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PHRM 865: Theraputics V > Lecture 15: Respiratory Tract Infections > Flashcards

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]
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2
Q

What are some important things to know about the Host defenses?

A
  • IgA promotes colonization
  • Alveolar Macrophages: increase acidity in lungs = hypoxic
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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
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4
Q

What is Community-Acquired Pneumonia?

A
  • Pneumonia developing OUTSIDE the hospital or < 48 hours. after admission
  • CAP
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5
Q

What is the pathogenesis of CAP?

A
  • Aspirations [Bacterial]
  • Aerosolization [droplets]
  • Bloodborne [Mostly becomes this]

Basically what you are breathing in

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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

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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
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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
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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
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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]
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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
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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)]
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13
Q

What are some of the important Radiography that should be done for CAP?

A
  • ALL patients should get
  • Dense Lobar Conslidation
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14
Q

What is the Major Criteria for Severe CAP?

A
  • Respiratory Failure
  • Septic Shock [needing Pressors]

NEEDS ONE

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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

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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]
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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

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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]

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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]
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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

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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

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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?`

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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
Q

What is HAP/VAP?

A
  • HAP: pneumonia >48h after admission
  • VAP: pneumonia >48h after intubation
26
Q

What is the pathogensis of HAP/VAP?

A
  • Microapsirations [normally gram (+) but after 48h becomes gram (-)
  • Direct Inoculation [from tube]
  • Mechanical Ventilator
27
Q

What are some of the risk factors that are asscoiated with HAP/VAP?

A
  • Old
  • Severe underlying disease
  • TIME IN HOSPITAL
  • Intubation [Endo/Naso]
  • Mechanical Ventilation
  • Altered mental status
  • Surgery
  • Preverious antibiotics
28
Q

What are the most common bacterial organisms that cause HAP/VAP?

A
  • Pseudomonas Aeruginosa
  • Enterobacterales
  • Acinetobacter Baumannii
  • Staph Aureus [MRSA]
29
Q

What are some of the risk factors for antibiotic resistance in VAP?

A
  • Prior IV antibiotics [within 3 months]
  • > 5 days hospitalized
  • Septic shock
  • Acute Respiratory Distress
  • Acute reanl replacement

also for HAP too [MDR & MRSA]

30
Q

What is the general basis of empiric treatment of clinically suspected VAP?

MRSA? MSSA? Antipseudo? Pseudo?

A
  • 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

MSSA: give zosyn, cefepime, imipenem, meropenem [empiric] & Cefazolin, Nefcillin, Oxacillin [directed]

31
Q

What is the Empiric Therapy of HAP with NO risk of mortality and NO risk of MRSA?

A
  • Zosyn 4.5g IV q6h
  • Cefepime 2g IV q8h
  • Imipenem 500mg IV q6h
  • Meropenem 1g IV q8h

MSSA Coverage
Direct MSSA use Nafcillin, Oxacillin, Cefazolin

32
Q

What is the Empiric Therapy of HAP with NO risk of mortality and RISK of MRSA?

A
  • ONE: Zosyn, Cefepime, Ceftazidime, Imip, Mero, Levo, Cirpo, Aztreonam
  • PLUS: Vanco, Linezolid
33
Q

What is the Empiric Therapy of HAP with RISK of mortality and RISK of MRSA?

A
  • TWO: Zosyn, Cefepime, Ceftazidime, Imip, Mero, Levo, Cirpo, AGs, Aztreonam
  • PLUS: Vanco, Linezolid
34
Q

What should you NOT used in HAP/VAP Treatment?

A
  • AGs: poor lung penetration, Nephrotoxicity & Ototoxicity
  • Polymycins: ONLY really for MDR
  • Tigecycline: poor outcomes & increaed mortality
35
Q

What are some of the agents that you would want to use in your Pathogen-specific treatments for HAP/VAP?

MSSA? MRSA? Enterobacterales? ESBL? MBL? KPC? Pseudo? Baumannii?

A
  • 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
Q

What is the duration of treatment for HAP/VAP?

37
Q

What is the cause of Acute Bronchitis and what are some of the common symptoms?

A
  • Repiratory VIRUSES
  • Cough, Sore Throat, Headache, Fever, Normal CXR
38
Q

What is the treatment for Acute Bronchitis?

A
  • Symptomatic = Antitussives, Antipyretics, Hydration
  • NO ANTIBIOTICS NEEDED
39
Q

What is Acute Exacerbation of Chronic Bronitis?

A
  • 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
Q

What are the 3 cardinal symptoms of Acute Excerbation of Chronic Bronchitis?

A
  • Increased Cought or SOB
  • Increased Sputum Volume
  • Increased Sputum Purulence

DONT treat when only 1; TREAT when theres 2 or 3

41
Q

What are the common bacteria what are asscoiated with Acute Excerbation of Chronic Bronchitis?

A
  • H. Inlfuenzae
  • S. Pneumoniae
  • M. catarrhalis
  • Enterobacterales & P. Aeruginosa [end-stage COPD]
42
Q

What are the risk factors for Uncomplicated Chronic Bronchitis in AECB?

A
  • Age < 65
  • FEV1 > 50%
  • < 4 excerbations/year
  • NO comorbidity
  • NO risk factors
43
Q

What are some of the inital treatment options for Uncomplicated Chronic Bronchitis in AECB?

A
  • 2nd gen MACs [Clarith/Azith]
  • 2nd or 3rd gen cephalo
  • Doxycycline
  • Amoxicillin
  • SMX/TMP
44
Q

What are the risk factors for Complicated Chronic Bronchitis in AECB?

A
  • Age > 65
  • FEV1 < 50%
  • > 4 excerbations/year
  • > 2 risk factors
45
Q

What is the initial treatment of Complicated Chronic Bronchitis in AECB?

A
  • Respirtatory FQ
  • Augmentin

Zosyn??

46
Q

What ar ehte risk factors for Complicated + P. Aeruginosa Chronic Bronchitis in AECB?

A
  • Severe Symptom
  • Purulent Sputum
  • FEV < 35%
  • > 2 risk factors
47
Q

What is the initial treatment for Complicated + P. Aeruginosa Chronic Bronchitis in AECB?

A
  • FQ + Antipseudo
  • Piperacillin/Tazobactam
  • Hospitized? = empiric IV to cover P. Aeruginosa
48
Q

What is the bacterial causes for Pharyngitis?

Pharyngitis = Strep Throat

A
  • Viruses [MOST COMNON; no antibiotics]
  • S. Pyogenes [MOST COMMON bacteria]
49
Q

What are the common symptoms of Pharyngitis?

A
  • Sore Throat with difficulty swallowing, Fever, enlarged lymph nodes, swollen uvula
  • CANNOT tell the difference between bacterial & viral
50
Q

What are some of the ways that we can diagnosis pharyngitis?

A
  • Throat culture
  • Rapid Antigen Detection Tests

Looking for Group A Strep

51
Q

`

What is the treatment for Pharyngitis?

A
  • 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

MACs used ONLY when b-lactam cannot be used

52
Q

What is the differences between Acute, Viral and Acute Bacterial Rhinosinusitis?

A
  • Acute: 4 weeks of purulent nasal drainage/face pain
  • Viral: Acute but from viruses
  • Acute Bacterial: Acute but from bateria [need clinical presentation]
53
Q

What are the common “bugs” in Acute Bacterial rhinosinuitis?

A
  • H. Influenzae
  • S. Pnumoniae
  • M. Catarrhalis
54
Q

What is the Diagnosis of Acute Bacterial Rhinosinusitis?

Persistents, Severe, Worsening

A
  • 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
Q

What is the Treatment for Acute Bacterial Rhinosinusitis?

PHRM 865: Theraputics V (42 decks)

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