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PR3151 (cleefy) > IC16 PR3151 LRTI > Flashcards

IC16 PR3151 LRTI Flashcards

1
Q

describe acute bronchitis?

A

characterised by acute cough (usually ≤3 weeks) due to inflammation of the trachea and lower airway.

usually self-limiting.
usually starts from URTI.

cough lasts for more than 3 weeks.

ABX treatment is NOT recommended unless confirmed for bacterial infection. It will not change the resolution time.

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2
Q

what is the differential diagnosis for acute bronchitis?

A

need to rule out exacerbation of COPD, pneumonia, or acute asthma.

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3
Q

when should patients with acute bronchitis return to the clinic?

A

1) fever
2) cough with changing frequency and extent
3) cough that lasts more than 3 weeks

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3
Q

describe pneumonia

A

infection of the parenchyma of the lung

proliferation of microbial pathogen in the alveolar level

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4
Q

what is the pathophysiology of pneumonia

A

1) exposure to the host
2) susceptible host
3) proliferation

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4
Q

what are the methods of exposure to pneumonia pathogen (pathophysiology)

A

1) inhalation
2) aspiration of oropharyngeal secretions
3) hematogenous spreading: e.g., bacterimia from extra-pulmonary sources

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5
Q

What are the risk factors for pneumonia?

A

1) smoking: suppress neutrophils
2) immunosuppressed: e.g., glucocorticoids, chemotherapy, HIV, sepsis
3) chronic respiratory conditions e.g., COPD, asthma, and lung cancer that destroy lung tissue and allow for more space for pathogen proliferation.

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6
Q

what are the systemic clinical presentation for pneumonia

A

fever
chills
malaise
altered mental status (elderly)
hypotension
tachycardia

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7
Q

what are physical examination evidence for pneumonia (lung auscultation)

A

1) inspiratory crackling during lung expansion

2) diminished breath sounds over the affected area

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7
Q

what are the localised clinical presentation for pneumonia

localised ie lung conditions (not general)

A

tachypnoea
chest pain
SOB
cough
hypoxia

increased sputum production

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8
Q

what are the radiological methods for pneumonia detection?

A

chest x-ray
lung CT
lung ultrasonography

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8
Q

what are the radiological evidence for diagnosis of pneumonia?

A

PRESENCE of NEW infiltrates or dense consolidations

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9
Q

what are the methods for pneumonia laboratory testing?

A

1) urinary antigen tests

2) culture and gram staining

3) blood culture
- rule out bacterimia

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10
Q

describe the urinary antigen test for pneumonia

what it tests for and the limitations

A

tests for
- strep pnuemo
- legionella pneumo

limitations
- may remain positive for days-weeks after antibiotic treatment

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11
Q

when to perform urinary antigen test for pneumonia

A

for severe CAP or hospitalised patients

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12
Q

what are the risk factors for CAP

A

SAME as pneumonia

and

history of pneumonia

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12
Q

prevention methods for CAP?

A

vaccinations: pneumococcal and influenza

smoking cessation

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12
Q

what are the different culture and gram staining methods for pneumonia

A

1) sputum
- low yield and contaminated by saliva (if culture has high epithelial cell count)

2) lower respiratory tract
- invasive: BAL (bronchoalveolar lavage)

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12
Q

pneumonia classification?

A

1) CAP
- <48h after hospital admission
- onset in the community

2) HAP
- >48h after hospital admission

3) VAP
- >48h after mechanical ventilation

HAP and VAP = nosocomial

note that CAP and HAP are now treated together

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13
Q

when should you initiate culture(s) per the IDSA guidelines for pneumonia?

indicate the cultures required.

A

blood and sputum culture required before abx treatment for patients with
1) severe CAP
2) risk factors for resistant bacteria e.g., MRSA, psedumonas

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14
Q

what are the risk factors for drug resistant bacteria in pneumonia

A

1) iv abx or recent hospitalisation in the last 90 days
2) empiric treatment for mrsa or pseudomonas
3) recent infection from mrsa or psedumonas (in the last year)

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15
Q

what are the likely pathogens for inpatient (severe) CAP?

A

strep pneumo
haemo infl
atypicals (MCL)

add on MRSA, psedumonas depending on risk factors

ADD ON
- s. aureus
- gram negatives e.g., Burkholderia, klebsiella

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15
Q

what are the likely pathogens for outpatient and inpatient (nonsevere) CAP?

A

strep pneumo
haemo infl
atypicals (MCL)

add on MRSA, psedumonas depending on risk factors

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16
Q

what is Burkholderia -> describe the type of problems and location…

A

burkholderia causes melioidosis = severe CAP in tropical countries

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17
Q

what other condition should patients be tested for when diagnosed with CAP (and for whom)

A

influenza
for all inpatients
during circulating seasons

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18
Q

what is the classification for PSI (risk classification)

A

RISK I: 0 (outpatient)
RISK II: ≤70 (outpatient)
RISK III: 71-90 (inpatient, brief)
RISK IV: 91-130 (inpatient)
RISK V: >130 (inpatient)

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18
Q

what is the criterion for CURB65 CAP stratification?

A

1) confusion
2) urea >7
3) RR ≥30
4) BP
SBP <90
DBP <60
5) Age ≥65

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19
Q

what is the point system for CURB65

A

0-1: outpatient
2: inpatient non severe
≥3 inpatient severe

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20
Q

what are the criteria in IDSA/ATS CAP classification?

A

major factors:
- mechanical ventilation
- septic shock requiring vasoactive medications

minor factors
- RR ≥ 30 breaths/min
- PaO2/FiO2 ≤ 250
- Multilobar infiltrates
- Confusion/disorientation
- Uremia (urea > 7 mmol/L)
- Leukopenia (WBC < 4 x 109/L)
- Hypothermia (core temperature < 36ºC)
- Hypotension requiring aggressive fluid resuscitation

21
Q

what is the empiric treatment for OUTPATIENT CAP with no comorbidities?

A

beta lactam:
- PO amoxicillin 1g q8

respiratory FQ
- PO moxi or levo

22
Q

what is the empiric treatment for OUTPATIENT CAP with comorbidities?

A

beta lactam + macrolides/doxycycline
- PO amoxiclav
- PO cefuroxime
ADD
- PO azithromycin/clarithromycin + doxycycline.

respiratory FQ
- PO moxi or levo

22
Q

what is the (standard) empiric treatment for INPATIENT NON-SEVERE CAP?

A

beta lactam + macrolides/doxycycline
- IV amoxiclav
- IV cefuroxime
- IV ceftriaxone
ADD
- IV azithromycin/clarithromycin + doxycycline.

respiratory FQ
- IV moxi or levo

23
Q

what is the (PSEDUMONAL risk factor COVER) empiric treatment for INPATIENT NON-SEVERE CAP?

A

modify regimen to

IV piptazo (add atypical coverage)
IV ceftazidime (add strep pneumo coverage)
IV cefepime (add atypical coverage)
IV meropenem (add atypical coverage)
IV levofloxacin

23
Q

what is the (MRSA risk factor COVER) empiric treatment for INPATIENT NON-SEVERE CAP

A

add
IV vancomycin or IV/PO linezolid

24
Q

what is the (standard) empiric treatment for INPATIENT SEVERE CAP?

A

beta lactam + ceftazidime (burkholderia) + macrolides (atypicals)
- IV amoxiclav
- IV pen G
ADD
- IV ceftazidime
ADD
- IV azithromycin or clarithromycin

OR

respiratory FQ + ceftazidime
- IV cipro or moxi
ADD
- IV ceftazidime

25
Q

what is the (MRSA risk factor COVER) empiric treatment for INPATIENT SEVERE CAP

A

ADD
IV vancomycin OR
IV/PO linezolid

26
Q

what is the (pseudomonas risk factor COVER) empiric treatment for INPATIENT SEVERE CAP

A

same as the empiric general regimen already covers for pseudomonas

26
Q

why is daptomycin not used for LRTI (compared to vancomycin)?

A

it will get destroyed in the lung tissue

26
Q

what is the dosing for amoxicilin in general CAP regimen for outpatient without comorbidities?

A

need to increase to a higher dose of
1g Q8 (take note)

27
Q

what additional agents should be added when there is anaerobes present in CAP

A

1st line: metronidazole

2nd line: clindamycin

27
Q

when to initiate anaerobic coverage for CAP?

A

during radiological investigations showing:
a) lung abscess
b) empyema

28
Q

what are some regimens that do not require additional anaerobe coverage?

A

piptazo and amoxiclav

29
Q

what additional agents to include if patient has influenza on top of CAP.

and what to do if positive PCR

A

start course of oseltamivir
- x5 days
- 75mg BD

if positive influenza PCR
- complete course
- may discontinue if patient reaches early clinical stability, low procalcitonin (<0.25ug/ml), OR has negative culture.

30
Q

why is respiratory FQ secondline for CAP treatment

A

high ADR profile

delay diagnosis of TB

develop resistance

only PO agent for Pseudomonas
- preserve therapy

31
Q

what is an adjunctive therapy to CAP
- purpose
- indication
- precautions

A

corticosteroids
- reduce inflammation in lungs
- MOSTLY ICU = add if shock refractory to fluid resuscitation or vasopressor support.
- avoid routine use

32
Q

when to de-escalate for CAP?

A

Hemodynamic stability

Improving clinically

For IV-to-Oral -able to ingest oral medications

33
Q

how to deescalate for CAP?

A

if positive culture:
- use AST and select for narrower/PO drugs

if no positive culture
- remove agents for burkholderia, Pseudomonas and MRSA in 48 hours if patient is improving
- change from IV to oral (maintain atypical, strep pneumo and haem cover)

34
Q

what is the treatment duration for CAP (if suspected or proven mrsa or pseudmonas )

A

7 days

34
Q

what is the treatment duration for CAP (minimally)

A

5 days

35
Q

when should treatment be stopped for CAP?

A

Resolution of vital sign abnormalities ie heart rate, respiratory rate, blood pressure, oxygen saturation, and temperature

Ability to maintain oral intake

Baseline mental status

36
Q

how to monitor response for CAP (step 4)

A

Most patients will achieve clinical stability within the first 48 to 72 hours
- Elderly patients and/or those with multiple co‐morbidities may take longer

Should not escalate antibiotic therapy in the first 72hours
- Unless culture‐directed or significant clinical deterioration

Radiographic improvement lags behind clinical improvement for resolution
- Repeat only if clinical deterioration

No need to repeat microbiological tests as well.

Adverse drug reactions of antibiotics

36
Q

when should treatment for CAP be extended?

A

1) CAP complicated with other deep-seated infections (e.g.meningitis, lung abscess)

2) Infection with other, less-common pathogens (e.g., Burkholderia pseudomallei (up to 3-6weeks), Mycobacterium tuberculosis (up to 3-6months) or endemic fungi)

37
Q

how long does it take for radiological findings to be cleared of CAP

A

ABOUT 6WEEKS TO 2MTHS

38
Q

what are the HAP/VAP patient-related risk factors

A

ECCSPM

elderly
COPD/cancer/immunosuppression
coma/impaired consciousness
smoking
prolonged hospitalisation
malnutrition

39
Q

what are the HAP/VAP infection control-related risk factors

A

lack of hand hygiene compliance
contaminated respiratory devices

40
Q

what are the HAP/VAP healthcare-related risk factors

A

prior abx use
mech ventilation
supine position
opioid analgesics
sedative (unable to breathe properly)

40
Q

HAP/VAP prevention methods?

include VAP specific methods

A

1) hand hygiene

2) judicious use of sedatives and abx

3) mech ventilator
- minimise prolonged or deep sedation
- minimise prolonged ventilation
- tilt head 30º (to facilitate breathing)

41
Q

what to cover empirically for VAP/HAP?

A

pseudomonas
enterobacterales
s.aureus

42
Q

when to cover MRSA empirically for VAP/HAP?

A

iv use in last 90 days

isolation of mrsa in last 1 year

hospitalisation in unit with >20% s.aureus is MRSA

if prevalence unknown but patient at high risk of mortality (ventilatory support due to HAP and septic shock)

42
Q

VAP/HAP abx selection should be guided by _____

A

Choice of antibiotics for HAP/VAP should be guided by local distribution of pathogens associated with HAP/ VAP and their antimicrobial susceptibilities.

If possible, obtain ICU-specific antibiogram for VAP

43
Q

when to use double pseudomonal agents for VAP/HAP?

A

use double pseudomonal agents from different classes if

a risk factor for antimicrobial resistance (prior intravenous antibiotic use within 90 d; acute renal replacement therapy prior to VAP onset; isolation of P. aeruginosa in last 1 year)

hospitalization in a unit where >10% of Pseudomonas isolates are resistant to an agent being considered for monotherapy

if prevalence of PA is not known but patient at high risk for mortality (include need for ventilatory support due to HAP and septic shock)

43
Q

what is the MRSA cover on top of double antipseudomonal regimen for VAP/HAP?

A

IV vancomycin
IV/PO linezolid

44
Q

what is the double antipseudomonal regimen for VAP/HAP?

A

1) ANTIPSEUDOMONAL B-LACTAM
- cefepime, piptazo, (ceftazidime), imipenem, meropenem

AND/OR

2) ANTIPSEUDOMONAL FQ
- (ciprofloxacin) or levofloxacin

OR

3) aminoglycosides: amikacin (DO NOT USE AS MONOTHERAPY)

  • bracket = AVOID use without MRSA cover
45
Q

when to deescalate for VAP/HAP

A

when
1) hemodynamically stable
2) improving clinically
3) able to take oral (from iv)

46
Q

treatment duration for VAP/HAP?

A

7 days

46
Q

how to deescalate for VAP/HAP

A

positive culture
- iv to oral and/or based on AST.
- change from double to single anti-pseudomonal

no positive culture
- maintain coverage according to local HAPVAP antibiogram
OR if not available, for psuedomonas, MSSA, MRSA, enteric GNR (do not do this for severe MDRO infection or if severely ill)
- change to oral from iv if possible

46
Q

which MRSA agents do we not use in VAP/HAP and why?

A

clindamycin
cotrimoxazole
doxycycline

BECAUSE these are more for community acquired MRSA.

47
Q

when to stop tx for VAP/HAP

A

resolution of vital sign abnormalities

for HAP: baseline mental status

48
Q

why should the course of abx be limited for VAP HAP

A

STUDIES show it is related to more deep seated infections like
meningitis
lung abscess

49
Q

monitoring symptoms for VAP HAP? (step 4)

A

Most patients will achieve clinical stability within the first 48 to 72 hours

Elderlypatients and/or those with multiple co‐morbidities may take longer

Should not escalate antibiotic therapy in the first 72hours UNLESS culture‐directed or significant clinical deterioration

Radiographic improvement lags behind clinical improvement for resolution
- Repeat only if clinical deterioration

No need to repeat microbiological test as well.

Adverse drug reactions of antibiotics

PR3151 (cleefy) (12 decks)

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