Infecoes Respiratorias Flashcards
Estudo PAC
Expectoração com coloração gram e cultura:
-não por rotina na PAC fora do hospital
-fazer na PAC no hospital com pneumonia grave (ter 1 critério major ou 3 ou mais minor)
-fazer na PAC no hospital com tto empírico ou previamente tratado para MRSA ou P.aeruginosa
-fazer na PAC no hospital quando antibioterapia ev últimos 90 dias
PAC grave:
Critérios major: Choque séptico a precisar de vasopressores; IR a precisar de VMI
Critérios minor: FR>30; PaO2/FiO2<250; infiltrados multilobares; confusão; AU>20; leucopenia <4000; trombocitopenia <100000; Hipotermia <36; Hipotensão a requerer fluidoterapia agressiva
Hemoculturas:
-não por rotina na PAC fora do hospital ou no hospital
-fazer na PAC no hospital com pneumonia grave
-fazer na PAC no hospital com tto empírico ou previamente tratado para MRSA ou P.aeruginosa
-fazer na PAC no hospital quando antibioterapia ev últimos 90 dias
Antigenuria pneumococos:
-não fazer por rotina exceto na pneumonia grave
Antigenuria Legionella:
-fazer qnd surto ou viagem recente
-fazer em pneumonia grave
Quando vírus influenza a circular, deve ser testado influenza em PCR (preferido a antigénio)
Quando suspeita clínica e confirmação radiologica de PAC deve ser iniciada antibioterapia empírica, independentemente de procalcitonina.
Adicionalmente ao juízo clínico, deve ser usada um regra de prever o prognóstico como PSI (preferido) ou CURB 65 para determinar a necessidade de internamento
Devem ser admitido para a UCI diretamente qnd critérios major.
Quando critérios minor usar o senso clínico
Tratamento PAC
Tratamento empírico fora do hospital:
-SEM comorbilidades ou fatores risco de patogeneos resistentes: Amoxicilina, Doxicilina ou Macrolido
-COMORBILIDADES (doença crónica cardíaca/respiratória/hepática/renal, diabetes, alcoolismo, cancro, asplenia): amoxiclav ou cefuroxima + macrolido ou doxiciclina, levofloxacina
Tratamento empírico no hospital:
-NAO grave e SEM fatores risco de P.aeruginosa ou MRSA: B lactamico (ampicilina+sulbaxtam, cefotaxima, ceftriaxone) + macrolido (doxiciclina se contraindicacao a macrolidos ou quinolonas), levofloxacina
-GRAVE e SEM fatores risco de P.aeruginosa ou MRSA: B lactamico + macrolido, B lactamico + quinolona
-adicionar cobertura anaeróbia: não por rotina na pneumonia de aspiração exceto abcesso pulmonar ou empiema
-fatores risco de MRSA: vancomicina ou linezolide
-fatores risco de P.aeruginosa: piperacilina-tazobactam, cefepima, ceftazidima, aztreonam, meropenem, imipenem
Tratamento com corticoides:
-NAO por rotina na PAC não grave, grave ou grave por influenza
-se PAC e choque séptico refratário
Tratamento antiinfluenza como oseltamivir:
-em PAC por vírus influenza fora e dentro do hospital
Duração de terapêutica antibiótica:
- não menos de 5 dias
-cursos maiores: pneumonia complicada por meningite, endocardite ou infeção dos tecidos moles profundos, infeção por Burkholderia pseudomallei/Mycobacterium tuberculosis/fungos endémicos
Pneumonia associada ao ventilador
We suggest obtaining distal quantitative samples (prior to any antibiotic treatment) in order to reduce antibiotic exposure in stable patients with suspected VAP and to improve the accuracy of the results.
We recommend obtaining a lower respiratory tract sample (distal quantitative or proximal quantitative or qualitative culture) to focus and narrow the initial empiric antibiotic therapy.
We suggest using narrow-spectrum antibiotics (ertapenem, ceftriaxone, cefotaxime, moxifloxacin or levofloxacin) in patients with suspected low risk of resistance (patients without septic shock, with no other risk factors for MDR pathogens and those who are not in hospitals with a high background rate of resistant pathogens) and early-onset HAP/VAP.
We recommend broad-spectrum empiric antibiotic therapy targeting P. aeruginosa and extended-spectrum β-lactamase (ESBL)-producing organisms, and, in settings with a high prevalence of Acinetobacter spp., in patients with suspected early-onset HAP/VAP who are in septic shock, in patients who are in hospitals with a high background rate of resistant pathogens present in local microbiological data and in patients with other (nonclassic) risk factors for MDR pathogens
We recommend initial empiric combination therapy for high-risk HAP/VAP patients to cover Gram-negative bacteria and include antibiotic coverage for MRSA in those patients at risk.
If initial combination therapy is started, we suggest continuing with a single agent based on culture results and only consider maintaining definitive combination treatment based on sensitivities in patients with extensively drug-resistant (XDR; i.e. susceptible to only one or two classes of antibiotics)/ pan-drug-resistant (PDR; i.e. not susceptible to any antibiotics) nonfermenting Gram-negative bacteria and carbapenem-resistant Enterobacteriaceae (CRE) isolates.
We suggest using a 7–8-day course of antibiotic therapy in patients with VAP without immunodeficiency, cystic fibrosis, empyema, lung abscess, cavitation or necrotising pneumonia and with a good clinical response to therapy.
Bronquiectasias-investigar causas
a. Co-morbidities and past medical history should be recorded in patients diagnosed with bronchiectasis to identify relevant and possibly causative disease such as rheumatoid arthritis, COPD, asthma, gastro-oesophageal reflux disease and inflammatory bowel disease.
b. Measure full blood count, serum total IgE and assessment of sensitisation (specific IgE or skin prick test) to Aspergillus fumigatus in ALL patients with bronchiectasis.
c. Serum Immunoglobulin G (IgG), Immunoglobulin A (IgA) and Immunoglobulin M (IgM) should be performed in ALL patients with bronchiectasis.
d. Consider measuring baseline specific antibody levels against capsular polysaccharides of Streptococcus pneumoniae in ALL patients to investigate for specific antibody deficiency. If pneumococcal antibodies are low, immunise with 23 valent polysaccharide pneumococcal vaccine, followed by measurement of specific antibody levels 4–8 weeks later.
e. Test for cystic fibrosis (according to NICE Guidelines for Cystic Fibrosis (CF)) in patients with supporting clinical features, for example, early onset, male infertility, malabsorption, pancreatitis.
f. Test for Primary Ciliary Dyskinesia (PCD) (according to ERS Guidelines for PCD Diagnosis) in patients with supporting clinical features, including a history of neonatal distress, symptoms from childhood, recurrent otitis media, rhinosinusitis, or infertility.
g. Sputum cultures should be performed in ALL patients with bronchiectasis for routine and mycobacterial culture.
✓ Consider testing for rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti CCP), antinuclear antibodies (ANA) and anti-neutrophil cytoplasmic antibodies (ANCA) in patients with coexisting clinical features of arthritis, connective tissue disease and/or systemic vasculitis.
✓ Consider testing for alpha 1 antitrypsin (A1AT) deficiency in patients with coexisting basal panacinar emphysema.
✓ Investigations for reflux and aspiration should be undertaken only in symptomatic patients, or where there are other suggestive clinical features.
✓ Consider bronchoscopy for patients with localised disease to rule out an endobronchial lesion or foreign body as the cause of bronchiectasis.
✓ A bronchial aspiration or bronchial wash targeting the areas of bronchiectasis from CT scan of the chest should be considered in patients who do not expectorate and can be particularly helpful in the diagnosis of NTM pulmonary disease.
✓ Serum protein electrophoresis should be performed in all patients with bronchiectasis with raised immunoglobulins.
✓ Consider HIV-1 serology in patient with bronchiectasis depending on prevalence of HIV-1 and clinical features suggestive of increased risk of retroviral infection.
Bronquiectasias-tratamento doença estável
Airway clearance techniques:
➢ Offer active cycle of breathing techniques or oscillating positive expiratory pressure to individuals with bronchiectasis.
➢ Consider gravity assisted positioning (where not contraindicated) to enhance the effectiveness of an airway clearance technique.
✓ Consider the inclusion of the forced expiration technique (huff) should be considered for all airway clearance techniques.
✓ Consider modified postural drainage (no head down tilt) in patients for whom postural drainage is contraindicated or not tolerated.
✓ If symptoms of gastroesophageal reflux increase with modified postural drainage (no head down tilt), an airway clearance technique in the sitting position should be taught.
✓ Consider autogenic drainage, positive expiratory pressure, high frequency chest wall oscillation and intrapulmonary percussive ventilation as an alternative airway clearance technique if other techniques are not effective or acceptable to the patient.
Terapêutica mucoactiva:
➢ Do not routinely use recombinant human DNase in adults with bronchiectasis.
➢ Consider the use of humidification with sterile water or normal saline to facilitate airway clearance.
✓ Consider a trial of mucoactive treatment in patients with bronchiectasis who have difficulty in sputum expectoration.
✓ Perform an airway reactivity challenge test when inhaled mucoactive treatment is first administered.
✓ Consider pre-treatment with a bronchodilator prior to inhaled or nebulised mucoactive treatments especially in individuals where bronchoconstriction is likely
ICS:
Inhaled corticosteroids have an established role in the management of asthma and in a proportion of patients with COPD which are common co-morbid conditions in bronchiectasis.
Antibioterapia de longo termo:
➢Consider long term antibiotics in patients with bronchiectasis who experience 3 or more exacerbations per year.
P. aeruginosa colonised patients
a. Use inhaled colistin for patients with bronchiectasis and chronic Pseudomonas aeruginosa infection.
b. Consider inhaled gentamicin as a second line alternative to colistin for patients with bronchiectasis and chronic P. aeruginosa infection.
c. Consider azithromycin or erythromycin as an alternative (eg, if a patient does not tolerate inhaled antibiotics) to an inhaled antibiotic for patients with bronchiectasis and chronic P. aeruginosa infection.
d. Consider azithromycin or erythromycin as an additive treatment to an inhaled antibiotic for patients with bronchiectasis and chronic P. aeruginosa infection who have a high exacerbation frequency.
Non- P. aeruginosa colonised patients
e. Use azithromycin or erythromycin for patient with bronchiectasis.
f. Consider inhaled gentamicin as a second line alternative to azithromycin or erythromycin.
g. Consider doxycycline as an alternative in patients intolerant of macrolides or in whom they are ineffective.
✓ Consider cyclical IV antibiotics in patients with repeated infections (≥5/year) despite other treatments.
Aspergilose invasiva-Diagnostico
Diagnóstico
• Histopathological examination and culture remain the ‘gold standard’ for diagnosing IA.
• It is strongly recommended that appropriate clinical specimens (e.g. tissue, bronchoalveolar lavage (BAL) f luid, sputum) be collected for fungal microscopy and culture as well as cyto-histological
• Growth at 50C is a simple way to distinguish A. fumigatus sensu stricto from other species within the A. fumigatus species complex.
• Matrix-assisted laser desorption time-of-flight mass spectrometry (MALDI-TOF MS) may be used for species identif ication
• Reserve DNA sequencing for isolates with atypical characteristics or for uncommon Aspergillus species
• When pulmonary IA is suspected, multislice noncontrast enhanced thoracic computed tomography (CT) is strongly recommended
• In adults, imaging of other sites including brain and sinuses should be based on signs and symptoms
• Serial GM measurements may be considered as a way to assess response to therapy but data are insufficient to determine the benefit of any other biomarkers
• It is strongly recommended that susceptibility testing be performed in patients previously exposed to mould- active azoles, those failing therapy, or those who have visited regions with high prevalence (>10%) of azoleresistant Aspergillus
• At a population level, it is strongly recommended that antifungal susceptibility testing be periodically performed (e.g. yearly) for the purpose of surveillance of azole-resistant Aspergillus
Aspergilose invasiva- tratamento
• Voriconazole, incorporating Therapeutic Drug Monitoring (TDM), is recommended as first-line therapy for pulmonary IA in those not currently on mould-active prophylaxis.
• If voriconazole cannot be used, isavuconazole is an alternative, particularly in the setting of severe and prolonged immunosuppression where coinfection by more than one fungus may be of concern.
• If voriconazole cannot be used, posaconazole is also an alternative. TDM is recommended.
• Liposomal amphotericin may be considered as an alternative treatment regimen in patients who develop IA while receiving a mould-active azole or those intolerant to voriconazole.
• Echinocandins can be considered as second-line or salvage therapy after voriconazole, isavuconazole and a lipid formulation of amphotericin B
• Combination therapy in the first-line setting is only weakly recommended but may be considered in severe disease, in critically ill patients, or in those with suspected azole resistance
• Changing from voriconazole monotherapy to liposomal amphotericin B or a voriconazole/echinocandin combination is recommended for azole-resistant disease
Breakthrough IA
Breakthrough IA infection is defined as that which has occurred while a patient has been exposed to a mouldactive antifungal agent.
• Verification of adherence to antifungal therapy together with TDM should be performed in suspected breakthrough IA.
• If breakthrough IA occurs on triazole prophylaxis or therapy, a switch to liposomal amphotericin B is strongly recommended
• If breakthrough IA occurs on liposomal amphotericin B therapy, a switch to voriconazole or isavuconazole is strongly recommended
• Where possible, definitive treatment targeted towards the specific fungal pathogen and with an agent conf irmed to be effective on antifungal susceptibility is strongly suggested
Refractory disease refers to an event where the IFD is progressing or failing to show improvement on clinical, mycological and/or radiological grounds while on treatment.
• Switching antifungal class in refractory IA is strongly recommended.
• Combination antifungal therapy and surgical management may also be considered.
• Document adequate triazole drug levels before declaring refractory IA
• Antifungal TDM in the management of IA is recommended during treatment with voriconazole or posaconazole
Adjunctive therapies
• Where feasible, immunosuppressive agents should be reduced
• Colony-stimulating factors may be used in neutropenic patients with IA.
• Interferon gamma is not recommended.
• Surgical resection may be of benefit for localised and surgically accessible pulmonary disease in patients who are refractory to antifungal therapy or who have localised complications
Tosse crónica
Tosse >8 semanas
Prevalence of chronic cough in the general adult population as ∼10%
Two-thirds were female
Most common age for presentation was in the sixth decade
We suggest that clinicians do not routinely perform a chest CT scan in patients with chronic cough who have normal chest radiograph and physical examination.
We suggest a short-term ICS trial (2–4 weeks) in adult patients with chronic cough
We suggest a short-term antileukotriene trial (2–4 weeks) in adult patients with chronic cough, particularly in those with asthmatic cough
We suggest a short-term trial (2–4 weeks) of ICS and long-acting bronchodilator combination in adults with chronic cough and fixed airflow obstruction
We suggest that clinicians do not routinely prescribe anti-acid drugs in adult patients with chronic cough. Anti-acid drugs are unlikely to be useful in improving cough outcomes, unless patients have peptic symptoms or evidence of acid reflux.
There is currently insufficient evidence to recommend the routine use of macrolide therapy in chronic cough. A 1-month trial of macrolides can be considered in the cough of chronic bronchitis refractory to other therapy, taking into account local guidelines on antimicrobial stewardship
We recommend a trial of low-dose slow-release morphine (5–10 mg twice daily) in adult patients with chronic refractory cough.
We suggest a trial of gabapentin or pregabalin in adults with chronic refractory cough.
We suggest a trial of cough control therapy (physiotherapy/speech and language therapy) in adult patients with chronic cough.
