Lower Respiratory Infection - Block 2

Question 1

What is the most commont cause of severe sepsis?

Answer 1

Pneumonia

Question 2

What are the routes respiratory pathogens can reach the LRT?

Answer 2

1. Direct inhalation
2. Aspiration
3. Spread from another infection through the bloodstream

Question 3

What are come things that complicate an infection?

Answer 3

1. Immunocompromised patient
2. Reduced lung antibacterial capacity from viruses
3. Intake of alcohol and narcotics
4. Reduced clearance of aspirated bacteria

Question 4

What is CAP?

Answer 4

Pneumonia developing outsde of the hospital setting or <48H after hospital admission

Question 5

What is HAP?

Answer 5

Pneumonia developing ≥48H after hospital admission

Question 6

What is VAP?

Answer 6

Pneumonia developing ≥48H after endotracheal intubation

Question 7

Most common pathogens of CAP?

Answer 7

Strep pneumoniae
G-: H flu, Moraxella
Atypical: Chlamidia pneumo, Mycoplasma, Legionella

Question 8

Most common pathogens of HAP?

Answer 8

PA, Acinetobacter
Kleb, E coli
S. aureus

Question 9

Most common pathogens of VAP?

Answer 9

S aureus
PA, Acinetobacter
Kleb, E coli

Question 10

S/s of pneumonia?

Answer 10

1. Fever, chills, malaise
2. Productive cough
3. Dyspnea

Question 11

Physic exam of Pneumonia?

Answer 11

Inspiratory crackles

Question 12

Lab test for pneumonia?

Answer 12

1. Leukocytosis
2. Low oxygen saturation
3. Chest radiograph: pulmonary infiltrates

Question 13

How do we diagnose pneumonia?

Answer 13

Clinical presentations and radiologic findings
* Blood and suptum cultures: confirm diagnosis and idenitfy etiology

Question 14

How do you diagnose of CAP?

Answer 14

1. Empiric therpay
2. Outpatient CAP management -> sputum cultures not recommended
3. Obtain blood & sputum cultures for patients with severe CAP
4. Urinary antigen tests for S. pneumoniae adn Legionella -> recommended for severe CAP

Question 15

Types of CAP severity assessment tools?

Answer 15

1. Pneumonia severity index
2. CURB-65
3. Major and minor criteria for severe CAP

Question 16

What is CURB-65?

Answer 16

Used in the outpatient setting or whe data necessary for PSI scoe is not reasily available:
* 0 – 1 = outpatient treatment (*)
* 1 – 2 = admission to general ward
* 3 – 5 = ICU admission

If the patient’s CURB-65 score ONLY equals one (1) because of age ≥ 65 years old & NO other major comorbidities are present, hospital admission is NOT necessarily indicated.

Question 17

What are the RF of CAP?

Answer 17

1. ≥65YO
2. DM
3. Asplenia
4. Chronic CV, pulmonary, renal, liver dx
5. Smoking/alcohol abuse

Question 18

Outpatient CAP management and tx?

Answer 18

No Comorbidities: Amoxicillin, doxycycline, macrolide (azithromycin, clarithromycin)

≥1 comorbid: Respiratory FQ (levo and moxi)
* Combo: b-lactam + macrolide or doxycyclinee

beta-lactams: high-dose amoxicillin or amoxicillin/clavulanate (preferred), cefpodoxime, cefuroxime, ceftriaxone (IM)

Question 19

Inpatient CAP management

Answer 19

Question 20

MRSA RF?

Answer 20

1. Known colonization
2. G+ cocci in clusters
3. Receipt of IV ABX: past 90 days
4. ESRD, MSM, crowds, incarceration, IVDU, contact sport

Question 21

RF of Pseudomonas?

Answer 21

1. Known colonization
2. G- bacilli
3. Receipt of IV ABX for the past 90 day
4. Structural lung dx: CF, COPD, bronchiectasis

Question 22

ABX for CAP?

Answer 22

Question 23

TX of inpatient CAP NKDA or Non-type 1 with no RF for MRSA or PA?

Answer 23

Combo is preferred: anti-pneumococal b-lactam + macrolide or doxycycline
OR
Respiratory FQ (levo or moxi)

Question 24

TX for inpatient CAP NKDA or Non-type 1 with MRSA only?

Answer 24

Anit MRSA (vanc or linezolid)
PLUS
Combo is preferred: anti-pneumococal b-lactam + macrolide or doxycycline
OR
Respiratory FQ (levo or moxi)

Question 25

Tx for inpatient CAP NKDA or Non-type 1 with RF of PA?

Answer 25

Anti-pseudomonal, anti-pneumococcal b-lactam **PLUS** Anti-pseudomonal FQ

Question 26

Tx for inpatient CAP NKDA or Non-type 1 with RF for MRSA and PA

Answer 26

Anti-MRSA agent (i.e., vancomycin, linezolid) **PLUS** Anti-pseudomonal, anti-pneumococcal β-lactam **PLUS** Anti-pseudomonal fluoroquinolone

Question 27

TX of inpatient CAP Type 1 allergies with no RF for MRSA or PA?

Answer 27

Respiratory fluoroquinolone (i.e., levofloxacin, moxifloxacin)

Question 28

TX of inpatient CAP Type 1 allergies with RF for MRSA?

Answer 28

Anti-MRSA agent (i.e., vancomycin, linezolid) **PLUS** Respiratory fluoroquinolone (i.e., levofloxacin, moxifloxacin)

Question 29

TX of inpatient CAP Type 1 allergies with RF for PA?

Answer 29

Levofloxacin **PLUS** Aztreonam **PLUS** Aminoglycoside

Question 30

TX of inpatient CAP Type 1 allergies with RF for PA and MRSA?

Answer 30

Anti MRSA (vancomycin, linezolid) **PLUS** Levofloxacin **PLUS** Aztreonam **PLUS** Aminoglycoside

Question 31

TX of ICU CAP NKDA or Non-type 1 allergies with no RF for MRSA and PA?

Answer 31

Combo therapy (preferred): anti-pneumococcal β-lactam + macrolide **(OR)** Combo therapy (alternative): anti-pneumococcal β-lactam + respiratory fluoroquinolone

Question 32

TX of ICU CAP NKDA or Non-type 1 allergies with RF for MRSA?

Answer 32

Anti-MRSA agent (i.e., vancomycin, linezolid) **(PLUS)** Combo therapy (preferred): anti-pneumococcal β-lactam + macrolide **(OR)** Combo therapy (alternative): anti-pneumococcal β-lactam + respiratory fluoroquinolone

Question 33

TX of ICU CAP NKDA or Non-type 1 allergies with RF for PA?

Answer 33

Anti-pseudomonal, anti-pneumococcal β-lactam **(PLUS)** Anti-pseudomonal fluoroquinolone

Question 34

TX of ICU CAP NKDA or Non-type 1 allergies with RF for PA and MRSA?

Answer 34

Anti-MRSA agent (i.e., vancomycin, linezolid) **(PLUS)** Anti-pseudomonal, anti-pneumococcal β-lactam **(PLUS)** Anti-pseudomonal fluoroquinolone

Question 35

TX of ICU CAP Type 1 allergies with no RF for PA and MRSA?

Answer 35

Respiratory fluoroquinolone + aztreonam

Question 36

TX of ICU CAP Type 1 allergies with RF for PA and MRSA?

Answer 36

Anti-MRSA agent (i.e., vancomycin, linezolid) **PLUS** Levofloxacin **PLUS** Aztreonam + aminoglycoside

Question 37

TX of ICU CAP Type 1 allergies with RF for PA?

Answer 37

Levofloxacin **(PLUS)** Aztreonam **(PLUS)** Aminoglycoside

Question 38

TX of ICU CAP Type 1 allergies with RF for MRSA?

Answer 38

Anti-MRSA agent (i.e., vancomycin, linezolid) **(PLUS)** Respiratory fluoroquinolone **(PLUS)** Aztreonam

Question 39

Classifications of HAP?

Answer 39

Question 40

RF for HAP?

Answer 40

1. MDR/Mortality: Ventilatory support, septic shock, Receipt of IV antibiotics during hospitalization in past 90 days) 2. MRSA 3. PA

Question 41

Tx for HAP with MDR?

Answer 41

1 anti-MRSA agent + 2 anti-pseudomonal agents (from different classes)

Question 42

Tx for HAP with MRSA?

Answer 42

1 anti-MRSA agent + 1 anti-pseudomonal agent

Question 43

Tx for HAP with MRSA and PA?

Answer 43

1 anti-MRSA agent + 2 anti-pseudomonal agents (from different classes)

Question 44

Tx for HAP with no MDR, MRSA, PA

Answer 44

1 anti-pseudomonal agent

Question 45

Tx for HAP wih PA?

Answer 45

2 anti-pseudomonal agent (from different classes)

Question 46

Classifications of VAP?

Answer 46

Question 47

RF for VAP?

Answer 47

Question 48

Tx for VAP with MDR?

Answer 48

1 anti-MRSA agent + 2 anti-pseudomonal agents (from different classes)

Question 49

Tx for VAP with MRSA?

Answer 49

1 anti-MRSA agent + 1 anti-pseudomonal agent

Question 50

Tx for VAP with MRSA and PA?

Answer 50

1 anti-MRSA agent + 2 anti-pseudomonal agents (from different classes)

Question 51

Tx for VAP with no MDR, MRSA, PA

Answer 51

1 anti-pseudomonal agent

Question 52

Tx for VAP with PA?

Answer 52

2 anti-pseudomonal agent (from different classes)

Question 53

Tx for Penicillin susceptible S. pneumoniae?

Answer 53

**Preferred:** ampicillin, amoxicillin, pen G **Alt:** Ceftriaxone, cefotaxime, macrolides, levofloxacin, moxifloxacin, doxycycline, clindamycin, vancomycin

Question 54

Tx for penicillin resistant S. pneumoniae?

Answer 54

**preferred:** Cetriaxone, cefotaxime, levofloxacin, moxifloxacin **Alt:** High dose amoxcillin, linezolid, clindamycin, vancomyci

Question 55

Tx for non-b-lactamase producing H flu?

Answer 55

**Preferred:** ampicillin, amoxicillin **Alt:** FQ, doxycycline, azithromycin, clarithromycn

Question 56

Tx for b-lactmase producing h flu?

Answer 56

**Preferred:** Ceftriaxone, cefotaxime, ampicillin-sulbactam, augmentin **Alt:** FQ, doxycyclin, azithromycin, clarithromycin

Question 57

Tx for mycoplasma

Answer 57

**Preferred:** Macrolid, doxycycline **Alt:** FQ

Question 58

Tx for Chlamydia pneumo?

Answer 58

**Preferred:** Macrolide, doxycycline **Alt:** FQ

Question 59

Tx for legionella?

Answer 59

**Preferred:** FQ, azithromycin **Alt:** Doxycycline

Question 60

Tx for MSSA?

Answer 60

**Preferred:** Cefazolin, anti-staph, penicillin **Alt:** Clindamycin, vancomycin

Question 61

Tx for MRSA

Answer 61

**Preferred:** Vanc, linezolid **Alt:** Telavancin, ceftaroline, Synercid, Clindamycin, Bactrm

Question 62

Tx for Pseudomonas?

Answer 62

**Preferred:** Anti-pseudomonal β-lactam or fluoroquinolone * AG for septic shock or high risk **Alt:** Colistin, polymixin B

Question 63

Tx for Acinetobacter

Answer 63

**Preferred:** Carbapnem or ampicillin-sulbactam **Alt:** Colistin, polymixin B

Question 64

Tx for ESBL?

Answer 64

**Preferred:** Carbapenem **Alt:** Zosyn or cefepime

Question 65

Tx for carbapenem resistance?

Answer 65

Ceftazidime/avibactam, meropenem/vaborbactam, imipenem/cilastatin/relebactam

Question 66

When shoudl resolution of pneumonia occur?

Answer 66

Within first 2 days -> 5-7 days