniae Respiratory viruses
most common bugs in inpatient CAP (non-ICU) ‘
7
S. pneumoniae M. pneumoniae C. pneumoniae H. influenzae Legionella spp Aspiration Respiratory viruses
what are the most common bugs in inpatient ICU
5
S. pneumoniae Staphylococcus aureus Legionella spp Gram-negative bacilli H. influenzae
infecting organisms and disease state of underlying bronchopulmonary disease?
3
H. influenzae
Moraxella catarrhalis
+ S. aureus during an influenza outbreak
patient on chronic oral steroids or severe underlying bronchopulmonary disease, alcoholism, frequent antibiotic use? what bugs are frequent in them
2
Enterobacteriaceae
Pseudomonas aeruginosa
Classic aspiration pleuropulmonary syndrome in alcohol/drug overdose or in seizures with gingival disease or esophageal motility disorders
1
anaerobes (aspiration of the common mouth bugs that leads to pneumonia)
what are common viruses in CAP *4
Influenza
RSV
Adenovirus
Parainfluenza virus
Drug resistant s. pneumoniae (DRSP) is more common in what groups…
5
Age < 2 years or > 65 years
B-lactam use within previous 3 months*** (amoxicillin?)
Alcoholism
Immunosuppressive illness or therapy
Exposure to child at day care
for a previously healthy patient what would you use for CAP
Macrolide PO (***azithromycin)
Doxycycline PO
what patients are at risk for drug resistant strep pneumoniae
what would you use to treat patients
one drug
OR
two drugs
Comorbidities age 65 use of antimicrobials (beta lactams) within 3 months alcoholism immunosuppressive illness or therapy exposure to child at day care
Respiratory fluoroquinolone PO (levofloxacin***, moxifloxacin)
B-lactam PO [high dose amoxicillin* or amoxicillin-clavulanate* preferred (alternates: ceftriaxone, cefuroxime)]
PLUS** a macrolide PO (azithromycin)
inpatient, non ICU
what do you use to cover CAP
one drug
OR
one drug PLUS one drug
Respiratory FQ IV or PO (levofloxacin***, moxifloxacin)
B-lactam IV (ceftriaxone, cefotaxime, or ampicillin preferred)
PLUS macrolide IV (azithromycin*)
inpatient ICU patient . what would you use for coverage for CAP
B-lactam IV (ceftriaxone***, cefotaxime, or ampicillin/sulbactam preferred)
PLUS macrolide (azithromycin) IV OR a respiratory FQ (levofloxacin***, moxifloxacin)
what are the risk factors for pseudomonas?
Structural lung disease (bronchiectasis)
Repeated COPD exacerbations
Frequent corticosteroid and/or antibiotic use
Prior antibiotic therapy
how do you treat patients with pseudomonas?
2 drugs
OR
1 drug plus 2 drugs
Anti-pseudomonal B-lactam IV (piperacillin-tazobactam, cefepime, meropenem)
PLUS FQ–> either ciprofloxacin or levofloxacin
Or
B-lactam PLUS: An aminoglycoside (gentamicin) AND azithromycin (covers atypicals)
An aminoglycoside (gentamicin) AND anti-pseudomonal fluoroquinolone (ciprofloxacin)
CA methicillin resistant staphylococcus aureus (CA-MRSA) risks….
4
End-stage renal disease (dialysis)
Injection drug abuse
Prior influenza
Prior antibiotic use (especially FQ)
treatment for CA-MRSA
Add vancomycin (Glycopeptide- inhibits cells wall synthesis) IV or linezolid (binds P site of 50S ribosome)
what criteria allow you do transition from IV to oral therapy?
what are the signs (7) that a person is improving clinically
Hemodynamically stable
Improving clinically: Temperature ≤ 37.8 ˚C HR ≤ 100 bpm RR ≤ 24 breaths/min SBP ≥ 90 mmHg Arterial 02 saturation ≥ 90% Ability to maintain oral intake Normal mental status
Tolerating oral medications
Normal functioning GI tract
what is the duration of therapy for antibiotics for CAP
Minimum of 5 days treatment
Most patients receive 7-10 days
what are the criteria for ending of therapy….
what is the exception?
Must be afebrile for 48-72 hours
No more than 1 CAP-associated sign of clinical instability
Exception:
Pseudomonas – 8 day course led to more relapse compared to 15 day course
what is the definition of Hospital acquired pneumonia?
occurs 48 hours or more after admission
2nd most common nosocomial infection in the U.S.
Increases hospital LOS ~7-9 days
Incidence: 5-10 cases per 1000 admissions
what is ventilator associated pneumonia
arises 48-72 hours after endotracheal intubation
Occurs in 9-27% of all intubated patients
Incidence increases with longer ventilation duration
Health care associated pneumonia ?
associated with history of hospitalization or exposure to healthcare settings
exposure to health care setting
chemo
hemodialysis
what is early onset of HAP, VAP, HCAP?
late onset?
early onset is <4 days
5+ or more days after admission
what are the common pathogens in HAP, VAP, HCAP?
Aerobic gram-negative P. aeruginosa E. coli K. pneumoniae Acinetobacter spp
GPCs (gram positive)
MRSA (more common in diabetes, head trauma, those hospitalized in ICUs)
Oropharyngeal Viridans group streptococci Coagulase-negative staphylococci Neisseria spp Corynebacterium spp
Pseduomonas aeruginosa mechanisms for being drug resistant?
multiple efflux pumps **
Decreased expression of outer membrane porin channel
Increasing resistance to: piperacillin (b-lactamase inhibitor), ceftazidime (third generation cephalosporin), cefepime (fourth generation cephalosporin), imipenem, meropenem (carbapenem), aminoglycosides, fluoroquinolones
MRSA (staph aureus)…. resistance mechanisms?
DRSP resistance mechanisms?
> 50% of ICU infections caused by S. aureus methicillin resistant
PBPs with 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
