IC16 LRTI Flashcards
How can pneumonia be spread? (3)
- Oropharyngeal secretions
- Inhalation of aerosols
- Hematogenous spreading
What are the three main risk factors for development of pneumonia?
Smoking
Chronic conditions
Immunosuppression
How does smoking increase risk for pneumonia development?
Smoking suppresses neutrophil function and damages the lung epitheliun
What are the SYSTEMIC s/sx of pneumonia?
Fever, chills, malaise, confusion in elderly, hypotension and tachycardia
What are the LOCAL s/sx of pneumonia?
cough, chest pain on coughing, shortness of breath, thacypnea, hypoxia, increased sputum production
What is the significance of radiographic findings in pneumonia?
CXR is the most important for diagnosis, requires new infiltrates or dense consolidations
When should the urinary antigen test be done for pneumonia?
In severe CAP or hospitalised patients
What sources should respiratory gram stain and culture be taken? (2)
Sputum or LRT sample
What are the pros and cons of using sputum for testing?
Not invasive
Prone to contamination, low yield
What are the pros and cons of using LRT for testing?
Less contamination
Invasive
How is CAP classified?
Onset in the community or less than 48h after admission
How is HAP classified?
Onset >= 48h after admission
How is VAP classified?
Onset >= 48h after starting mechanical ventilation
What are the common pathogens for outpatient or non-severe inpatient? (3)
Strep pneuno
H. influenzae
Atypicals
What are the common pathogens for inpatient severe? (5)
Strep pneuno
H. influenzae
Atypicals
S aureus
GN bacilli
What is CURB65 used for?
Determines inpatient/outpatient in CAP
What are the CURB65 components?
Confusion (new onset)
Urea > 7mmol/L
RR >= 30 bpm
BP (sbp < 90 or dbp <= 60)
Age >= 65
What is the IDSA minor/major criteria used for?
Determine severe CAP
one or more major OR
thee or more minor
What are the 2 major criteria for IDSA
Mechanical ventilation
Septic shock requiring vasoactive medications
What are the 8 minor criteria for IDSA
RR >= 30 bpm
Urea > 7 mmol/L
Leukopenia (WBC < 4 x 10^9 /L)
Confusion or disorientation
PO2 FiO2 < 250
Hypothermia (core temp < 36ºC)
Multilobar infiltrates
Hypotension requiring aggressive fluid resuscitation
What are empiric treatment options for outpatient CAP with no comorbidities?
(hint: rmb the table!)
PO Amoxicillin 1g q8h
PO Levofloxacin 750mg OD
PO Moxifloxacin (no dose)
What are empiric treatment options for outpatient CAP with comorbidities or inpatient non-severe CAP?
(hint: rmb the table!)
PO Amoxicillin-clavulanate 625mg TDS
PO Cefuroxime 500mg BD
(with)
PO Azithromycin 500mg OD
PO Clarithromycin 500mg BD
PO Doxycycline 100mg BD
OR
PO Levofloxacin 750mg OD
PO Moxifloxacin (no dose)
What are empiric treatment options for severe inpatient CAP
(rmb the combination of 3!!, cover for burkholderia)
(hint: cover for 3, so 3rd gen)
IV Amoxicillin-clavulanate* 625mg TDS
IV Penicillin G (no dose)
(with)
IV Clarithromycin 500mg BD
IV Azithromycin 500mg OD
(with)
IV Ceftazidime 2g q8h
OR
PO Levofloxacin 750mg OD
PO Moxifloxacin* (no dose)
(with)
IV Ceftazidime 2g q8h
Which fluoroquinolone covers pseudomonas and which doesnt?
Lefloxacin covers
Moxifloxacin does not cover
What should you cover if there is a lung abcess or empyema?
Cover for anaerobes
If standard regimen does not cover, add IV metronidazole or IV/PO Ciprofloxacin
Respiratory quinolones are NOT first-line. What are the prominent side effects associated with them? (4)
Tendonitis, tendon rupture
QTc prolongation
CNS disturbances
Hypoglycemia
How long should CAP be treated for?
5 days
What can be done for patients on mechanical ventilation to reduce instances of VAP? (3)
- Limit duration of mechanical ventilation
- Minimise levels of deep sedation
- Elevate the bed head by 30º
What 2 pathogens should be empirically covered in HAP/VAP?
Pseudomonas and S. aureus
What are MRSA risk factors? (4)
(cover for MRSA if any ONE of the following)
- post IV abx use in the last 90 days
- isolation of MRSA in the last 1 year
- hospitalisation in a unit where MRSA makes up > 20% of S. aureus cases
- MRSA prevalence not known but patient at high mortality risk
What are Pseudomonas risk factors? (3)
(cover for pseudomonas if any ONE of the following)
- Risk factors for antimicrobial resistance (IV abx in last 90 days, acute RRT, isolation of pseudomonas in last 1 year)
- Hospitalisation in a unit where > 10% of pseudomonas is resistant to an agent being considered for monotherapy
- Unknown pseudomonas prevalence but high mortality risk
Why should aminoglycosides not be used as monotherapy in HAP/VAP?
Very toxic, high risk of nephrotoxocity and ICU patients are already hemodynamically unstable hence giving them a higher risk for nephrotoxicity
What drugs should be used for pseudomonas cover in HAP/VAP? (5)
(hint: PseudoMonal Cover = PMC)
IV Piperacillin-tazobactam 4.5g q6h
IV Cefepime 2g q8h
IV Ceftazidime 2g q8h
IV Meropenem 1g q8h
IV Imipenem-Cilastatin 500mg q8h
What agents can be added on for double pseudomonal cover in HAP/VAP? (4)
(hint: 2 classes)
IV Levofloxacin 750mg OD
IV Ciproflixacin 400mg BD
(or)
IV Gentamicin 5mg/kg OD
IV Amikacin 15mg/kg OD
What agents can be added for MRSA cover in HAP/VAP? (2)
(add)
IV Vancomycin 15mg/kg q8h
PO/IV Linezolid 600mg q12h
How long should HAP/VAP be treated for?
7 days, extend to 10 if need
2-3 weeks if deep seated infections
4-6 weeks for less common bacteria
