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A13AMC @ UoN > L08 - Treatment of Respiratory Infections (inc. TB) > Flashcards

L08 - Treatment of Respiratory Infections (inc. TB) Flashcards

1
Q

Define CAP

A

Community Acquired Pneumonia

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2
Q

Give four examples of groups in which CAP is more common

A

Males
The elderly
Alcoholics
Chronic disease sufferers

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3
Q

What proportion of CAP do conventional bacteria cause?

A

60-80%

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4
Q

What proportion of CAP do ‘atypical’ bacteria cause?

A

10-20%

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5
Q

What proportion of CAP do viruses cause?

A

10-20%

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6
Q

What two conventional bacteria are frequently implicated in CAP?

A

S. pneumoniae

H. influenzae

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7
Q

What three ‘atypical’ bacteria are frequently implemented in CAP?

A

M. pneumoniae
C. pneumoniae
L. pneumophila

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8
Q

What four microbiological investigations are most commonly used in diagnosis of CAP?

A

Sputum analysis/culture
Immunofluorescence on sputum samples
Blood cultures
Urinary pneuomococcal/legionella antigen

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9
Q

What three factors is antimicrobial management for CAP based on?

A

Assessment of likely pathogen
Severity
Likelihood of drug resistance

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10
Q

What is CURB65?

A 
CURB65 is a scoring system for CAP:
Confusion MMT <8
Urea >7mmol/l
Resp. rate >30/min
Blood pressure <90 (s) or <60 (d)
65 y/o
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11
Q

What is the treatment regimen for a low severity CAP score (0-1)?

A

Amoxicillin 500mg q.d. for 7 days OR
Doxycyline 200mg (LD) then 100 mg o.d.
If unable to take oral therapy can give i.v. Amoxicillin

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12
Q

What is the treatment regimen for a moderate severity CAP score (2)?

A

Amoxicillin 500mg q.d. for 7 days + Clarithromycin 500mg b.d. for 7 days OR Doxycyline 200mg (LD) then 100 mg o.d.
If unable to take oral therapy can give i.v. Benzyplenicillin

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13
Q

If patients are allergic to penicillin what antibiotics can be prescribed instead? - CAP Score <2

A

Mild - i.v. Cefuroxime 1.5g t.d. (+ i.v. Clarithromycin 500mg b.d.)
Severe - Ciprofloxacin 400mg b.d. + Vancomycin

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14
Q

What is the treatment regimen for a severe CAP score (3)?

A

Co-amoxiclav 1.2g t.d. + Clarithromycin 500mg b.d. for 10 days

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15
Q

If patients are allergic to penicillin what antibiotics can be prescribed? - CAP Score >3

A

Levofloxacin 500mg b.d. + Vancomycin 1g b.d. for 10 days

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16
Q

If MRSA is likely what antibiotics should be prescribed?

A

Levofloxacin 500mg b.d. + Vancomycin 1g b.d. for 10 days

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17
Q

In what cases should the time course of the treatment be extended?

A 
Infection with:
Legionella
Staphylococcal
Gram-ve Pneumonia
Extend to 14-21 days
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18
Q

When should Mycoplasma infection be suspected?

A

Young patient
Long prodrome
Pactchy consolidation (CXR)
Extra-pulmonary disease

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19
Q

How should Mycoplasma infection be treated?

A

Tetracyclines for >14 days

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20
Q

When is CAP caused by S. aureus more likely?

A

During an influenza outbreak

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21
Q

How should CAP caused by S. aureus be treated?

A

Flucloxacillin 2g i.v. q.d. ADDED to standard regimen

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22
Q

When should Legionellosis be suspected?

A

Severe CAP (outbreak)
Multi-lobe involvement (CXR)
Hyponatraemia
Focal neurological disease

23
Q

How should Legionellosis be treated?

A

High dose macrolide (up to 4mg Erythromycin per day) + Rifampicin 600mg b.d.

24
Q

What bacterium causes TB?

A

M. tuberculosis

25
Q

What proportion of the world is infected with M. tuberculosis?

A

1/3

26
Q

What racial groups are particularly at risk?

A

Indian

Sub-Saharan Africa

27
Q

What is a caseating granuloma?

A

An organised collection of macrophages, specifically w/ necrosis (common sign in TB)

28
Q

What is commonly associated with granuloma development in TB?

A

Peripheral lymphocyte infiltration

29
Q

What happens to M. tuberculois bacterium after invasion?

A

The immune cells trap them in granulomas, and the life cycle is changed

30
Q

What is the life cycle of M. tuberculosis within the human body?

A 
Invasion + Colonization
Latency
Resuscitation
Disease Reactivation + Dissemination
Transmission
31
Q

What is different about milliary tuberculosis?

A

Early phase is uncontrolled, with wide spread of TB

Diagnosed by millet seed like spots on CXR

32
Q

What is the MoA of Rifampicin?

A

Inhibits mycobacterial RNA polymerase (Bactericidal)

33
Q

What is Rifampicin used for?

A

Essential component of short-course regimens:

Rifampicin 450mg o.d. (<50kg) OR 600mg o.d. (>50kg)

34
Q

What are the common side effects of Rifampicin?

A 
Hepatitis
Rash
Fever
Flu syndrome
Multiple drug interactions
35
Q

What is the MoA of Isoniazid?

A

Inhibits cell wall mycolic acid synthesis

Rapid bactericidal effect on replicating organisms at 300mg o.d.

36
Q

What are the side effects of Isoniazid?

A

Hepatitis
Peripheral neuropathy
Cutaneous hypersensitivity

37
Q

What is the MoA of Pyrazinamide?

A

Entirely unknown
Plays a key role in sterilising inflammatory tissue
1.5g o.d. (<50kg) or 2g o.d. (>50kg)

38
Q

What are the side effects of Pyrazinamide?

A 
Hepatitis
Anorexia
Flushing
Cutaneous hypersensitivity
Hyperuricaemia
39
Q

What is the MoA of Ethambutol?

A

Entirely unknown

Mod. bactericidal, 15mg/kg/day used as an adjunct (1-2 mo)

40
Q

What are the side effects of Ethambutol?

A

Optic neuritis

41
Q

What is the MoA of Streptomycin?

A

Binds to mycobacterial ribosome (16S rRNA + S12 protein) inhibiting protein synthesis
Bactericidal, 15mg/kg, must be given parenterally

42
Q

What are the side effects of Streptomycin?

A

Ototoxicity

43
Q

What are the two principles which underlie therapeutic regimens?

A

Mycobacterium within an infected individual are at different phases of replication
Mycobacterial population contains naturally occurring resistance mutants

44
Q

What are the two phases of therapy?

A

Bactericidal - Majority of organisms are killed

Sterilising - Persisting organisms are eliminated

45
Q

What is the problem with single drug therapy?

A

Mycobacteria develop chromosomal mutations too fast (1in10^6 - 1in10^8)
In a bacillary population large enough single drug therapy ALWAYS selects resistant organisms

46
Q

What is the minimum duration of therapy required for eradication?

A

Six months

47
Q

What is the standard antituberculous regimen in the UK?

A

Rifampicin + Isoniazid + Pyrazinamide + Ethambutol for 2 months THEN
Rifampicin + Isoniazid for 4 months
Otherwise patient is RIPE for infection

48
Q

What are DOT programmes?

A

DOT programmes use a nurse/surrogate to directly observe all doses being taken

49
Q

What is the most common pattern of drug resistant TB?

A

Isolated Isoniazid resistance (4-6%)

50
Q

What is the second most common pattern of drug resistant TB?

A

Rifampicin resistance (2%)

51
Q

What factors suggest MDR TB?

A

Previous TB treatment
Known contact with a case of MDR TB
Infection in a country/group with high prevalence of MDR TB
Failure to respond to conventional treatment
Co-existing HIV infection

52
Q

What is the initial management of MDR TB?

A

> 4 drugs to which the organism is likely to be sensitive

Treatment continuing until 3-6 mo AFTER sputum is culture negative

53
Q

What is the long term management of MDR TB?

A

After initial treatment therapy should be continued with 3> drugs for 15-18 months
Surgery may be necessary

A13AMC @ UoN (20 decks)

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