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CDM 3 Exam 1 > Lecture 6 - Respiratory 1 > Flashcards

Lecture 6 - Respiratory 1 Flashcards

1
Q

Most common causes of CAP? (viral)

A

Human rhinovirus
Influenza A/B

1/4 cases roughly

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2
Q

Most common causes of CAP (bacterial)

A

Strep. pneum
H. influenze
Atypicals

~ 1/7 cases

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3
Q

Pathogen mode of entry for CAP?

A

Aspiration = most common
Aerosolization
Bloodborne = uncommon

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4
Q

Risk factors for CAP?

A

65+
Smoking tobacco
Alcohol use disorder
Chronic medical conditions affecting immune system
Immunocompromised or on immunosuppressive agents
Acid-suppressing agents
Altered lvl of consciousness

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5
Q

CAP symptoms

A

cough, maybe productive
chest pain
shortness of breath/inc work of breathing
Fever/sweating/chills
fatigue
N/V/D

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6
Q

CAP diagnosis tests

A

Sputum gram stain/culture = gold standard

some invasive methods used in some cases
blood culture if severe disease or suspected Pseudomonas and MRSA
Rapid viral antigen test during flu test
Urine antigen tests
Multiplex PCR-based tests becoming more common**

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7
Q

Procalcitonin

A

responds rapidly, more specific to bacterial infection

can peak 6-12hrs after infection

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8
Q

Procalcitonin Guidelines

A

< .25 = less likely bacterial infection + maybe wait it out
> .25 = more likely bacterial infection + start ABX right away

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9
Q

Calculation of CURB-65 Score

A

Confusion = disorientation to person, place or time (A&O X 3 = not confused)
Uremia = BUN > 20mg/dL
Respiratory rate = > 30B/min
BP = SBP < 90 or DBP < 60
Age > 65

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10
Q

CURB < 1 =

A

Outpatient treatment

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11
Q

CURB 2 =

A

Inpatient vs observation

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12
Q

CURB > 3 =

A

Admission, possibly ICU

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13
Q

Outpatient treatment CAP, previously healthy and no antimicrobials within previous 3 months

A

Macrolides (azith = 500 1 PO, then 250mg QD)(Clarith = 500mg BID or 1000mg QD)
consider alternative if > 25% strep pneum macrolide resistant, usually not most appropriate

Doxy = 100 BID** Best option
Amox = 1000 TID

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14
Q

Outpatient treatment CAP, presence of comorbidities or antimicrobial use within previous 3 months

A

Levo = 750mg QD
Moxi = 400mg QD

B-lactam + macrolide(or doxy)
Amox/Clav 875/125 or 2000/125 BID
Cepodoxime 200mg BID
Cefuroxime 500mg BID

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15
Q

when should you worry about QTc with fluoroquinolone?

A

> 450 might be concerned, monitor carefully
500 probs wouldn’t add

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16
Q

Non-ICU inpatient treatment

A

Levo 750mg IV QD or Maxi 400mg IV QD

B-lactam + macrolide (or doxy) preferred**
Amp/sulbac 3g IV q6h
Ceftriaxone 1-2g IV q24hr
Ceftaroline 600mg IV q12h
Azimuth 500mg IV q24hr

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17
Q

ICU inpatient treatment

A

B lactam + macrolide or respiratory fluoroquinolone

if severe penicillin allergy, Aztreonam 2g IV q8h + fluoroquinolone

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18
Q

Criteria for clinical stability

A

Temp < 37.8C
HR < 100b/m
RR < 24
SBP > 90
O2 sat > 90%
Ability to maintain oral intake
Normal mental status

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19
Q

When can patients switch to oral therapy and stop Abx?

A

once hemodynamically stable can switch to oral of same class

Treat atleast 5 days, afebrile for 48-72hrs before stoping Abx

if no response or worsening = escalate or change in treatment

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20
Q

Adjunctive corticosteroid use in CAP

A

may benefit in severe and non-severe CAP, inc risk of hyperglycemia
May inc mortality in influenza pneumonia

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21
Q

Influenza A/B Txm

A

oseltamivir 75 BID X 5 days
Zanamivir (inh) 10mg Bid X 5 days (bronchospasm**)
Peramivir 600mg IV X 1 ($$$)

Start within 48hrs of symptoms

CAP-dep endonuclease inhib = Baloxavir 40mg or 80mg if > 80kg X 1 dose

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22
Q

Respiratory Syncytial virus

A

Ribavirin = immunocompromised w/ severe disease

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23
Q

Prophylaxis Influenza A/B Txm

A

Oseltamivir 75mg QD X 7 days
Zanamivir 10mg (inh) X 7 days

both after exposure

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24
Q

Respiratory syncytial virus prophylaxis

A

Palivizumab = prevention in high risk pediatric patients

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25
Q

Most common & preferred antivirals for COVID-19 are…

A

Remdesivir = polymerase inhib
Nirmatrelvir/ritonavir = Pro inhib

26
Q

COVID management outpatient

> 7 days of symptoms and/or low risk of progression (age/immunocompromised)

A

Symptomatic management alone

27
Q

COVID management outpatient

CrCL < 30 or sig drug interactions to other drugs

A

Remdesivir
Bebtelovimab if no other options available

28
Q

COVID management outpatient

< 5 days of symptoms

A

Nirmatrevir/ritonavir = paxlovid
Molnupiravir if no other options available

29
Q

Inpatient COVID + No supplemental oxygen needed

A

No corticosteroids

30
Q

Inpatient COVID + need supplemental Oxygen

A

Remdesivir w/ minimal oxygen req**

Remdesivir + dexamethasone
Dexamethasone

Baricitinib or Tocilizumab if oxy demand rapidly inc**

31
Q

Inpatient COVID + high flow oxygen or non invasive ventilation

A

Dexamethasone
Dexamethasone + remdesivir

Baricitinib or Tocilizumab if oxy demand rapidly inc

32
Q

Inpatient COVID + Vent or ECMO

A

Dexamethasone

if w/I 24hr of ICU admission then Dexamethasone + tocilizumab

33
Q

CAP modifiable risk factors

A

Smoking
Alcohol use disorder
Acid-suppressant use
Anti-psyh meds

Immunizations**

34
Q

Immunization recommendations > 65

A

PCV20 or PCV15+PPSV23

35
Q

Immunization recommendations 2-64

A

Prevnar + Pneumovax for high risk groups

Hib for high risk groups

36
Q

Hospital acquired pneumonia (HAP)

A

occurs > 48hrs after admission and did not appear to be developing at time of admission

most common cause of death among nosocomial infections

37
Q

Ventilator-associated pneumonia (VAP)

A

a subset of HAP that occurs after > 48hrs of endotracheal intubation

90% of HAP cases in ICU

38
Q

Sources of pathogens for HAP

A

Healthcare devices
Environment
Transfer of organisms between patients and staff

Colonization w/ S.aureus and gram - bacilli

39
Q

Nosocomial pneumonia Risk factors

A

Prior antibiotic exposure*
Endotracheal intubation/mechanical vent**

advanced age
severity of underlying disease
Acid-suppressing agents
Supine position
Altered mental status
surgery
Duration of hospitalization
Enteral nutrition + nasogastric tubes

40
Q

Sources of pathogens for VAP

A

Intubation and mechanical vent increase risk of pneumonia dramatically

Leakage around ET tube cuff into lungs causes infections.

41
Q

Diagnosis of VAP or HAP

A

New infiltrate on CXR
Fever
Inc O2 req
Thick or inc respiratory secretions
Blood cultures for suspected VAP

41
Q

Diagnosis of VAP or HAP

A

New infiltrate on CXR
Fever
Inc O2 req
Thick or inc respiratory secretions
Blood cultures for suspected VAP

non invasive sampling preferred for culture

42
Q

Early onset HAP/VAP

A

2-4 days of hospitalization
Better prognosis
Less likely due to MDR pathogens

43
Q

Late onset HAP/VAP

A

> 5 days of hospitalization
Higher morbidity/mortality
More likely due to MDR pathogens

44
Q

Which coverage should always be included in HAP/VAP

A

coverage for S.aureus and P.aeruginosa

45
Q

Healthcare Associated Pneumonia (HCAP) Definition

A

Hospitalized for 2+ days in last 90 days
Live in LTC facility
IV infusion in past 30 days
Wound care in past 30 days
Hemodialysis
Contact w/ family member w/ MDR pathogen

46
Q

Anti-MRSA ABX for HAP/VAP

A

Vanco 15-20 mg/kg IV q8-12h
Linezolid 600mg IV q12h

47
Q

Anti-Pseudomonal B-Lactam HAP/VAP

A

Pip/Tazo 4.5g q6
Cefepime 2g q8
Ceftazidime 2g q8
Meropenem 1g q8
Imipenem 500mg q6
Azretonam 2g q8

48
Q

Non-B-Lactam Anti-Pseudomonal HAP/VAP

A

Levo 750 IV q24
Cipro 400 IV q8
Gentamicin/tobramycin 7mg/kg IV q24
Amikacin 15 mg/kg IV q24
Colistin/Polymixin B

49
Q

Treatment for HAP

A

combo of agents to cover S.aureus (MRSA) and Pseudomonas

50
Q

Treatment for VAP

A

combo of agent to cover S.aureus (MRSA) and Pseudomonas

51
Q

When to use Dual Antipsuedomonals in HAP

A

Unlikely unless….

IV ABX in last 90 days
Need vent
Septic shock
ARDS
CF or Bronchiestasis

52
Q

When to use Dual Antipsuedomonals in VAP

A

guidelines suggest in all cases unless resistance < 10% = unlikely

53
Q

When is Inhaled ABX therapy used?

A

usually only recommended when pathogen is susceptible to only AG or polymyxins

54
Q

Inhaled ABX therapy

A

Tobramycin 300mg nebulas inhaled BID
Colistin 75-300mg inhaled BID

55
Q

Recommended duration of ABx treatment?

A

7 days

P.aeruginosa and Acinetobacter may have higher relapse with < 14 days txm

56
Q

When to add MRSA coverage for HAP?

A

IV abx within 90 days
MRSA prevalence > 20% or unknown
Need vent support
Septic shock

57
Q

When do to dual anti-pseudomonal coverage for HAP?

A

IV bitoics w/ past 90 days
need vent
septic shock
ARDS preceding VAP
Cystic fibrosis
Bronchiestasis

58
Q

When to add MRSA coverage for VAP

A

IV abx within 90 days
MRSA prevalence >10- 20% or unknown
Need vent support
Septic shock

59
Q

When to do dual anti-pseudomonal coverage for VAP

A

IV bitoics w/ past 90 days
unit resistant for mono agent > 10% or unknown
late onset
acute renal replacement therapy prior to VAP

septic shock
ARDS preceding VAP
Cystic fibrosis
Bronchiestasis

60
Q

Guideliens dumbed down

A

HAP = everyone gets MRSA, most get single pseudomonal
VAP = every gets MRSA, most get dual pseudomonal

61
Q

VAT (Ventilator- Associated Tracheobronchitis)

A

No radiographic evidence of pneumonia
ABx generally not recommended

CDM 3 Exam 1 (10 decks)

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