Lower Respiratory Flashcards
Stuff discussed in class
What are the 2 main etiologies of bronchitis?
Viral & Smoking
Bronchitis:
1) List 2 Txs they DON’T benefit from
2) What Tx should you use caution with when the cough is productive?
3) Clinical effectiveness of what Tx has not been well established?
4) What is an accepted Tx?
1) Aerosolized β2-receptor agonists & oral or aerosolized corticosteroids
2) Antitussives (Medicare doesn’t cover)
3) Expectorants
4) Antibiotics (amox. if Sx >5-7days)
True or false: you can use antibiotics for bronchitis, but not in chronic bronchitis
True
Chronic Bronchitis:
1) Main etiology?
2) What increases?
3) How long does the chronic cough productive of sputum have to last for Dx?
1) Smoking
2) Mucus-secreting goblet cells
3) 3 consecutive months of the year for 2 consecutive years (w/o other known cause)
Chronic bronchitis:
1) How were the Sxs summed up in class?
2) Is it usually G+ or G- bacteria?
1) “Blue bloaters, pink puffers”
2) G+; only G- in 5% of cases
Chronic bronchitis: List 4 Tx options for simple CB (no risk factors)
1) Azithromycin 500mg PO Qday (PAE; five days of therapy acceptable)
2) Amox/clav. 875mg BID
3) Doxycycline 100mg BID
4) Levofloxacin 500mg Qday
1) What are risk factors that can make a case of CB complicated?
2) What Tx option is not available for these cases?
3) How long is Tx? (for both complicated an uncomplicated)
1) Age > = 65, chronic COPD, > 4 exacerbations / year, heart disease, home oxygen use, abx use in past 3 months, corticosteroid use in past month
2) Azithromycin
3) 5-7 days
How would you Tx inpatient complicated CB (Chronic bronchitis)? Why?
Levofloxacin 750mg IV daily; empirically covering P. aeruginosa
1) 75% of ____________ cases are due to respiratory syncytial virus (RSV) (hint: common in babies).
2) What is the recommended Tx?
1) Bronchiolitis
2) Nebulized hypertonic saline
List 3 Txs that are NOT routinely recommended for bronchiolitis
1) Aerosolized β2-agonists
2) Systemically administered corticosteroids
3) Ribavirin
List the 2 vaccines and 2 other ways to prevent bronchiolitis. Who is each recommended in?
1) Abrysvo (vaccine)
-Adults ≥60-75 years of age + pregnant pts 32-36 weeks
2) Arexvy (vaccine)
-Adults ≥60-75 years of age
3&4) 2 Monoclonal antibodies:
-Nirsevimab (Beyfortus)
-Palivizumab (Synagis)
Differentiate between antigenic drift and shift (important concept for influzena)
1) Drift: point mutations in surface antigens that leads to the variability of seasonal influenza
2) Shift: genetic reassortment culminating in novel surface antigens that leads to a new influenza variant (e.g., avian flu & swine flu)
What is the pathophysiology of influenza?
Influenza A antigens
1) Hemagglutinin (H1 – H16): allows entry
2) Neuraminidase (N1 – N9): allows exit
Influenza is transmitted via person-to-person inhalation of respiratory droplets.
1) What is the incubation period?
2) What is the infectious period?
1) 1 – 7 days incubation period (average of 2 days)
2) 1 day before symptom onset and up to 7 days after symptom onset; children may be infectious for up to 10 days after onset
What condition can happen secondary to influenza?
(hint: flu and this are combined as the 8th leading cause of death in the US
9th leading cause in 2020; not in top 10 all cause mortality for 2021, 2022, 2023)
Secondary bacterial pneumonia
What is the gold standard for influenza testing?
Reverse-transcription polymerase chain reaction (RT-PCR)
Influenza vaccine:
1) When is a booster dose appropriate?
2) What abt a high dose?
3) Is it safe in pregnancy?
4) Any special notes for immunocompromised pts?
1) Booster dose at least 4 weeks after the initial dose in children between 6 months and less than 9 years of age if no previous vaccination
2) High dose if age > = 65 years old or solid organ transplant
3) Safe during any trimester of pregnancy
4) Immunocompromised patients (e.g., HIV) may benefit from high dose vaccine regardless of age
1) Influenza post-exposure prophylaxis should not be given when? What is it called?
2) What ages is it appropriate for?
3) What is another form?
1) Postexposure prophylaxis should not be given if >48 hours has elapsed since exposure
-Oseltamivir
2) FDA said 14 days and older, CDC expanded recommendation for treatment in those less than 14 days
3) Zanamivir
Give 5 examples of who to give post-exposure prophylaxis for influenza (Oseltamivir) to
1) Persons at high risk of serious illness and/or complications and cannot be vaccinated.
2) Exposed during the first 2 weeks following vaccination
3) Persons with severe immune deficiency or who may have an inadequate response to vaccination
4) Long-term care facility residents
5) As soon as possible after exposure, ideally no later than 48 hours after exposure
Oseltamivir dosing:
1) For adult Tx
2) For adult prophylaxis
3) Exceptions to this?
1) 75mg capsule 2x/day for 5 days
2) 75mg capsule 1x/day for 10 days
3) For control of outbreaks in long-term care facilities and hospitals, give for a minimum of 2 weeks, and continue up to 1 week after the last known case (guideline dosage); up to 6 weeks during a community outbreak (FDA dosage)
List and describe 2 groups of influenza Txs discussed in class
1) Cap-dependent endonuclease inhibitor: Baloxavir
2) NA inhibitors: Oseltamivir, Zanamivir, Peramivir
Baloxavir (Xofluza):
1) What group of drugs?
2) What is an important interaction to note?
3) Can pregnant/ breastfeeding pts use?
4) List a side effect
1) Cap-dependent endonuclease inhibitor for influenza
2) Chelation w. dairy products
3) Not recommended for patients that are pregnant or breast feeding
4) Increased liver enzymes
1) What influenza Tx may reduce the duration of illness in a community setting by approximately 1 day (versus placebo)?
2) What neuropsychiatric complications have been associated with this?
1) Neuraminidase inhibitors
2) Delirium, seizures, hallucinations, and self-injury in pediatric patients (mostly from Japan) have been reported following treatment with oseltamivir and peramivir
NA inhibitors (for influenza):
1) Which 2 require renal dosing?
2) Which 2 have GI & neuropsychiatric side effects?
1) Oseltamivir (Tamiflu) & Peramivir (Rapivab)
2) Oseltamivir (Tamiflu) & Peramivir (Rapivab)
What 2 things do Oseltamivir (Tamiflu) and Peramivir (Rapivab) have in common? (besides the fact that they are both NA inhibitors for flu)
1) Require renal dosing
2) GI & neuropsychiatric side effects
Which 2 NA inhibitors (for flu) are 5 day treatments?
Oseltamivir (Tamiflu) & Zanamivir (Relenza)
What is the preferred Tx for influenza in pregnancy?
Oseltamivir (Tamiflu)
Which NA inhibitor (for flu) is given via IV for 1 day?
Peramivir (Rapivab)
1) Which NA inhibitor (for flu) is given via capsule or solution?
2) Which is via diskhaler?
1) Oseltamivir (Tamiflu)
2) Zanamivir (Relenza)
Describe how you dose Oseltamivir for flu Tx
Begin w/in 48hrs of Sx onset:
-75mg BID x 5 days
-Weight-based dose for pediatrics
-CrCl 30 – 60 mL / min: 30 mg BID x 5 days
-CrCl 10 – 30 mL / min: 30 mg Qday x 5 days
Describe how you dose Oseltamivir for flu prophylaxis
75mg Qday x 10 days
What may happen if antitussives like Benzonatate (Tessalon Perles) are chewed or dissolved?
Oral mucosa anesthesia
a) Hydrocodone 10 mg / Chlorpheniramine 8 mg / 5 mL ER (Tussionex)
b) Hydrocodone 5 mg / Homatropine 1.5 mg / 5 mL (Hydromet)
c) Codeine 10 mg / Guaifenesin 100mg / 5 mL
(Cheratussin AC)
1) All 3 have what side effects?
2) Can they be used in peds?
1) Nausea, itching, constipation and respiratory depression
2) The FDA in January 2018 recommended against routine use of codeine/hydrocodone-containing cough/cold products for patients <18 years
Bromfed DM:
1) Dose frequency for peds?
2) Type of med?
1) Every 4 hours PRN
2) Antitussive
Antitussives:
1) Which is an antihistamine?
2) How would you classify pseudoephedrine?
3) Name one that’s a nonopioid antitussive
1) Brompheniramine
2) Sympathomimetic nasal decongestant
3) Dextromethorphan
At what age can you give a pt an antitussive?
≥2 years of age (with caution)
List common causes of CAP
S. pneumoniae
S. aureus
H. influenzae
M. pneumoniae, Legionella species, and C. pneumoniae
What condition is a concern for people w/ crowded living conditions and poor access to healthcare (e.g., homeless or incarcerated)?
Mycobacterium tuberculosis
Pneumonia:
1) People with HIV are opportunistic infections such as ______________ (fungi) and _______________ species.
2) Who else is at risk?
1) Pneumocystis jiroveci; Mycobacterium species.
2) Neutropenic pts; pts with TB
Define each type of pneumonia:
1) CAP (community)
2) HAP (hospital)
3) VAP (ventilator)
1) Pneumonia developing outside the hospital or <48 hrs after admission
2) Pneumonia developing >48 hrs after admission
3) Pneumonia developing >48 hrs after endotracheal intubation
1) Necrotizing lesions are associated with what type of pneumonia?
2) Name 2 things that are not routine for outpatient CAP
1) Staphylococcal
2) Blood or sputum cultures
What is the preferred pneumonia differentiating tool for most current guidelines?
Pneumonia Severity Index
(CURB-65 also relevant tho)
What is CURB-65?
Confusion
Uremia (BUN > 20 mg/dL [7.1 mmol/L])
Respiratory rate ≥30 breaths/min
Blood pressure (systolic <90 mm Hg, diastolic ≤60 mm Hg)
Age ≥65 years
True or false: major criteria for pneumonia will require ICU support
True
List some minor criteria for community-acquired pneumonia
1) RR >30 breaths/ min
2) PaO2/FaO2 ratio <250
3) Confusion/ disorientation
4) Leukopenia (<4000 cells/ ul)
5) Thrombocytopenia (<100,000/ ul)
6) Hypothermia (<36c)
7) Hypotension (req. aggressive fluid resuscitation)
8) Multilobar infiltrates
List the major criteria for community-acquired pneumonia
1) Septic shock with need for vasopressors
2) Respiratory failure req. mechanical ventilation
For CAP, what tests do you need to get? Why?
1) Gram stain / culture & blood cultures
-To empirically Tx for MRSA or P. aeruginosa
2) Serum procalcitonin levels (not required to start empiric therapy)
How should you Tx outpatient CAP (CURB-65 <2; no more than 2 minor criteria) in healthy adults?
1) Amoxicillin – strongest recommendation
2) Doxycycline
3) Azithromycin or clarithromycin
-Pneumococcal resistance to macrolides < 25%
How should you Tx adults w/ chronic heart, lung, liver or renal disease; diabetes mellitus; alcoholism; malignancy; asplenia for outpatient CAP (CURB-65 <2; no more than 2 minor criteria)?
1) Combination therapy:
-Amox./clav. (Augmentin) + azithromycin
-Cefuroxime + doxycycline
2) Monotherapy: Levofloxacin, moxifloxacin, or gemifloxacin
How would you Tx inpatient nonsevere CAP (CURB-65 = 2; no more than 2 minor criteria) w/ out risk factors for MRSA or P. aeruginosa?
Combination therapy (IV beta-lactam w/ beta-lactamase inhibitor or cephalosporin + macrolide):
1) Ampicillin / sulbactam + azithromycin
2) No doxycycline; use IV instead of PO
-ceftriaxone acceptable
How would you tx inpatient severe CAP (CURB-65 > 2; and 3 or more minor criteria) w/ out risk factors for MRSA or P. aeruginosa?
1) Combination therapy
-IV beta-lactam w/ beta-lactamase inhibitor or cephalosporin + macrolide
-IV beta-lactam w/ beta-lactamase inhibitor or cephalosporin + respiratory fluroquinolone
No monotherapy
How would you tx inpatient severe CAP (CURB-65 > 2; and 3 or more minor criteria) with risk factors for MRSA or P. aeruginosa?
1) MRSA
-Vancomycin
-Linezolid
2) P. aeruginosa
-Piperacillin-tazobactam
-Cefepime
-Ceftazidime
-Aztreonam
-Meropenem
-Imipenem
Name something not routinely used to Tx CAP
Corticosteroids
When is Oseltamivir useful for pneumonia?
Useful independent of duration of illness before diagnosis
Concomitant w/ standard antibiotic therapy
How should you begin to Tx HAP / VAP?
Start empirically
When do HAP/ VAP pts have a high risk of mortality if there’s risk factors (like if IV antibiotics in past 90 days)?
High risk of mortality:
1) Ventilator support
2) Septic shock
1) What is the empiric MRSA therapy for HAP if there’s risk factors (like if IV antibiotics in past 90 days)?
2) What abt if no risk factors?
1) Vancomycin or linezolid
2) Piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem
1) What is the empiric P. aeruginosa therapy for HAP if there’s risk factors (like if IV antibiotics or structural lung disease (i.e. cystic fibrosis))?
2) What abt if no risk factors?
1) 2 antipseudomonal
2) 1 antipseudomonal
1) What is the empiric MRSA therapy for VAP? What are risk factors?
2a) What is the empiric P. aeruginosa therapy for VAP if there’s risk factors? Why?
2b) What abt if there’s not any risk factors?
1) Triple therapy (>10 – 20% S. aureus prevalence); 5 or more days of hospitalization or acute renal replacement therapy prior.
2a) Triple therapy; >10% of gram-negative isolates are resistant to an agent being considered for monotherapy
2b) 1 antipseudomonal
Directed therapy HAP/VAP:
1) What abt for acinetobacter spp.?
2) What abt for carbapenem resistant pathogens?
1) Carbapenem or ampicillin/sulbactam
2) Only sensitive to polymyxins; IV polymyxin (colistin or polymyxin B) + inhaled colistin
What is the duration of therapy for HAP/VAP?
Varies widely
CAP with CURB <2:
1) How do you Tx if the pt has no comorbidities or risk factors for MRSA or Pseudomonas aeruginosa?
2) What abt if there is comorbidities?
1) Amoxicillin or doxycycline or macrolide (if local pneumococcal resistance is <25%)
2) Combination therapy with amoxicillin/clavulanate or cephalosporin AND macrolide or doxycycline
OR
-monotherapy with respiratory fluoroquinolone!!
CAP with CURB = 2:
1) For nonsevere pt pneumonia (<3 minor criteria) + risk factors for MRSA, how do you Tx?
2) For nonsevere pt pneumonia (<3 minor criteria) + risk factors for P. aeruginosa, what do you do?
3) For severe pt pneumonia (>3 minor criteria) + risk factors for P. aeruginosa, what do you do?
1) Obtain cultures but withhold MRSA coverage unless culture results are positive. If rapid nasal PCR is available, withhold additional empiric therapy against MRSA if rapid testing is negative or add coverage if PCR is positive and obtain cultures
2) Obtain cultures
3) Obtain cultures
Summary slide:
1) How do you interpret CURB-65 criteria for CAP?
2) What are the criteria?
1) Inpatient if 2 criteria / inpatient ICU if > 2 criteria
Inpatient or inpatient severe = 3 or more minor criteria or one major criteria (shock w/ vasopressors or mechanical ventilation)
2) Confusion
Uremia (BUN > 20 mg/dL [7.1 mmol/L])
Respiratory rate ≥30 breaths/min
Blood pressure (systolic <90 mm Hg, diastolic ≤60 mm Hg)
Age ≥65 years
Summary: How to Tx outpatient CAP?
1) 1) Amoxicillin 1 gram TID
2) Azithromycin 500mg on day 1 and 250mg on days 2 – 5 (but avoid in regions with a high rate (>25%) of macrolide-resistant S. pneumoniae)
3) Doxycycline 100mg BID
Summary:
How to Tx outpatient CAP w/ chronic heart, lung, kidney or liver disease; DM; EtOH abuse; malignancy; asplenia; etc?
Amox/clav. 875 mg BID + azithromycin 500mg on day 1 and 250mg on days 2-5
Summary:
1) How to Tx inpatient CAP?
2) What if previous MRSA infection?
3) What if previous P. aeruginosa infection?
4) What if hospitalization and IV abx in past 90 days?
1) Ceftriaxone 1–2 g IV/IM Q 24 H + azithromycin 500mg IV q 24 hours
2) Levaquin 750mg qday IV q 24 hours
-Add linezolid 600 mg IV or PO Q 12 H or vancomycin 15–20 mg/kg IV Q 12 H & obtain cultures if previous MRSA infection
3) Switch ceftriaxone to cefepime 1–2 g IV Q 8–12 H
4) Obtain culture but DO NOT empirically treat for MRSA or P. aeruginosa
Summary: How long is the duration of therapy for CAP?
7 to 14 days
Summary: How to Tx HAP if no risk factors?
1) Piperacillin / tazobactam 4.5 g IV q 6 H
2) Cefepime IV
3) Levofloxacin IV
Summary:
How to Tx HAP if risk factors? (hospitalization and IV abx in past 90 days, prior MRSA infection)
Add vanc or linezolid:
1) Cefepime 2 grams IV q 8 h + vancomycin 15–20 mg/kg IV Q 12 H or linezolid 600 mg IV or PO Q 12 H
2) Levofloxacin 750 mg IV daily + vancomycin 15–20 mg/kg IV Q 12 H or linezolid 600 mg IV or PO Q 12 H
Summary:
How to Tx HAP if hospitalization and IV abx in past 90 days, high risk mortality [intubated or septic shock] or structural lung disease [bronchiectasis or cystic fibrosis]?
Cefepime 2 grams IV q 8 h + amikacin 15-20 mg/kg IV q 24 h + vancomycin 15–20 mg/kg IV Q 12 H or linezolid 600 mg IV or PO Q 12 H
Summary:
How to Tx VAP if No MDR / MRSA / P. aeruginosa risk factors?
1) Piperacillin / tazobactam 4.5 g IV q 6 H
2) Cefepime 2 grams IV q 8 h
3) Levofloxacin 750 mg IV daily
Summary: How to Tx VAP if MDR risk factors or MRSA risk factors?
Cefepime 2 grams IV q 8 h + amikacin 15-20 mg/kg IV q 24 h + vancomycin 15–20 mg/kg IV Q 12 H or linezolid
Summary: What do you need to know abt aminoglycosides?
1) Traditional or extended interval dosing
2) High peak serum concentrations are necessary to obtain microbiologically active concentrations in the alveoli
3) Concentration-dependent (Cmax:Min)
Summary: What do you need to know abt vancomycin?
1) Can use loading dose
2) Target trough is 15 – 20 mg / mL
1) What are Paxlovid and Lagevrio?
2) When do you need to start?
1) Dose packs [COVID Txs)
2) Within 5 days post symptom onset
True or false: COVID19 is an endemic
True
What do hydroxychloroquine, azithromycin and ivermectin have in common?
All questionable COVID Txs
