Infectious Disease: Respiratory Flashcards
Acute Bacterial Rhinosinusitis
Major Symptoms include?
Purulent anterior nasal drainage
Purulent or discolored posterior nasal drainage
Nasal congestions or obstruction
Facial congestion or fullness
Facial pain or pressure
Hyposmia or anosmia
Fever
Acute Bacterial Rhinosinusitis
Minor Symptoms
HA
Ear pain, pressure, or fullness
Halitosis
Dental pain
cough
Fever (for subacute or chronic sinusitis)
Fatigue
Acute Bacterial Rhinosinusitis
Conventional criteria for diagnosis of ABRS?
At least 2 major symptoms OR
1 major and >/= 2 minor symptoms
Acute Bacterial Rhinosinusitis
Microbiology (common bacteria)?
S. Pneumonia (GP) (30-40%)
H. influenzae (GN) (20-30%)
M. Catarrhalis (GN) (12-20%)
Acute Bacterial Rhinosinusitis
Microbiology (common viruses)?
Rhinovirus
Influenza virus
Adenovirus
Acute Bacterial Rhinosinusitis
First Line Therapy
Who gets it?
Duration?
Amoxacillin/Clavulanate (Augmentin) (Standard Dose)
Toxic, Fail topical decongestants, or w/ comorbid conditions, or sx for > 7d
5-7 days
Acute Bacterial Rhinosinusitis
PCN Allergy
Levofloxacin
Doxycycline
Acute Bacterial Rhinosinusitis
Risk For Abx Resistance or Failed Therapy
Amox/Clav (high dose)
Clindamycin + cefixime OR cefpodoxim
Levofloxacin
Acute Bacterial Rhinosinusitis
When to Use High Dose of Amox/Clav:
What is the High dose?
Duration
2g q12 h
10-14d
Acute Bacterial Rhinosinusitis
When to Use High Dose of Amox/Clav?
Regions where PNS SPNA is prevalent
Severe infection
Attendance at daycare
Age <2 or > 65
Recent hospitalization
Abx use w/n last mo
Immunocompromised
CAP Pneumonia Criteria
Coming in from the community, doesn’t meet HC criteria
Nosocomial Pneumonia Criteria: HAP
Occuring > 48 hrs after hospitalization
Nosocomial VAP Criteria: VAP
Occring > 48 hrs after intubation
CAP Pneumonia Probable Pathogens
Strep Pneumoniae
Mycoplasma pneumoniae
H. Influenzae
Chlamydophilia
Legionella spss.
Nosocomial Pneumonia Probable Pathogens
Staphylococcus aureus
Pseudomonas aeruginosa
Enterobacter spss.
Klebsiella spss.
Acinetobacter
E. coli
CAP Outpatient therapy
Previously Health
No recent abx use (w/n 90d)
Macrolide Or Doxycycline
Azithro 500mg POx1 then 250mg x 4d
Doxycycline 100mg PO BID x5-7d
CAP Outpatient therapy comorbidities requiring higher treatment than Macrolide OR Doxycycline includes?
Chronic heart, lung, liver or renal dz
DM
Alcoholics
Malignancy/Immunosuppression
Previous abx (w/n 3mo)
CAP Outpatient therapy
Comorbidities including
Chronic heart, lung, liver or renal dz
DM
Alcoholics
Malignancy/Immunosuppression
Previous abx w/n 3 mo
Respiratory FQ OR Beta-lactam + Macrolide (or doxycycline)
CAP Outpatient therapy
Comorbidities including
Chronic heart, lung, liver or renal dz
DM
Alcoholics
Malignancy/Immunosuppression
Previous abx w/n 3 mo
Respiratory FQ’s for this are?
Moxifloxacin 400mg PO daily x 5-7days
Levofloxacin 750mg PO daily x 5-7days
CAP Outpatient therapy
Comorbidities including
Chronic heart, lung, liver or renal dz
DM
Alcoholics
Malignancy/Immunosuppression
Previous abx w/n 3 mo
Beta Lactam + Macrolide (or Doxycycline)
Amoxicillin 1g PO TID x 5-7d
Amox/Clav 2g PO BID x5-7d
Cefpodoxime 200mg PO q12h x 5-7d
Cefuroxime 500mg PO q12 h x 5-7d
Ceftriaxone 1g IV daily x 5-7d
+
Azithro500mg PO x1 then 250mg x 4d
or doxycycline 100mg PO BID x 5-7d
CAP Inpatient therapy
Non-severe, inpatient (Non-ICU patient)
Beta-Lactam + Macrolide (or doxycycline)
Beta-Lactam + Macrolide (or doxycycline)
Ceftriaxone 1g IV daily x 7-10d
Cefotaxime 1g IV q8h x 7-10d
Amp/Sulbactam 3g IV q6h x 7-10d
Ertapenem1g IV daily x 5-7d
+
Azithromycin 500mg PO/IV daily x 5d
Doxycycline 100mg PO/IV BID x 5-7d
CAP Inpatient Therapy
Non-severe, inpatient (Non-ICU patient)
Respiratory FQ
Moxifloxacin 400mg IV daily x 5-7d
Levofloxacin 750mg IV daily x 7-10d
CAP Inpatient therapy
Severe, inpatient (ICU patient)
Beta-lactam + Macrolide OR Respiratory FQ
Ceftriaxone 1g IV daily x 7-10d
Cefotaxime 1g IV q8h x 7-10d
Amp/Sublactam 3g IV q6h x 7-10d
+
Azithromycin 500mg IV daily x 5d
Moxifloxacin 400mg IV daily x 5-7d
Levofloxacin 750mg IV daily x 5-7d
Empiric Treatment of VAP
Basic Empiric Therapy (No special circumstance)
Piperacillin/tazobactam 4.5g IV q6h
Cefepime 1g IV q8h
Ceftazidime 2g IV q8h
Imipenem/cilastatin 500mg IV q6h
Meropenem 1g IV q8h
OR
Aztreonam 2g IV q8h
Empiric Treatment of VAP
Additional Gram-Positive Coverage
(if Unit MRSA rate is >10-20% or if unknown)
Vancomycin 15mg/kg q12h
OR
Linezolid 600mg IV q12h
Empiric Treatment of VAP
Double-coverage of Pseudomonas
(RF for resistance, unit where >10% of GN isolates are resistant to monotherapy, or GN resistance is unknown)
Ciprofloxacin 400mg IV q8h
Levofloxacin 750mg IV daily
Amikacin 15-20mg/kg IV daily
Gentamicin 5-7 mg/kg IV daily
Tobramycin 5-7 mg/kg IV daily
OR
Polymixin (colistin, polymixin B)
Empiric Treatment of HAP
Not at High Risk for Mortality and No Factors Increasing the Likelihood of MRSA
Choose 1
Piperacillin/Tazobactam 4.5g IV q6h
Cefepime 1g IV q8h
Levofloxacin 750mg IV daily
Imipenem/cilastatin 500mg IV q6h
Meropenem 1g IV q8h
Empiric Treatment of HAP
Not at High Risk for Mortality BUT w/ Factors Increasing the Likelihood of MRSA
Piperacillin/tazobactam 4.5g IV q6h
Cefepime 1g IV q8h or Ceftazidime 2g IV q8h
Levofloxacin 750mg IV daily or Ciprofloxacin 400mg IV q8h
Imipenem/cilastatin 500mg IV q6h or Meropenem 1g IV q8h
OR
Aztreonam 2g IV q8h
+
Vancomycin 15 mg/kgq 12h
Or
Linezolid 600 mg IV q12h
Empiric Treatment of HAP
High Risk of Mortality or Receipt of IV Abx w/n 90d
Piperacillin/tazobactam 4.5g IV6h
Cefepime 1g IV q8h or Ceftazidime 2g IV q8h
Imipenem/cilastatin 500mg IV q 6h or Meropenem 1g IV q8h
+
Levofloxacin 750mg IV daily or Ciprofloxacin 400mg IV q8h
Amikacin 15-20mg/kg IV daily or Gentamicin 5-7 mg/kg IV daily or Tobramicin 5-7 mg/kg IV daily
+
Vancomycin 15mg/kg IV q12h
OR
Linezolid 600mg IV q12h
MRSA Risk Factors
Prior IV abx use w/n 90d
Hospitalization in a unit where > 20% of S. aureus isolates are MRSA
MRSA rates are unknown
High Risk for Mortality
Ventilator support d/t HAP
Septic Shock
Pneumonia Treatment durations
CAP=
Nosocomial=
Pseudomonal pneumonias=?
MRSA pneumonia=?
5-7d
7d
at least 14d (maybe???)
often requires longer duration
When to switch IV to PO abx?
Hemodynamic Stability (SBP > 90mmHg)
Tolerating PO
Normally fxning GI tract
Afebrile for ~48h
Empyema Classifications:
Uncomplicated parapneumonic effusion
Exudative effusion
Resolves w/ resolution of pneumonia
Empyema Classifications:
Complicated parapneumonic effusion
Bacterial invasion of the pleural space
Increased neutrophils and pleural fluid acidosis
LDH > 1000 IU/L
Cultures are often falsely negative
Anaerobes
Empyema Classification:
Thoracic Empyema
Evident bacterial infection of the pleural liquid
Pus and/or presence of bacteria on gram-stain
Empyema Diagnosis:
Pleural Fluid Laboratory Analysis orders includes
Microbiology
Cell count (w/ diff)
Chemistries (total protein, LDH, glucose)
pH
Empyema Diagnosis:
Light’s Criteria includes
Total serum protein
Pleural fluid protein
Serum LDH
Pleural fluid LDH
Empyema Diagnosis using Light’s Criteria
Transudative vs. Exudative
Exudative effusion is present if?
1 of the following occurs
LDH > 2/3 Upper Limit of Normal for serum
Plueral Fluid: Serum Protein is > 0.5
Pleural Fluid: Serum LDH > 0.6
Empyema Microbiology
Typically the same pathogens that cause pneumonia
Notable exception - anaerobes
*Fusobacterium
*Prevotella
*Peptostreptococcus
*Bacteroides
Empyema Treatment
Abx Treatment
Treat Underlying Pneumonia
BUT….add anaerobic coverage (if your primary regimen does not provide anaerobic coverage)
*Clindamycin
*Metronidazole
Empyema Treatment
Duration of Treatment
Very pt specific
Until clinical improvement
Depends upon other interventions
Empyema Treatment
Surgical Interventions: Chest tube placement/drainage if?
pH is < 7.2
Positive culture or gram-stain
Purulent
May need more than 1 tube placed if the collections are loculated
Larger bore tubes are necessary for more purulent fluid
Impact on treatment duration
Pulmonary Infections: Tuberculosis Diagnostics
Induration >/= 5mm + is positive in which patients?
HIV infected-person
Recent contact w/ TB infected person
CXR changes c/w TB
Organ transplant recipients
Immunosuppression
Pulmonary Infections: Tuberculosis Diagnostics
Induration >/= 10mm + is positive in which patients?
Recent immigrants from high-prevalence countries
IV drug users
Residents & employees of high-risk congregate settings
Mycobacterial lab personel
Persons w/ clinical conditions that place them at high risk
Children < 4yo
Infants, children & adolescents exposed to adults in high-risk categories
Pulmonary Infections: Tuberculosis Diagnostics
Induration >/= 15mm + is positive in which patients?
In any person who does not meet any of the other criteria
Pulmonary Infections: Tuberculosis Treatment (Latent TB Infection)
Drugs used to treat?
Isoniazid and Rifapentine
Rifampin
INH + Rifampin
Isoniazid
Pulmonary Infections: Tuberculosis Treatment (Latent TB Infection)
Isoniazid and Rifapentine
Duration
Interval
Minimum Doses
3mo
Once weekly
12
Pulmonary Infections: Tuberculosis Treatment (Latent TB Infection)
Rifampin
Duration
Interval
Minimum Doses
4mo
Daily
120
Pulmonary Infections: Tuberculosis Treatment (Latent TB Infection)
INH + Rifampin
Duration
Interval
Minimum Doses
3mo
Daily
90
Pulmonary Infections: Tuberculosis Treatment (Latent TB Infection)
Isoniazid
Duration
Interval
Minimum Doses
9mo
Daily
270
Pulmonary Infections: Tuberculosis Treatment (Active TB - Non-HIV)
Initial Treatment Phase
Preferred Regimen
Alternative Regimen 1
Alternative Regimen 2
INH, RIF, PZA, & EMB Daily 56 doses (8 weeks)
INH, RIF, PZA & EMB Daily 14 doses (2 weeks) THEN Twice Weekly 12 doses (6 weeks)
INH, RIF, PZA & EMB Thrice Weekly 24 doses (8 weeks)
Pulmonary Infections: Tuberculosis Treatment (Active TB - Non-HIV)
Continuation Treatment Phase
Preferred Regimen
Alternative Regimen 1
Alternative Regimen 2
INH & RIF Daily 126 doses (18 weeks) OR INH & RIF Twice Weekly 36 doses (18 weeks)
INH & RIF Twice Weekly 36 doses (18 weeks)
INH & RIF Thrice Weekly 54 doses (18 weeks)
