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Pharmacy - Year 2 > Infections - comm acq pneumonia - PD > Flashcards

Infections - comm acq pneumonia - PD Flashcards

1
Q

Inf markers - systemic?

A

Fever
Rigor
Chills
Myalgia
Malaise
Headache
Anorexia
Delirium

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2
Q

Inf markers - local/peripheral

A

Erythema
Pain
Heat
Swelling
Pus

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3
Q

Inf markers - vital signs

A

change in body temp
Tachycardia
Hypotension
Tachypnoea

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4
Q

Inf markers - Haematology

A

Increase WBC count
Change to neutrophils (generally increase but low in neutropenic sepsis)
Increased platelets

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5
Q

Inf markers - Biochemistry

A
  • Increased C reactive protein
  • Increased erythrocyte sedimentation rate
  • Increased serum creatinine
  • Increased liver function test
  • Change to procalcitonin level
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6
Q

inf markers - Microbiology tests

A

Presence of organism
Microscopy
Culture
Serology
Polymerase chain reaction

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7
Q

inf markers - Urinalysis

A

Presence of leucocyte esterase
Presence of nitrates

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8
Q

examples of respiratory infections

A
  • Covid 19
  • Infective exacerbation of COPD
  • Tuberculosis (TB)
  • Bronchiectasis
  • Empyema
  • Acute bronchitis
  • Influenza
  • Pleurisy
  • Pneumonia (community acquired)
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9
Q

What is pneumonia?

A
  • ‘Inflammation of the lungs caused by a bacterial or viral infection, in which the air sacs fill with pus and can become solid’
    children under 5 and adults over 70 - highest mortality
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10
Q

both lungs definition and single lung?

A

bilateral pneumonia
unilateral pneumonia

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11
Q

3 categories

A
  • CAP
  • HAP (hospital)
  • Aspiration pneumonia
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12
Q

CAP - symptoms?

A
  • Overgrowth of pathogenic bacteria in upper resp tract – leading to infection
  • Bacteria responsible depends on local epidemiology
  • Severity depends:
    Invading organism and response antimicrobial treatment
    Patients underlying co-morbidities
    Presence of risk factors
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13
Q

CAP Risk factors

A
  • Age >65
  • PMHx of COPD
  • Cigarette smoke
  • Care homes
  • Alcohol abuse
  • Use of acid-reducing drugs – stomach acid decrease allows pathogens to colonise upper resp tract more easily (GIS ISU)
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14
Q

Diagnosis and assessment?

A
  • Thorough history from patient – including HxPC
  • Blood tests (CRP+, WCC +)
  • Patient observations
    1. BP
    2. HR
    3. Resp rate
    4. Temp
    5. O2 sat
  • Chest X-ray – shows new signs of consolidation
    1. Within 4 hours of presentation
    2. Within 1 hour if suspecting sepsis
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15
Q

Differential Diagnosis?

A
  • Covid 19 associate CAP – treatment differ
  • Acute bronchitis
  • Infective exacerbation of COPD
  • Tuberculosis
  • Empyema
  • Lung cancer
  • Pulm Emb
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16
Q

Treatment?

A
  • Severity of patients condition can be calculated on scoring system but clin judgement also advised
  • Patient gets 1 point if they have any of the following parameters
17
Q

CURB - 65 - hospital
CRB – 65 (primary care). (prediction of >18 years pneumonia mortality risk)

A

C – Confusion
U – Urea > 7.0mmol/L
R – Resp rate >30 / min
B – Blood pressure
1. Low systolic <90 mmHg
2. Low diastolic <60 mmHg
65 – Age > 65 years
CRB – 65 scoring
- 0 – low severity - <1% mortality
- 1-2 – Intermediate – 1-10% mortality
- 3-4 – High - >10% mortality
CURB – 65 scoring
- 0-1 – low severity - <3% mortality
- 2 – Intermediate – 3-15% mortality
- >3 – High - >15% mortality

18
Q

use of CRB - 65

A
  • Use to help guide mortality risk, place of care and antibiotics.
19
Q

Confusion?

A

(abbreviated mental test score <8 – age, time, address for recall at end of test. Year, place, identification of 2 persons, DOB, year of WW1, present monarch, count backwards 20-1)

20
Q

Score 3-4?

A

urgent hopsital admission
- Clinically assess need for dual therapy to cover atypical infections if high CRB65 score. However, mycoplasma infection is rare in over 65s.
- Give safety net advice and likely duration of different symptoms, such as cough 6 weeks
- If recent influenza infection, consider need for anti-staphylococcal cover e.g doxycycline monotherapy or addition of flucloxacillin to standard treatment
- If failure of first-line agents, patients should be reassessed for on-going signs of infections before further treatment is prescribed
- British HIV association recommend testing for HIV in adult patients presenting with CAP

21
Q

If CRB is 0?

A

Treat at home
First line –
- Amoxicillin
- 500mg TDS
Second line (failure 1st line treatment/penicillin allergy/atypical pathogen suspected)
- Doxycycline
- 200mg stat then 100mg OD
- Clarithromycin
- 500mg BD
Third line (prev treatment failure)
- Co – trimoxazole
- 960mg BD
Treatment duration for all is 5 days. Stop antibiotic treatment after 5 days unless microbiological results suggest a longer course length is needed or the person is not clinically stable.

22
Q

Amoxicillin?

A

Class: Penicillin
Side effects:
- Common
- GI issues: n+v, diarrhoea, abdominal pain
- Rash
- Yeast infections: oral thrush, vaginal candidiasis

  • Uncommon (but severe)
  • Anaphylaxis: severe allergic reaction
  • Liver enzyme abnormalities
  • Severe diarrhoea
    Contraindication:
  • Allergy to penicillin or cephalosporins
  • History of severe allergic reactions
  • Mononucleosis – risk of skin rash
    Cautions
  • Renal impairment
  • Pregnancy – gen safe
  • Breastfeeding – gen sfe – caution advised
  • GI diseases – caution with history like colitis, antiobiotics can exacerbate issues
  • Mononucleosis – more prone to developing rash
23
Q

Doxycycline

A

Class: Tetracycline antibiotic
Side effects:
- Common
- GI: n+v, diar, abdominal discomfort
- Photosensitivity
- Oesophageal irritation- can cause irritation or ulceration in the oesophagus if not taken with enough water
- Skin rash
- Dizziness or vertigo

  • Less common
  • Anaphylaxis
  • Liver toxicity
  • Tooth discolouration
  • Intracranial hypertension
  • Superinfection
    Contraindications
  • Pregnancy (esp 2nd and 3rd trimester): c/I due to potential to cause harm to foetus. Category D
  • Children under 8
  • Hypersensitivity to tetracyclines – if allergic reaction to similar don’t use
  • Severe liver disease
    Cautions
  • Renal impairment
  • Pregnancy
  • Breastfeeding
  • Photosensitivty
  • GI conditions
  • Superinfection risk
24
Q

Clarithromycin?

A

Class: Macrolide antibiotic
Side effects:
- Common
- GI issues + dyspepsia
- Taste disturbances
- Headache
- Rash

  • Uncommon
  • Hepatoxicity
  • QT interval prolongation
  • Severe allergic reaction
  • Clostridium difficile-ass diarrhoea – disrupt normal gut flora
  • Pancreatitis
    Contraindications
  • Hypersensitivity to macrolides
  • Severe hepatic impairment
  • Concurrent use with certain meds – (ergotamine, pimozide, fentanyl, terfenadine)
    Cautions
  • Renal impairment
  • Liver disease
  • Pregnancy – category C
  • Breastfeeding – gen sfe – caution advised
  • Cardiac arrythmias – monitor closely
  • Drug interaction – CYP3A4 inhibitor and can increased plasma conc of certain drugs (statins, benzos, CCBs)
25
Q

Cotrimoxazole?

A

Class: Combination antibiotic
Side effects:
- Common
- GI
- Rash
- Headache
- Fatigue

  • Less common but severe
  • Hypersensitivity reactions (Stevens-Johnson syndrome)
  • Haematological reactions: leukopenia, thrombocytopenia, and agranulocytosis, aplastic anaemia
  • Liver toxicity
  • Renal impairment
  • Hyperkalaemia
  • Pneumonitis
  • Blood dyscrasias

Contraindications:
- Hypersensitivity to sulfonamides or trimethoprim – contra ind in severe allergic reactions (anaphylaxis or S-J syndrome)
- Severe renal or hepatic impairment
- Folate deficiency
- Pregnancy (esp in the first trimester) – foetal harm
- Breastfeeding – gen not recommended esp in infants under 2 months
- Infants under 2 months of age – due to risk of kernicterus
Cautions
- Renal impairment
- Liver disease
- Elderly
- Glucose 6 phosphate dehydrogenase
- Pregnancy (2nd and 3rd)
- Alcohol consumption
- Drug interactions (warfarin, methotrexate, phenytoin)
Indications
- UTI
- Resp tract infections – pneumonia
- GI infections
- Ear
- Skin
- Prophylaxis

26
Q

CRB – 65 score – 1 and at home?

A

First line –
- Amoxicillin
- 500mg TDS
- PLUS
- Clarithromycin
- 500mg BD

Second line (failure 1st line treatment/penicillin allergy/atypical pathogen suspected)
- Doxycycline
- 200mg stat then 100mg OD

Third line (prev treatment failure)
- Co – trimoxazole
- 960mg BD
Treatment duration for all is 5 days. Stop antibiotic treatment after 5 days unless microbiological results suggest a longer course length is needed or the person is not clinically stable.

27
Q

CURB-65 score ? >3

A
  • Non-pen allergic
  • Co-amoxiclav
  • PO – 625mg TDS (5 days)
  • IV – 1.2g TDS (5 days)
  • Clarithromycin
  • PO/IV – 500mg BD
  • Pen allergic
  • Levofloxacin
  • PO/IV – 500mg BD (all 5 days treatment)
28
Q

Co-amoxiclav?

A

Class: Penicillin
Side effects:
- As per amoxicillin
- Hepatic disorders
Contra indications
- Hx of jaundice due to co-amoxiclav administration
Monitoring
- Liver function
Notes
- Allergy potential
Unlikely you will see co-amox for CAP in hospital setting, unless advised by microbiology consultant or for very specific indications
Why?
- High risk of clostridium difficile – infective diarrhoea often associated with the excess use of broad spectrum antibiotics
- High resistance rates beginning to develop

29
Q
A

Amoxacillin 1g TDS plus
- Clarithromycin (PO/IV) 500mg BD

30
Q

Levofloxacin?

A

Class: Quinolone
Side effects:
- GI upset
- QT prolongation
- Affect glucose control
- Photosensitivity reactions
- Eye disorders
- Headache
- Convulsions
- Tendon damage
- Serious musclo-skeletal and nervous system disorders

Fluoroquinolone antibiotics: must now only be prescribed when other commonly recommended antibiotics are inappropriate

Levofloxacin – MHRA warnings
1. Can induce cnvulsions
2. Tendon damage
- C/I in patients with Hx of quinolone induced tendon damage
- Patients >60 at an increased risk
- Risk increased when used with corticosteroids
- Stop immediately is tendonitis suspected
3. Increased Risk of aortic aneurysm/dissection
4. Increased risk of disabling, long lasting or irreversible adverse reactions affecting the musclo-skeletal and nervous system
- Patients should be provided with MHRA advice sheet outlining s/e to lookout for
Levofloxacin
Cautions
- Patients with QT prolongation risk factors
- Use in children
- Patients >60 - +s/e risk
- Disorders that pre-dispose patient to seizures: (epilepsy, alcohol dependence)
- Contra-indications – Hx of quinolone induced tendon damage
- Counselling: provide MHRA advice leaflet, look out for signs
- Monitoring: signs of s/e – discuss with the patient, renal function

31
Q

Summary

A

0-1 (low severity)

Non-pen allergic
Amoxicillin (PO) – 500mg TDS

Pen allergic
Doxycycline (PO) – 200mg STAT, 100mg OD
OR
Clarithromycin (PO) – 500mg BD

2 (moderate severity)
Non-pen allergic
Amoxicillin (PO) - 500mg – 1000mg TDS
PLUS
Clarithromycin (PO) – 500mg BD
Pen allergic
Doxycycline (PO) – 200mg STAT, 100mg OD
OR
Clarithromycin (PO) – 500mg BD

> 3 (highest severity)
Non-pen allergic
Co-amoxiclav (IV) – 1.2g TDS
PLUS
Clarithromycin (PO/IV) – 500mg BD

Pen allergic:
Levofloxacin (PO/IV) – 500mg BD

32
Q

Counselling

A
  • Patient expectation in terms of symptom resolution should be addressed
  • Symptoms resolution timeline
  • 1 week: fever should have resolved
  • 4 weeks: chest pain and sputum production should have substantially reduced
  • 6 weeks: cough and breathlessness should have substantially reduced
  • 3 months: most symptoms should have resolved but fatigue may still be present
  • 6 months: most people will feel back to normal

Pharmacy - Year 2 (7 decks)

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