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IC16 LRTI Flashcards

1
Q

What are the possible LRTIs?

A

bronchitis
pneumonia

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2
Q

What is acute bronchitis?

A

acute cough that lasts for <3 weeks due to inflammation of the trachea & bronchi

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3
Q

Which pathogen is more likely to cause acute bronchitis?

A

virus > bacteria

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4
Q

How does acute bronchitis typically come about?

A

typically preceded by a viral URTI

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5
Q

How do we treat acute bronchitis?

A

no need treatment as it is self-limiting

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6
Q

When do we use antibiotics for acute bronchitis?

A

when the patient develops a bacterial superinfection as a complication of the acute bronchitis

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7
Q

How do we counsel a patient with acute bronchitis?

A
  • the cough may last for 3 weeks
  • abx is not needed as it will not help you recover from your cough faster
  • see a Dr if you develop fever, SOB, chest pain, cough increases in extent/frequency, or significant cough persists >3 weeks
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8
Q

What is pneumonia?

A

infection of the alveoli due to proliferation of microbial pathogens at the alveolar level

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9
Q

What are the possible pathogens that can cause pneumonia?

A

bacteria, fungi, virus

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10
Q

Which pathogen is most likely to cause pneumonia?

A

bacteria

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11
Q

Describe the pathogenesis of pneumonia (how it comes about)

A
  1. bacteria enters the lower respiratory tract via 3 mechanisms
  2. bacteria proliferates in lower respiratory tract and alveoli
  3. pneumonia
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12
Q

Describe the various pathways that bacteria can enter our lower respiratory tract to cause pneumonia

A
  • aspiration of oropharyngeal secretions (breathe in bacteria from your own oropharyngeal section)
  • inhalation of aerosols (inhale droplets that contain the bacteria)
  • hematogenous spreading (bacteremia from another distant infection site)
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13
Q

What are the risk factors for pneumonia?

A
  • smoking (suppress neutrophil function + impair MCC + damage lung epithelium)
  • chronic lung conditions (eg. asthma, COPD) (destroy lung tissue + creates niduses for bacteria to multiply)
  • immune suppression (eg. HIV, sepsis, GC, chemotherapy)
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14
Q

What should we look out for when pneumonia is suspected?

A
  • systemic symptoms
  • localised symptoms
  • physical exam
  • CXR
  • lab findings
  • urinary antigen tests
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15
Q

What are the systemic symptoms that pneumonia presents with?

A
  • fever
  • chills
  • malaise
  • altered mental status in elderly
  • tachycardia
  • hypotension
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16
Q

What are the localised symptoms that pneumonia presents with?

A
  • cough*
  • chest pain
  • SOB
  • tachypnea (RR >22)
  • hypoxia
  • increased sputum production
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17
Q

What does the type of cough that presents with pneumonia tell us?

A

wet cough - due to Strep pneumoniae
dry cough - due to H influenzae

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18
Q

What results from the physical exam support the diagnosis of pneumonia?

A
  • diminished breath sounds over affected area
  • crackles when breathing in
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19
Q

What are the radiographic findings that support the diagnosis of pneumonia?

A

evidence of NEW infiltrates/dense consolidation in CXR

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20
Q

What are the general lab findings that support the diagnosis of pneumonia?

A

signs of systemic infection (high WBC, cRP, procalcitonin)

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21
Q

What is urinary antigen test for?

A

detect presence of strep pneumoniae/legionella pneumophilia

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22
Q

What do the results of the urinary antigen test tell us?

A

positive for strep pneumoniae/legionella pneumophilia = EXPOSURE to the bacteria

bacteria can be causing pneumonia now OR is from previous infection

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23
Q

When is urinary antigen test recommended for pneumonia?

A
  • severe CAP
  • hospitalized patients
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24
Q

What kind of cultures do we need to obtain for pneumonia?

A
  1. blood culture
  2. respiratory culture & gram-stain
    (obtain pre-treatment)
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25
Q

What kind of samples should we use for respiratory culture?

A

lower respiratory tract sample eg. bronchoalveolar lavage (BAL)

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26
Q

What kind of samples should we NOT use for respiratory culture and why?

A

sputum culture; highly contaminated + low yield

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27
Q

When is pre-treatment blood and respiratory cultures indicated?

A
  • severe CAP
  • risk factors for drug resistant pathogens (MRSA & PA)
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28
Q

What are the types of pneumonia?

A

community acquired (CAP)
hospital acquired (HAP)
ventilator associated (VAP)

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29
Q

What are some non-pharmacological strategies to reduce the risk of contracting CAP?

A
  • smoking cessation
  • immunization (influenza, pneumococcal)
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30
Q

What are the possible bacteria causing CAP?

A
  • Strep pneumoniae
  • H influenzae
  • Atypicals (Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella pneumophilia)
  • Staph aureus
  • G(-) bacilli, esp Burkholderia pseudomallei (tropical country)
  • MRSA & PA based on risk factors
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31
Q

What are the other pathogens to consider for pneumonia?

A
  • influenza during circulating season (april-june, dec-feb)
  • COVID-19 if presents w covid symptoms
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32
Q

What are the tools used for risk stratification of CAP?

A
  1. Pneumonia Severity Index (PSI)
  2. CURB-65
  3. IDSA/ATS Criteria for Severe CAP
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33
Q

PSI:
1. How many variables does it involve?
2. How many classes of CAP does it use?
3. How/where do we treat patients of the different classes?

A
  1. 20 variables
  2. 5 classes (Class I-V)
  3. class I-II: outpatient
    class III: short hospitalization/observation
    class IV-V: inpatient
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34
Q

CURB-65:
1. How many variables does it involve?
2. What are the variables?
3. How many risk classes of CAP does it use?
4. How/where do we treat patients of the different classes?

A
  1. 5 variables
    [C] Confusion
    [U] urea > 7 mmol/L
    [R] RR > 30
    [B] BP (SBP <90 or DBP ≤60)
    [65] Age ≥65
  2. 3 risk classes
  3. score 0-1: outpatient
    score 2: inpatient
    score 3-5: inpatient, consider ICU
    (general ward –> high dependency ward –> ICU)
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35
Q

IDSA/ATS Criteria for Severe CAP:
What are the classifications of criteria it uses?

A

major & minor criteria

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36
Q

What are the major criteria?

A
  • ventilation
  • septic shock requiring vasoactive meds
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37
Q

What are the minor criteria? (8)

A
  • RR ≥30
  • PaO2/FiO2 ≤250
  • multilobar infiltrates
  • confusion/disorientation
  • uremia (urea >7)
  • leukopenia (WBC <4)
  • hypothermia (core temp <36)
  • hypotension requiring aggressive fluid resuscitation
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38
Q

What is the criteria for severe CAP according to IDSA/ATS Criteria?

A

at least 1 major criterion
OR
at least 3 minor criteria

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39
Q

What is the sequence/flow of thoughts when deciding how to treat CAP?

A
  1. consider severity of CAP & thus site of care
  2. what are the potential pathogens causing that severity of CAP
  3. what are the abx to use for empiric therapy
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40
Q

What are the different severities of CAP?

A

outpatient, no comorbs
outpatient, w comorbs
inpatient, non-severe
inpatient, severe

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41
Q

What are the likely bacteria causing pneumonia under the “outpatient, no comorbs” category?

A

Strep pneumoniae

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42
Q

What are the first line abx to use for empiric treatment of “outpatient, no comorbs” category of CAP?

A

Penicillin
- Amoxicillin 1g q8h (highest dose)

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43
Q

What are the alternative abx to use for empiric treatment of “outpatient, no comorbs” category of CAP in the event of severe penicillin allergy?

A

Respi fluoroquinolones (levo, moxi)

44
Q

What are the likely bacteria causing pneumonia under the “outpatient, w comorbs” category?

A
  • Strep pneumoniae
  • H influenzae
  • Atypicals
45
Q

What are the first line abx to use for empiric treatment of “outpatient, w comorbs” category of CAP?

A

PO beta lactams + atypical coverage

BL:
- Amox/clav
- Cefuroxime

Atypical coverage:
- Macrolides (clarithro, azithro)
- Doxycycline

46
Q

Why can’t amoxicillin be used for “outpatient, w comorbs” pneumonia? Why must amox-clav be used?

A

amoxicillin is specific for strep pneumoniae

however, H influenzae has reported resistance against amoxicillin via production of beta lactamases

therefore, for “outpatient w comorbs” category whereby H influenzae is a possible bacteria, have to use amox-clav instead to cover the possibility of H influenzae

47
Q

How do we choose which atypical cover to use?

A

based on contraindication

QTC prolongation = avoid macrolides
esophagitis/photosensitivity = avoid tetracyclines

48
Q

Which macrolide is preferred and why?

A

azithro > clarithro
1. OD frequency
2. less 3A4 DDI

49
Q

What are the alternative abx to use for empiric treatment of “outpatient, w comorbs” category of CAP in the event of severe penicillin allergy?

A

Respi fluoroquinolones (levo, moxi)

50
Q

What is the route of administration of antibiotics for outpatient treatment?

A

Oral

51
Q

What are the likely bacteria causing pneumonia under the “inpatient, non-severe” category?

A
  • Strep pneumoniae
  • H Influenzae
  • Atypicals
  • MRSA & PA based on risk factors
52
Q

What are the risk factors for MRSA for “inpatient, non-severe” pneumonia?

A
  • Respiratory isolation of MRSA in the last 1 year
  • Hospitalization/parenteral abx use in the past 90 days + positive MRSA PCR screening
53
Q

What are the risk factors for PA for “inpatient, non-severe” pneumonia?

A

Respiratory isolation of PA in the last 1 year

54
Q

What are the MRSA agents that can be used in the treatment of pneumonia?

A
  • IV Vanco
  • IV Linezolid
55
Q

Why is daptomycin not used for MRSA in pneumonia?

A

Daptomycin is inactivated by lung surfactant

56
Q

What do you do in the case of PA risk factors?

A

MODIFY regimen to include PA coverage (not adding extra as one of the options provided should already have PA coverage)

57
Q

What are the anti-pseudomonal agents that can be used in the treatment of pneumonia?

A
  • Pip-tazo
  • Ceftazidime
  • Cefepime
  • Meropenem
  • Levofloxacin
58
Q

What are the first line abx to use for empiric treatment of “inpatient, non-severe” category of CAP?

A

Strep pneumoniae, H influenzae, Atypicals: Beta lactams + atypical coverage

BL:
- Amox/clav
- Cefuroxime
- Ceftriaxone

Atypical coverage:
- Macrolides
- Doxycycline

59
Q

What are the alternative abx to use for empiric treatment of “inpatient, non-severe” category of CAP in the event of severe penicillin allergy?

A

Respi fluoroquinolones (levo, moxi)

60
Q

What is the route of administration for inpatient treatment of non-severe CAP?

A

start w oral if patient doing well
otherwise, initiate IV and step down to oral when patient improves

61
Q

What are the likely bacteria causing pneumonia under the “inpatient, severe” category?

A
  • Strep pneumoniae
  • H Influenzae
  • Atypicals
  • Staph aureus
  • G(-) bacilli, eg. Klebsiella pneumoniae, esp Burkholderia pseudomallei
  • MRSA & PA based on risk factors
62
Q

What are the first line abx to use for empiric treatment of “inpatient, severe” category of CAP?

A

Beta lactams + atypical coverage + Burkholderia coverage

BL:
- Amox/clav
- Pen G

Atypical coverage:
- Macrolides ONLY

Burkholderia coverage:
- Ceftazidime
- Meropenem (not usually used as v broad spectrum)

63
Q

What are the alternative abx to use for empiric treatment of “inpatient, severe” category of CAP?

A

Respi fluoroquinolone + Ceftazidime

64
Q

What is the route of administration of antibiotics for the inpatient treatment of severe CAP?

A

parenteral

65
Q

What are the antibiotics in the regimen for “inpatient, severe” CAP that can cover for PA?

A
  • Ceftazidime
  • Levofloxacin
66
Q

What do the following antibiotics cover with respect to CAP?
1. Amoxicillin
2. Amox/clav
3. Pen G
4. Cefuroxime
5. Ceftriaxone
6. Ceftazidime
7. Macrolides
8. Doxycycline

A

amox: Strep pneumoniae
amox/clav: Strep pneumoniae + H Influenzae + anerobes
Pen G: Strep pneumoniae
Cefuroxime: Strep pneumoniae + H Influenzae
Ceftriaxone: Strep pneumoniae + H Influenzae
Ceftazidime: Burkholderia, H Influenzae, PA
Macrolides: Atypicals, H influenzae
Doxycycline: Atypicals, H Influenzae

67
Q

When will we need to include strong anaerobic coverage for CAP?

A

if the following are detected:
- lung abscess
- empyema (accumulation of pus in pleural space)

68
Q

What antibiotics should be added for anaerobic coverage if standard regimen for CAP has no anaerobic coverage?

A
  1. Metronidazole (PO/IV)
  2. Clindamycin (PO/IV)
    *though amox/clav has anaerobic coverage, it is not specific for it. hence, cannot specifically add amox/clav just for anaerobic coverage. UNLESS amox/clav is already part of regimen, then no need to add metronidazole or clindamycin anymore
69
Q

What are the treatment options for CAP if influenza is suspected?

A

Oseltamivir

70
Q

Recap: When can we initiate oseltamivir for influenza?

A

within 2 days, up to 5 days for high risk patients

71
Q

When do we give patients oseltamivir?

A

positive influenza PCR

72
Q

How many days does the patient need to be on oseltamivir?

A

5 days

73
Q

In what scenario should antibiotics for the empiric treatment of CAP be stopped?

A

when there is no evidence of bacterial pathogen (ie. pneumonia most likely viral)
- negative cultures
- low procalcitonin levels (<0.25 mcg)
- early clinical stability

74
Q

If antibiotics for CAP should be stopped as CAP is not bacterial (-ve culture, low procalcitonin, early clinical stability), when exactly should it be stopped?

A

at the 2nd/3rd day

75
Q

What are the medications that should NOT be used as first line/routinely used for CAP?

A
  • respi fluoroquinolones
  • corticosteroid
76
Q

When do we de-escalate antibiotics for CAP?

A
  1. hemodynamically stable (stable vitals)
  2. improving clinically
  3. able to ingest oral meds (for IV-PO conversion)
77
Q

How do we de-escalate antibiotics for CAP when culture results are positive for suspected pathogens?

A

based on AST

78
Q

How do we de-escalate antibiotics for CAP in the event of no positive cultures?

A
  1. stop MRSA, PA and Burkholderia coverage in 48h if pathogen is NOT isolated + patient is improving (ie. these resistant bacteria unlikely to be present)
  2. IV-PO conversion within same ABX or same CLASS
  3. continue coverage against Strep pneumoniae, H influenzae, atypicals
79
Q

How long will most patients take to achieve clinical stability?

A

2-3 days

80
Q

What is the minimum duration of active antibiotics for CAP provided patient achieved clinical stability?

A

5 days

81
Q

What is the minimum duration of active antibiotics for CAP for patients with suspected MRSA/PA provided patient achieved clinical stability?

A

7 days

82
Q

What does ‘clinical stability’ mean in the context of CAP?

A
  • vital signs become normal (HR, RR, BP, O2 sat, temp)
  • can eat
  • regain baseline mental status
83
Q

What is the minimum duration of active antibiotics for patients with CAP due to Burkholderia or other less common pathogens (eg. MTb)?

A

3-6 weeks

84
Q

When will longer courses of antibiotic therapy be considered for CAP?

A

CAP complicated with other deep-seated infections (eg. meningitis, lung abscess) [2-3 wks]

85
Q

How long do we have to wait before we can escalate antibiotic therapy for CAP?

A

3 days

86
Q

When do we repeat radiographic imaging (eg. CXR)?

A

if patient deteriorates clinically (to see if there is new pneumonia/existing pneumonia spread)

*do NOT repeat CXR to see improvements

87
Q

What is the definition of CAP, HAP, VAP?

A

CAP: onset in community / <48h after admission
HAP: onset ≥48h after admission
VAP: onset ≥48h after being put on ventilator

88
Q

What are the risk factors for nosocomial pneumonia (HAP, VAP)?

A
  1. patient factors
    - elderly
    - smoking
    - comorbs (COPD, cancer, immunosuppression)
    - prolonged hospitalization
    - impaired consciousness (coma)
    - malnutrition
  2. infection control factors
    - lack of hand hygiene compliance
    - contaminated respiratory care devices
  3. healthcare factors
    - prior abx use
    - sedatives
    - opioid analgesics
    - ventilation
    - supine position (lying down)
89
Q

What are some non-pharmacological methods to prevent HAP/VAP?

A
  1. practice consistent hand hygiene
  2. judicious use of abx & meds w sedative effects
  3. for VAP,
    - limit duration of mechanical ventilation
    - minimise duration & deep levels of sedation
    - elevate head of bed by 30 deg
90
Q

What are the main bacteria to empirically cover for HAP/VAP?

A
  1. PA
  2. Staph aureus
  3. Enterobacterales (Klebsiella, E Coli, Enterobacter)
91
Q

What are the risk factors for MRSA in the case of nosocomial pneumonia?

A
  1. prior IV abx use within 90 days
  2. isolation of MRSA in the last 1 year
  3. hospitalized (>20% of SA are MRSA, which is all hospitals in SG)
  4. patient at high risk for mortality (eg. need ventilatory support due to HAP & septic shock)
92
Q

When do we initiate single antipseudomonal coverage for HAP/VAP?

A

no/low MDRO risk

93
Q

When do we initiate double antipseudomonal coverage for HAP/VAP?

A
  • risk factors for AMR (IV abx in the past 90 days, RRT before VAP onset, isolation of PA in the past 1 year)
  • > 10% of PA isolates in that hospital are resistant to monotherapy agent
  • high mortality risk (eg. on ventilator)
94
Q

What antipseudomonal agents can we use for SINGLE anti-PA coverage and to cover Enterobacterales?

A
  • Pip-tazo
  • Cefepime
  • Ceftazidime*
  • Carbapenems (imi, mero)

*ceftazidime has been shown to drive ESBL production, therefore cefepime is preferred over ceftazidime

95
Q

What antibiotic class should we AVOID for single antipseudomonal therapy?

A

amiNOglycosides

96
Q

What anti-pseudomonal agents can we add on for DOUBLE anti-PA coverage?

A
  • Fluoroquinolones (cipro, levo)
  • Aminoglycosides (amikacin)
97
Q

Which fluoroquinolone is preferred for double anti-PA coverage? Why?

A

cipro > levo

  1. better to reserve levo for CAP and TB
  2. levo has additional G(+) coverage that is not needed in this scenario as the other single anti-PA agents alr has G(+) coverage
98
Q

What anti-MRSA antibiotics can we use for nosocomial pneumonia?

A

IV Vanco
IV/PO Linezolid

99
Q

Recap: When can we de-escalate therapy for nosocomial pneumonia?

A
  1. hemodynamically stable
  2. improving clinically
  3. can eat oral meds
100
Q

How do we de-escalate therapy for nosocomial pneumonia in the event of positive cultures?

A
  1. use AST
  2. step down to SINGLE anti-PA coverage
101
Q

How do we de-escalate therapy for nosocomial pneumonia in the event of NO positive cultures?

A
  1. step down abx and maintain coverage against PA, Enterobacterales & MSSA - UNLESS patient very sick/significant risk for MDRO, then maintain MRSA coverage
  2. IV-PO conversion
102
Q

How long will most patients with nosocomial pneumonia take to achieve clinical stability?

A

2-3 days

103
Q

What does “clinical stability” mean in the context of nosocomial pneumonia?

A
  1. normal vital signs
  2. HAP - regain baseline mental status (obv not possible for VAP..)
104
Q

What is the minimum duration of active antibiotics required for nosocomial pneumonia?

A

7 days REGARDLESS OF PATHOGEN

105
Q

When will we require longer duration of therapy for nosocomial pneumonia?

A

if complicated with other deep-seated infections (eg. meningitis, lung abscess)

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