Infection: Respiratory conditions

Question 1

What drug is licensed for administration by inhalation for the treatment of severe bronchiolitis caused by the respiratory syncytial virus (RSV) in infants?

Answer 1

Ribavirin - however, there is no evidence that ribavarin produces clinically relevant benefit in RSV

Question 2

What is a monoclonal antibody licensed for preventing serious lower respiratory-tract disease caused by respiratory syncytial virus in children at high risk of the disease; it should be prescribed under specialist supervision and on the basis of the likelihood of hospitalisation?

Answer 2

Palivizumab is a monoclonal antibody licensed for preventing serious lower respiratory-tract disease caused by respiratory syncytial virus in children at high risk of the disease; it should be prescribed under specialist supervision and on the basis of the likelihood of hospitalisation

Question 3

What is Palivizumab used for?

Answer 3

Palivizumab is a monoclonal antibody licensed for preventing serious lower respiratory-tract disease caused by respiratory syncytial virus in children at high risk of the disease; it should be prescribed under specialist supervision and on the basis of the likelihood of hospitalisation

Question 4

For TB, how many drugs are used in combination for the initial phase of treatment?

What are they?

Answer 4

Four:
Rifampicin (red-orange urine)
Ethambutol 
Pyrazinamide 
Isoniazid (enzyme inhibitor, peripheral neuropathy hence addition of pyridoxine Vitamin B6)

Question 5

What drug can be used in the initial phase of TB treatment if resistance to isoniazid has been established prior to therapy?

Answer 5

The macrolide streptomycin.

Question 6

Following the initial phase of TB treatment with four drugs, the continuation phase begins with treatment using what two drugs for what period of time?

Answer 6

Rifampicin
Isoniazid (with pyridoxine)
For a further FOUR months

Question 7

For TB in pregnancy and breastfeeding, the standard unsupervised six month treatment regimen can be used with what exception?

Answer 7

NOT streptomycin during pregnancy if isoniazid resistance is present.

Question 8

How does the treatment of CNS TB differ from pulmonary TB? (2)

Answer 8

Same duration of initial phase: 2 months.

1. 10 month duration of continuation phase.
2. Initial high dose of dexamethasone or prednisolone should be started at same time as TB therapy and then slowly withdrawn over 4-8 weeks.

Question 9

How does the treatment of pericardial TB differ from pulmonary TB?

Answer 9

An initial high dose of oral prednisolone should be offered to patients with active pericardial tuberculosis at the same time as initiation of antituberculosis therapy; it should then be slowly withdrawn over 2–3 weeks.

Question 10

Anyone under what age who is a close contact (prolonged, frequent or intense contact, e.g. household contacts or partners) of a person with pulmonary or laryngeal tuberculosis should be tested for latent tuberculosis?

Answer 10

65

Question 11

What does chemoprophylaxis for latent TB consist of?

Answer 11

1. Isoniazid (with pyridoxine) alone for SIX months (if interactions with rifampicin are a concern)

OR

2. Rifampicin and isoniazid (with pyridoxine) for THREE months (when hepatotoxicity is a concern)

Question 12

During the first two months of treatment with rifampicin (for TB) what can occur?

Answer 12

Transient disturbance of liver function with elevated serum transaminases is common but generally does not require interruption of treatment. Occasionally more serious liver toxicity requires a change of treatment particularly in those with pre-existing liver disease.

Question 13

When can ethambutol be omitted from TB treatment?

Answer 13

Ethambutol hydrochloride is included in a treatment regimen if isoniazid resistance is suspected; it can be omitted if the risk of resistance is low.

Question 14

How is TB treatment modified if there is resistance to isoniazid?

Answer 14

Initial two months the same just minus isoniazid.

Continuation phase: rifampacin and ethambutol for SEVEN months (up ten if extensive disease)

Question 15

How is TB treatment modified if there is resistance to pyrazinamide?

Answer 15

Initial two months the same just minus pyrazinamide.

Continuation phase: Rifampicin and isoniazid (w/ pyridoxine) for SEVEN months.

Question 16

How is TB treatment modified if there is resistance to rifampicin?

Answer 16

Offer treatment with at least six antituberculosis drugs to which the mycobacterium is likely to be sensitive.

Question 17

How is TB treatment modified if there is resistance to ethambutol?

Answer 17

No change other to omit ethambutol from regimen.

Question 18

In the management of TB in children why is care needed in the use of ethambutol?

Answer 18

However, care is needed in young children receiving ethambutol hydrochloride because of the difficulty in testing eyesight and in obtaining reports of visual symptoms.

Question 19

What is the drug of choice for the treatment of mild to moderate pneumocytis pneumonia?

Answer 19

Co-trimoxale in high dosage.

Atovaquone is licensed for the treatment of mild to moderate pneumocystis infection in patients who cannot tolerate co-trimoxazole

(A combination of dapsone with trimethoprim is given by mouth for the treatment of mild to moderate disease [unlicensed indication].)

Question 20

What is the drug of choice for the treatment of mild to moderate pneumocystis pneumonia in patients with GP6D-deficiency?

Answer 20

Atovaquone is licensed for the treatment of mild to moderate pneumocystis infection in patients who cannot tolerate co-trimoxazole.

OR Dapsone + trimethoprim

(OR clindamycin and primaquine but associated with toxicity)

Question 21

What is the drug of choice for SEVERE pneumocystis penumonia?

Answer 21

Still co-trimoxazole in high-dosage but either via the mouth or IV infusion.

Pentamidine isetionate given by intravenous infusion is an alternative for patients who cannot tolerate co-trimoxazole, or who have not responded to it. Pentamidine isetionate is a potentially toxic drug that can cause severe hypotension during or immediately after infusion.

(Corticosteroid treatment can be lifesaving in those with severe pneumocystis pneumonia.)

Question 22

What is the drug of choice for SEVERE pneumocystis penumonia in a patient with GP6D?

Answer 22

Pentamidine isetionate given by intravenous infusion is an alternative for patients who cannot tolerate co-trimoxazole, or who have not responded to it. Pentamidine isetionate is a potentially toxic drug that can cause severe hypotension during or immediately after infusion.

Corticosteroid treatment can be lifesaving in those with severe pneumocystis pneumonia.

Question 23

What is the drug of choice for the prophylaxis of pneumocystis pneumonia?

Answer 23

Co-trimoxazole daily or on alternative days.

Inhaled pentamidine isetionate (or parenteral) if unable to tolerate co-trimoxazole.

Or dapsone.
Or atovaquone (unlicensed)

Question 24

What is the antibacterial therapy for Haemophilus influenzae epiglottitis?

Answer 24

Cefotaxime (or ceftriaxone)

or Chlormaphenicol.

Question 25

What are the antibacterial treatment options for acute exacerbations of chronic bronchitis?

Answer 25

Amoxicillin or ampicillin or tetracycline as first line - 5 days normal duration.

Alternatively: a macrolide like clarithromycin for ~ 5 days.

Question 26

What is the antibacterial therapy for pneumonia: low-severity community-acquired?

Answer 26

Amoxicillin (or ampicillin).

atypical: clarithro or other macrolide.

Staphylococci: add fluclox
7 days or 14-21 for staphylococci.

Question 27

What is the antibacterial therapy for pneumonia: low-severity community-acquired suspected aypical pathogens?

Answer 27

Pneumococci with decreased penicillin sensitivity being isolated, but not yet common in UK.

If atypical pathogens suspected, add clarithromycin (or azithromycin or erythromycin).

If staphylococci suspected (e. g. in influenza or measles), add flucloxacillin.
Suggested duration of treatment 7 days (14–21 days for infections caused by staphylococci)

Question 28

What is the antibacterial therapy for pneumonia: low-severity community-acquired suspected staphylococci (e.g. influenzae or measles)?

Answer 28

Amoxicillin + flucloxacillin for 14-21 days.

If atypical pathogens suspected, add clarithromycin (or azithromycin or erythromycin).
If staphylococci suspected (e. g. in influenza or measles), add flucloxacillin.
Suggested duration of treatment 7 days (14–21 days for infections caused by staphylococci)

Question 29

What is the antibacterial therapy for pneumonia: low-severity community-acquired in pen-allergic patients?

Answer 29

Alternatives, doxycycline or clarithromycin (or azithromycin or erythromycin)
Suggested duration of treatment 7 days (14–21 days for infections caused by staphylococci)

Question 30

What is the treatment for pneumonia: moderate-severity community-acquired?

Answer 30

Amoxicillin and clarithromycin OR
Doxycycline alone.

If MRSA suspected add vancomycin or teicoplanin.

7 day treatment or 14-21 if suspected staphylococci.

Question 31

What is the treatment for pneumonia: moderate-severity community-acquired suspected MRSA?

Answer 31

Amoxicillin (or ampicillin) + Clarithromycin (or other macrolides) + Vancomycin (or teicoplanin)

OR

Doxycyline + Vancomycin (or teicoplanin)

Treatment duration would be 14-21 days for staphylococci.

Question 32

What is the general treatment for pneumonia: high-severity community acquired?

Answer 32

Benzylpenicillin + Clarithromycin (or azi/ery)

OR

Benzylpenicillin + doxycycline.

If MRSA + Vanco or teicoplanin.

Duration: 7-10 days (14-21 if staphylococci suspected)

Question 33

What is the duration of treatment of pneumonia: high-severity community acquired?

Answer 33

Benzylpenicillin + Clarithromycin (or azi/ery)

OR

Benzylpenicillin + doxycycline.

If MRSA + Vanco or teicoplanin.

Duration: 7-10 days (14-21 if staphylococci suspected)

Question 34

What is the treatment for pneumonia: high-severity community acquired if life-threatening infection, or if Gram-negative infection suspected, or if co-morbidities present, or if living in long-term residential or nursing home?

Answer 34

Co-amoxiclav + Clarithromycin (or azi/ery)

+ vanco/teico if MRSA

7-10 days (maybe 14-21 if staphylococci or enteric bacilli suspected)

Question 35

What is the antibacterial treatment for pneumonia possibly caused by atypical pathogens?

Answer 35

Clarithromycin (or azi/erythro).

If high-severity Legionella infection, add rifampicin for first few days.

Suggested duration: 14 days, usually 7-10 for Legionella.

Question 36

What is the antibacterial treatment for pneumonia possibly caused by Legionella?

Answer 36

Clarithromycin (or azi/erythro).

If high-severity Legionella infection, add rifampicin for first few days.

Suggested duration: 14 days, usually 7-10 for Legionella.

Question 37

What is the treatment for atypical pneumonia caused by chlamydial or mycoplasma infections?

Answer 37

Doxycyline

Suggested duration of treatment 14 days.

Question 38

What is the antibacterial therapy for pneumonia: hospital acquired early-onset infection less than 5 days after admission to hospital?

Answer 38

Co-amoxiclav OR Cefuroxime:
7 days.

If life-threatening infection, or if history of antibacterial treatment in the last 3 months, or if resistant micro-organisms suspected, treat as for late-onset hospital-acquired pneumonia:

an antipseudomonal penicillin (e.g. piperacillin with tazobactam) or a broad-spectrum cephalosporin (e.g. ceftazidime) or another antipseudomonal beta-lactam or a quinolone (e.g. ciprofloxacin)
If meticillin-resistant Staphylococcus aureus suspected, add vancomycin.
For severe illness caused by Pseudomonas aeruginosa, consider adding an aminoglycoside.
Suggested duration of treatment 7 days (longer if Pseudomonas aeruginosa confirmed)

Question 39

What is the antibacterial therapy for pneumonia: hospital acquired late-onset infection more than 5 days after admission to hospital?

Answer 39

Antipsuedomonal penicillin such as piperacilin with tazobactam OR

a broad-spectrum cephalosporin like Ceftazidime OR

another antipsuedomonal beta-lactam OR

a quinolone (ciprofloxacin)

IF MRSA: vanco.

For severe illness caused by Pseudomonas aeruginosa, consider adding an aminoglycoside.
Suggested duration of treatment 7 days (longer if Pseudomonas aeruginosa confirmed)