Exam 3 - LRTI Flashcards
when does CAP occur
outside the hospital or within the first 48 hours of admission
what are the three main ways CAP can occur
aspiration
aerosolization
blood born
what are the main bacterial pathogens for CAP
strep pneumo
h. influenzae
Mycoplasma pneumo
legionella pneumo
chlamydia pneumo
staph aureus
what tests should be completed to assess risk for staph aureus in CAP patients
MRSA nasal pcr
what are additional risk factors for CAP patients
alcoholism
COPD/smoker
lung disease
ABX recently
what is more common for CAP bacteria or virus
virus
what is the classic presentation for CAP
sudden fever, chills, dyspnea, productive cough, chest pain
how do the elderly present with CAP
may not have classic signs of fever and leukocytosis
more likely to have altered mental status, weakness, functionality
what are the typical presenting vitals for a CAP patient
febrile (>38 degrees celsius)
tachycardia
hypotensive
tachypnea
what tests should be done for CAP diagnosis
chest x-ray for all suspicious cases
WBC w/ differential
SCr, BUN, electrolytes
PCR swabs
pulse ox
cultures (save for more severe)
how many minor criteria do you need to meet in order to have severe CAP
need at least 3
what are the minor criteria for severe CAP
Resp rate greater than 30
multilobar infiltrates
confusion/disorientation
uremia BUN > 30
leukopenia WBC <4000
thrombocytopenia
hypothermia
hypotension requiring aggressive fluids
how many major criteria are needed to classify as severe CAP and what are they
at least 1
septic shock requiring vasopressors
respiratory failure requiring mechanical ventilation
what is supportive care for CAP
humidified air
bronchodilators
fluids
CAP empiric therapy for:
outpatient
healthy w/o comorbidities
Amox 1gm PO Q8H
Doxy 100mg PO BID
Azith zpack (high resistance)
CAP empiric therapy for:
outpatient
w/ comorbidities
- Levo 750mg PO QD
- Moxi 400mg PO QD
- b-lactam + macrolide or doxy (preferred option)
CAP what b-lactams should be used when treating outpatient CAP w/ comorbidities
- Augmentin
- Cefpodoxime
- Cefuroxime
CAP empiric therapy for:
inpatient
non severe
no MRSA/pseudomonas
- Levo 750 or Moxi 400
- B-lactam + macrolide
CAP empiric therapy for:
inpatient
severe
no MRSA/pseudomonas
- Levo or Moxi + B-lactam
- B-lactam + macrolide
what b-lactams should be used inpatient w/ CAP
- Amp/sulbactam
- ceftriaxone
what can be used in place of a macrolide in inpatient CAP
doxycycline
what are risks for MRSA in CAP
2-14 days post influenza
previous MRSA
previous hospitalization and use of IV antibiotics within 90 days
what are risks for pseudomonas in CAP
previous pseudomonas
previous hospitalization and IV antibiotics in 90 days
CAP empiric therapy for:
inpatient
MRSA risks
Vanc or Linezolid
CAP empiric therapy for:
inpatient
pseudomonas risk
-Pip/tazo
-cefopime
-meropenem
when to use corticosteroids in CAP
only when there is septic shock
duration of therapy for CAP
minimum of 5 days
CAP pen-susc streptococcus pneumoniae 1st line treatment
pen G or amox
CAP pen-resist strep pneumo 1st line treatment
ceftriaxone or respiratory FQ
CAP h. influenzae first line treatment
2nd/3rd gen cephalosporin
unasyn
augmentin
CAP mycoplasma pneumoniae 1st line treatment
macrolide or doxy
CAP chlamydia pneumoniae first line treatment
macrolide or doxy
CAP legionella first line treatment
FQ or azithromycin
CAP MSSA first line treatment
cefazolin or nafcillin
CAP MRSA first line treatment
vanc or linezolid
CAP anaerobes first line treatment
b-lactam/bL inhibitor and add metronidazole if utilizing cephalosporin
CAP enterbacterales first line treatment
3rd/4th gen cephalosporin
carbapenem
what is hospital acquired pneumonia
greater than 48 hours after hospital admission
what is VAP
greater than 48 hours after endotracheal intubation
how to diagnose HAP/VAP
no standard diagnosis mostly based on timing and presentation
what are the risks for HAP/VAP
advanced age
severe comorbidities
duration of hospitalization
multidrug resistance (prior ABX use)
HAP common pathogens
Pseudomonas aeruginosa
Enterobacterales
Acinetobacter
Staph Aureus greatest concern!
what is the duration of therapy for HAP
7 days if clinically stable
what are MRSA risks in HAP
previous MRSA or ABX in 90 days
>10-20 MRSA rates
unknown MRSA prevalence
what are pseudomonas risks in HAP
> 10% incidence
resistance rates unknown
HAP empiric therapy for:
MRSA coverage
vanc or linezolid
HAP empiric therapy for pseudomonas
pip/tazo
cefepime
imipenem
meropenem
levofloxacin
HAP empiric therapy for:
not high risk
Pip/tazo
cefepime
imipenem
meropenem
levo
what are you trying to cover in HAP w/ no high risk
goal is to cover MSSA and pseudomonas
HAP empiric therapy for:
not high risk
w/ MRSA
pip/tazo, cefepime, imipenem, meropenem, levo PLUS vanc or linezolid
what is the goal when treating HAP w/ no high risk but MRSA
goal is to cover MRSA and pseudomonas
HAP empiric therapy for:
high risk
w/ MRSA
pick 2 different classes from pip/tazo, cefepime, imipenem, meropenem, levo, tobra/amikacin
PLUS vanc or linezolid
what is the goal when treating HAP w/ high risk and MRSA
goal is to cover MRSA and multidrug resistant pseudomonas
VAP empiric therapy
pick two from pip/tazo, cefepime, imipenem, meropenem, levo, tobra/amikacin PLUS vanc or linezolid
what is the goal when treating VAP
goal is to cover MRSA and pseudomonas
when should daptomycin be used in LRTI
NEVER! inactivated by pulmonary surfactant
when should aminoglycosides be used in LRTI
never as monotherapy and avoid empiric unless necessary (lots of AEs)
when to use polymyxins in LRTI
avoid empiric, reserve for high MDR patients
when to use tigecycline
good if also intra-abdominal infections.
