Lecture 15: Respiratory Tract Infections Flashcards
1
Q
What are some of the Host Defense Mechanisms?
A
- Nasopharynx [Nose hair, mucociliary apparatus, IgA]
- Oropharynx [Saliva, Epithelial Cells]
- Trachea, Bronchi [Cough, epiglottic reflexes]
- Terminal Airways, Alveoli [Surfactant]
2
Q
What are some important things to know about the Host defenses?
A
- IgA promotes colonization
- Alveolar Macrophages: increase acidity in lungs = hypoxic
3
Q
What are some factors that interfere with host defenses?
A
- Altered Consciousness
- Smoking [disrupts mucociliary]
- Viruses [S. Aureus]
- Alcohol
- Mechanical Vent
- Asplenia [S. Pneumoniae]
- Elderly
4
Q
What is Community-Acquired Pneumonia?
A
- Pneumonia developing OUTSIDE the hospital or < 48 hours. after admission
- CAP
5
Q
What is the pathogenesis of CAP?
A
- Aspirations [Bacterial]
- Aerosolization [droplets]
- Bloodborne [Mostly becomes this]
Basically what you are breathing in
6
Q
What are the specific pathogens that are found in CAP?
A
- Streptococcus Pneumoniae
- Haemophilus Influenzae
- Myocplasma Pneumoniae
- Legionella Pnenmophila
- Chlamydia Pneumoniae
Not really S. Aureus; only if there is a history of it
7
Q
When discussing Streptococcus Pneumoniae in CAP, what are some of the drug resistant risl factors?
A
- Antibiotics within 3 months
- Age > 65
- DM, CAD, CHF, HIV
- Alcohol Abuse, Cirrhosis
- Immunosrppressive Medications
8
Q
When discussing Mycoplasma Pneumoniae, what is important to know?
A
- Atypical Pathogen; spreads person-to-person
- Presents with Cough, Ear Pain, Nausea, Vomiting, Diarrhea
- NO consolidation
9
Q
When discussing Legionella Pneumophila, what is important to know about it?
A
- Atypical Pathogen
- Transmitted by inhalation of areosols
- More so affects: Male, middle age, smokers
10
Q
When discussing Staphylococcus Aureus, what is important to know about it?
A
- Post Influenza [worsened illness suddenly]
- If nares are MRSA (-) by PCR; then most like dont have it [98.1% right]
11
Q
What is the clinical presentation of CAP?
A
- Sudden onset of fever, chills, chest pain, SOB, prodcutive cough
- Tachycardia, Blood Pressure [Increased 10 bpm for every oC elevation
12
Q
What are some of the important pysical exams for CAP?
A
- Tachypnea, Cyanosis, Nasal Flare = Serious Respiratory Compromise
- Conslidation [Dullness, Crackles, Egophany (E->A sounds)]
13
Q
What are some of the important Radiography that should be done for CAP?
A
- ALL patients should get
- Dense Lobar Conslidation
14
Q
What is the Major Criteria for Severe CAP?
A
- Respiratory Failure
- Septic Shock [needing Pressors]
NEEDS ONE
15
Q
What is the Minor Criteria for
Severe CAP?
A
- RR > 30 bpm
- Hypotension
- Multilobar
- Confusion
- Uremia [BUN >20]
- Leukopenia
- Thrombocytopenia
- Hypothermia
NEEDS >2
16
Q
What are the two important clinical predictions for the Prognosis of CAP?
A
- Pneumonia Severity Index [PSI]
- CURB-65 [Confusion, Uriema, Respiratory Rate, Low Blood Pressure, Age > 65]
17
Q
What is the Empiric Treatment of CAP for Healthy outpatients WITHOUT comorbidites?
A
- Amoxicillin 1g po q8h
- Doxycycline 100mg po q12h
- Azithromycin 500mg PO, then 250mg PO
- Clarithromycin 500mg PO q12h
Macrolide ONLY used when the resistance is < 25%, most likely not going to use them
18
Q
What is the Empiric Treatment of CAP for outpatients WITH comorbidites?
A
- Levi 750mg qd or Moxi 400mg qd
- B-lactam + Mac OR B-lactam + doxycycline
- Augmentin, Cefodoxime, Cefuroxime
- Azithromycin; Clarithromycin 500mg
- Doxycycline 100mg q12h
FQ: QTc prolongation, drug-drug interactions [cations/warfarin], renal impairment [levo]
19
Q
What is the Empiric Treatment of Non-severe CAP inpatient?
A
- B-lactam + Mac [Unasyn, Cefotaxime Ceftraixone, Ceftaroline + Azitromycin, Clarithromycin]
- Levo 750mg or Moxi 400mg
- B-lactam + Doxycycline [if contrainidated to FQ & MACs]
20
Q
What is the Empiric Treamtent of Severe CAP inpatient?
A
- B-lactam + Mac [Unasyn, Cefotaxime, Ceftriaxone, Ceftaroline + Azithromycin, Clarithromycin]
- B-lactam + FQ [Unasyn, Cefotaxime, Ceftriaxone, Ceftaroline + Levo, Moxi]
FQ maybe not used as much because of the increasing resistance to them
21
Q
With the Empiric Treatmets of CAP, what should be used in the Concern of MRSA or Pseudomonas Aeruginousa?
A
- MRSA: NASAL PCR 1st; + Vancomycin or linezolid
- P.Aeruginosa: Zosyn, Cefepime, Ceftazidime, Aztreonam, Meropenem, Imipenem
NO Dapto for MRSA
NO Erta for P. Aeruginosa
22
Q
When should Corticosteroids be used in the treatment of CAP inpatient?
A
- Not really used in nonsevere or severe
- Might be good in refractory septic shock?
MACs have an inflammtory repsonse, so maybe corticosteroids may be good?`
23
Q
How long does the normal duratoin of CAP treatment last?
A
- When they are clinical stabilty and for no less than a total of 5 days
24
Q
What makes you “Clincally stable”?
A
- Temp < 37.8C
- HR < 100bpm
- RR < 24
- SBP > 90mmhg
- O2 stat > 90%
- Able to eat or take oral medications
- Normal Mental Status
25
What is HAP/VAP?
- HAP: pneumonia >48h after admission
- VAP: pneumonia >48h after intubation
26
What is the pathogensis of HAP/VAP?
- Microapsirations [normally gram (+) but after 48h becomes gram (-)
- Direct Inoculation [from tube]
- Mechanical Ventilator
27
What are some of the risk factors that are asscoiated with HAP/VAP?
- Old
- Severe underlying disease
- **TIME IN HOSPITAL**
- Intubation [Endo/Naso]
- Mechanical Ventilation
- Altered mental status
- Surgery
- Preverious antibiotics
28
What are the most common bacterial organisms that cause HAP/VAP?
- Pseudomonas Aeruginosa
- Enterobacterales
- Acinetobacter Baumannii
- Staph Aureus [**MRSA**]
29
What are some of the risk factors for antibiotic resistance in VAP?
- **Prior IV antibiotics [within 3 months]**
- **> 5 days hospitalized**
- Septic shock
- Acute Respiratory Distress
- Acute reanl replacement
## Footnote
also for **HAP** too [MDR & MRSA]
30
What is the general basis of empiric treatment of clinically suspected VAP?
## Footnote
MRSA? MSSA? Antipseudo? Pseudo?
- Give MRSA if: Risk Factors of resistance, >10-20% in ICU, unknown prevalence
- Give MSSA
- **2** antipseudomonal if: Risk Factors of resistance, >10% in ICU, Unknown Resistance
- P. Aeruginos if: without risk factors of resistance, < 10% in ICU
## Footnote
MSSA: give zosyn, cefepime, imipenem, meropenem [empiric] & Cefazolin, Nefcillin, Oxacillin [directed]
31
What is the **Empiric Therapy** of HAP with **NO** risk of mortality and **NO** risk of MRSA?
- Zosyn 4.5g IV q6h
- Cefepime 2g IV q8h
- Imipenem 500mg IV q6h
- Meropenem 1g IV q8h
## Footnote
**MSSA Coverage**
Direct MSSA use Nafcillin, Oxacillin, Cefazolin
32
What is the **Empiric Therapy** of HAP with **NO** risk of mortality and **RISK** of MRSA?
- **ONE**: Zosyn, Cefepime, Ceftazidime, Imip, Mero, Levo, Cirpo, Aztreonam
- **PLUS**: Vanco, Linezolid
33
What is the **Empiric Therapy** of HAP with **RISK** of mortality and **RISK** of MRSA?
- **TWO**: Zosyn, Cefepime, Ceftazidime, Imip, Mero, Levo, Cirpo, AGs, Aztreonam
- **PLUS**: Vanco, Linezolid
34
What should you NOT used in HAP/VAP Treatment?
- AGs: poor lung penetration, Nephrotoxicity & Ototoxicity
- Polymycins: ONLY really for MDR
- Tigecycline: poor outcomes & increaed mortality
35
What are some of the agents that you would want to use in your Pathogen-specific treatments for HAP/VAP?
## Footnote
MSSA? MRSA? Enterobacterales? ESBL? MBL? KPC? Pseudo? Baumannii?
- MSSA: Cefazolin, Nafcillin, Oxacillin
- MRSA: Vancomycin, :Linezolid
- Enterobacterale: Whatever
- ESBL: Carbapenems [DOC]
- MBL: Aztreonam + Ceftazidime/avibactam, Cefiderocol
- KPC: Cefetazidime/avibactam, meropenem/vaborbactam, Imipenem/cilistain/releabatam, cefiderocol
- Pseudo: Cefetazidime/avibactam, Imipenem/cilistain/releabatam, ceftoloazone/tazobactam, cefedierocol
- Baumannii: Unasyn
36
What is the duration of treatment for HAP/VAP?
- 7 days
37
What is the cause of Acute Bronchitis and what are some of the common symptoms?
- Repiratory **VIRUSES**
- Cough, Sore Throat, Headache, Fever, Normal CXR
38
What is the treatment for Acute Bronchitis?
- Symptomatic = Antitussives, Antipyretics, Hydration
- **NO ANTIBIOTICS NEEDED**
39
What is Acute Exacerbation of Chronic Bronitis?
- The presence of a chronic cough productinve of sputum on most days for at least **3 consecutive months** each year for **2 consecutive years**
40
What are the 3 cardinal symptoms of Acute Excerbation of Chronic Bronchitis?
- Increased Cought or SOB
- Increased Sputum Volume
- Increased Sputum Purulence
## Footnote
**DONT** treat when only 1; **TREAT** when theres 2 or 3
41
What are the common bacteria what are asscoiated with Acute Excerbation of Chronic Bronchitis?
- H. Inlfuenzae
- S. Pneumoniae
- M. catarrhalis
- Enterobacterales & P. Aeruginosa [end-stage COPD]
42
What are the risk factors for **Uncomplicated** Chronic Bronchitis in AECB?
- Age < 65
- FEV1 > 50%
- < 4 excerbations/year
- NO comorbidity
- NO risk factors
43
What are some of the inital treatment options for **Uncomplicated** Chronic Bronchitis in AECB?
- 2nd gen MACs [Clarith/Azith]
- 2nd or 3rd gen cephalo
- Doxycycline
- Amoxicillin
- SMX/TMP
44
What are the risk factors for **Complicated** Chronic Bronchitis in AECB?
- Age > 65
- FEV1 < 50%
- > 4 excerbations/year
- > 2 risk factors
45
What is the initial treatment of **Complicated** Chronic Bronchitis in AECB?
- Respirtatory FQ
- Augmentin
## Footnote
Zosyn??
46
What ar ehte risk factors for **Complicated + P. Aeruginosa** Chronic Bronchitis in AECB?
- Severe Symptom
- Purulent Sputum
- FEV < 35%
- > 2 risk factors
47
What is the initial treatment for **Complicated + P. Aeruginosa** Chronic Bronchitis in AECB?
- FQ + Antipseudo
- **Piperacillin/Tazobactam**
- Hospitized? = empiric IV to cover P. Aeruginosa
48
What is the bacterial causes for Pharyngitis?
## Footnote
Pharyngitis = Strep Throat
- Viruses [MOST COMNON; no antibiotics]
- S. Pyogenes [MOST COMMON bacteria]
49
What are the common symptoms of Pharyngitis?
- Sore Throat with difficulty swallowing, Fever, enlarged lymph nodes, swollen uvula
- CANNOT tell the difference between bacterial & viral
50
What are some of the ways that we can diagnosis pharyngitis?
- Throat culture
- Rapid Antigen Detection Tests
## Footnote
Looking for Group A Strep
51
# `
What is the treatment for Pharyngitis?
- Penicillin V [DOC 1; no resistance?]
- Amoxicillin [DOC 2]
- 2nd gen cephalos [if Pen & Amox fail]
- Allergic to penicillins: 1st gen cephalo, Azith or Clarith, Clindamycin
## Footnote
MACs used ONLY when b-lactam cannot be used
52
What is the differences between Acute, Viral and Acute Bacterial Rhinosinusitis?
- Acute: 4 weeks of purulent nasal drainage/face pain
- Viral: Acute but from viruses
- Acute Bacterial: Acute but from bateria [need clinical presentation]
53
What are the common "bugs" in Acute Bacterial rhinosinuitis?
- H. Influenzae
- S. Pnumoniae
- M. Catarrhalis
54
What is the Diagnosis of Acute Bacterial Rhinosinusitis?
## Footnote
Persistents, Severe, Worsening
- **Persistent** signs/symptoms for >10d WITHOUT improvement
- **Severe** signs/symptoms of high fever, nasal discharge for 3-4d
- **Worsening** signs/symptoms of NEW onset of fever, headache, discharge [Double-sickening]
55
What is the Treatment for Acute Bacterial Rhinosinusitis?
- Augmentin
