Lecture 6 - Respiratory 1 Flashcards
Most common causes of CAP? (viral)
Human rhinovirus
Influenza A/B
1/4 cases roughly
Most common causes of CAP (bacterial)
Strep. pneum
H. influenze
Atypicals
~ 1/7 cases
Pathogen mode of entry for CAP?
Aspiration = most common
Aerosolization
Bloodborne = uncommon
Risk factors for CAP?
65+
Smoking tobacco
Alcohol use disorder
Chronic medical conditions affecting immune system
Immunocompromised or on immunosuppressive agents
Acid-suppressing agents
Altered lvl of consciousness
CAP symptoms
cough, maybe productive
chest pain
shortness of breath/inc work of breathing
Fever/sweating/chills
fatigue
N/V/D
CAP diagnosis tests
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**
Procalcitonin
responds rapidly, more specific to bacterial infection
can peak 6-12hrs after infection
Procalcitonin Guidelines
< .25 = less likely bacterial infection + maybe wait it out
> .25 = more likely bacterial infection + start ABX right away
Calculation of CURB-65 Score
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
CURB < 1 =
Outpatient treatment
CURB 2 =
Inpatient vs observation
CURB > 3 =
Admission, possibly ICU
Outpatient treatment CAP, previously healthy and no antimicrobials within previous 3 months
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
Outpatient treatment CAP, presence of comorbidities or antimicrobial use within previous 3 months
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
when should you worry about QTc with fluoroquinolone?
> 450 might be concerned, monitor carefully
500 probs wouldn’t add
Non-ICU inpatient treatment
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
ICU inpatient treatment
B lactam + macrolide or respiratory fluoroquinolone
if severe penicillin allergy, Aztreonam 2g IV q8h + fluoroquinolone
Criteria for clinical stability
Temp < 37.8C
HR < 100b/m
RR < 24
SBP > 90
O2 sat > 90%
Ability to maintain oral intake
Normal mental status
When can patients switch to oral therapy and stop Abx?
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
Adjunctive corticosteroid use in CAP
may benefit in severe and non-severe CAP, inc risk of hyperglycemia
May inc mortality in influenza pneumonia
Influenza A/B Txm
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
Respiratory Syncytial virus
Ribavirin = immunocompromised w/ severe disease
Prophylaxis Influenza A/B Txm
Oseltamivir 75mg QD X 7 days
Zanamivir 10mg (inh) X 7 days
both after exposure
Respiratory syncytial virus prophylaxis
Palivizumab = prevention in high risk pediatric patients
Most common & preferred antivirals for COVID-19 are…
Remdesivir = polymerase inhib
Nirmatrelvir/ritonavir = Pro inhib
COVID management outpatient
> 7 days of symptoms and/or low risk of progression (age/immunocompromised)
Symptomatic management alone
COVID management outpatient
CrCL < 30 or sig drug interactions to other drugs
Remdesivir
Bebtelovimab if no other options available
COVID management outpatient
< 5 days of symptoms
Nirmatrevir/ritonavir = paxlovid
Molnupiravir if no other options available
Inpatient COVID + No supplemental oxygen needed
No corticosteroids
Inpatient COVID + need supplemental Oxygen
Remdesivir w/ minimal oxygen req**
Remdesivir + dexamethasone
Dexamethasone
Baricitinib or Tocilizumab if oxy demand rapidly inc**
Inpatient COVID + high flow oxygen or non invasive ventilation
Dexamethasone
Dexamethasone + remdesivir
Baricitinib or Tocilizumab if oxy demand rapidly inc
Inpatient COVID + Vent or ECMO
Dexamethasone
if w/I 24hr of ICU admission then Dexamethasone + tocilizumab
CAP modifiable risk factors
Smoking
Alcohol use disorder
Acid-suppressant use
Anti-psyh meds
Immunizations**
Immunization recommendations > 65
PCV20 or PCV15+PPSV23
Immunization recommendations 2-64
Prevnar + Pneumovax for high risk groups
Hib for high risk groups
Hospital acquired pneumonia (HAP)
occurs > 48hrs after admission and did not appear to be developing at time of admission
most common cause of death among nosocomial infections
Ventilator-associated pneumonia (VAP)
a subset of HAP that occurs after > 48hrs of endotracheal intubation
90% of HAP cases in ICU
Sources of pathogens for HAP
Healthcare devices
Environment
Transfer of organisms between patients and staff
Colonization w/ S.aureus and gram - bacilli
Nosocomial pneumonia Risk factors
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
Sources of pathogens for VAP
Intubation and mechanical vent increase risk of pneumonia dramatically
Leakage around ET tube cuff into lungs causes infections.
Diagnosis of VAP or HAP
New infiltrate on CXR
Fever
Inc O2 req
Thick or inc respiratory secretions
Blood cultures for suspected VAP
Diagnosis of VAP or HAP
New infiltrate on CXR
Fever
Inc O2 req
Thick or inc respiratory secretions
Blood cultures for suspected VAP
non invasive sampling preferred for culture
Early onset HAP/VAP
2-4 days of hospitalization
Better prognosis
Less likely due to MDR pathogens
Late onset HAP/VAP
> 5 days of hospitalization
Higher morbidity/mortality
More likely due to MDR pathogens
Which coverage should always be included in HAP/VAP
coverage for S.aureus and P.aeruginosa
Healthcare Associated Pneumonia (HCAP) Definition
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
Anti-MRSA ABX for HAP/VAP
Vanco 15-20 mg/kg IV q8-12h
Linezolid 600mg IV q12h
Anti-Pseudomonal B-Lactam HAP/VAP
Pip/Tazo 4.5g q6
Cefepime 2g q8
Ceftazidime 2g q8
Meropenem 1g q8
Imipenem 500mg q6
Azretonam 2g q8
Non-B-Lactam Anti-Pseudomonal HAP/VAP
Levo 750 IV q24
Cipro 400 IV q8
Gentamicin/tobramycin 7mg/kg IV q24
Amikacin 15 mg/kg IV q24
Colistin/Polymixin B
Treatment for HAP
combo of agents to cover S.aureus (MRSA) and Pseudomonas
Treatment for VAP
combo of agent to cover S.aureus (MRSA) and Pseudomonas
When to use Dual Antipsuedomonals in HAP
Unlikely unless….
IV ABX in last 90 days
Need vent
Septic shock
ARDS
CF or Bronchiestasis
When to use Dual Antipsuedomonals in VAP
guidelines suggest in all cases unless resistance < 10% = unlikely
When is Inhaled ABX therapy used?
usually only recommended when pathogen is susceptible to only AG or polymyxins
Inhaled ABX therapy
Tobramycin 300mg nebulas inhaled BID
Colistin 75-300mg inhaled BID
Recommended duration of ABx treatment?
7 days
P.aeruginosa and Acinetobacter may have higher relapse with < 14 days txm
When to add MRSA coverage for HAP?
IV abx within 90 days
MRSA prevalence > 20% or unknown
Need vent support
Septic shock
When do to dual anti-pseudomonal coverage for HAP?
IV bitoics w/ past 90 days
need vent
septic shock
ARDS preceding VAP
Cystic fibrosis
Bronchiestasis
When to add MRSA coverage for VAP
IV abx within 90 days
MRSA prevalence >10- 20% or unknown
Need vent support
Septic shock
When to do dual anti-pseudomonal coverage for VAP
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
Guideliens dumbed down
HAP = everyone gets MRSA, most get single pseudomonal
VAP = every gets MRSA, most get dual pseudomonal
VAT (Ventilator- Associated Tracheobronchitis)
No radiographic evidence of pneumonia
ABx generally not recommended
