Lower Respiratory Infections

Question 1

Most common infections involving lower respiratory tract?

Answer 1

bronchitis, bronchiolitis, pna

Question 2

What is bronchitis?

Answer 2

inflammation of the walls of the bronchi and bronchioles which causes narrowing

Question 3

What is bronchiesctasis?

Answer 3

widening of the bronchi and bronchioles but excessive mucus production narrows the bronchial tree

Question 4

Acute bronchitis usually affects who? chronic bronchitis? bronchiolitis?

Answer 4

ind. of all ages

adults

infancy

Question 5

Signs/sxs of bronchiolitis?

Answer 5

Prodrome with irritability, restlessness, and mild fever

Cough and coryza, V/D, noisy breathing, and increased RR

Labored breathing with retractions, nasal flaring, and grunting

tachycardia, wheezing/inspiratory rales

Question 6

Main cause of Acute bronchitis?

Answer 6

mostly viral, so no abx

therapy is symptomatic: Ibuprofen/Acetaminophen, fluids for rehydration

antitussives rarely indicated

Question 7

What bacteria can cause bacterial acute bronchitis?

Answer 7

mycoplasma pneumoniae

Chlamydophilia pneumoniae, B. pertussis

Question 8

When should you suspect bacterial etiology of acute bronchitis?

Answer 8

fever for more than 4-6 d

predisposed pts (immunocompromised)

if suspected by hx of if confirmed by culture serology/PCR

Question 9

How can you tx bacterial acute bronchitis?

Answer 9

azithromycin or respiratory fluoroquinolone

Question 10

Acute bronchiolotitis

Answer 10

RSV is the most common cause

usually self limiting in healthy infants

if severe: +/- O2 therapy, IV fluids, subset (aerosolized bronchodilators, Ribavirin)

Question 11

What pts can benefit from Ribavirin?

Answer 11

pts with bronchopulmonary dysplasia, congenital heart disease, prematurity or immunodeficiency

Question 12

other tx approach for acute bronchitis in pts with underlying pulmonary or cardiovascular disease?

Answer 12

Prophylaxis against RSV

• give monthly during RSV season
• RSV immune globulin or Palivizumab ( a monoclonal ab for RSV)

Question 13

ADEs of Palivizumab?

Answer 13

fever, rash, ab formation, anaphylaxis (rare), thrombocytopenia

Question 14

Hallmark of chronic bronchitis?

Answer 14

chronic cough, excessive sputum production, expectoration w/ persistent presence of microorganisms in the pts sputum

Question 15

signs/sxs of chronic bronchitis?

Answer 15

excessive sputum expectoration, cyanosis

PE: in/exp rales, rhonchi and mild wheezing. Hyperresonance on percussion.

Question 16

Tx for chronic bronchitis?

Answer 16

attempts to mobilize and enhance sputum expectoration: chest physiotherapy, humidification of inspired air

O2

aerosolized bronchodilators (albuterol)

abx

Question 17

Most common organisms that cause chronic bronchitis?

Answer 17

H. Influenzae, M. Catarrhalis, S. pneumoniae, E. coli

Question 18

What abx should you use for the tx of chronic bronchitis?

Answer 18

which ever abx has the lowest resistance and highest sensitivity

Question 19

signs/sxs of pna?

Answer 19

abrupt onset of fevers, chills, dyspnea, productive cough

rust colored sputum or hemoptysis

pleuritis CP

Question 20

Pna PE?

Answer 20

tachypnea and tachycardia. Dullness to percussion, increased tactile fremitus, CW retractions, diminished breath sounds over affected areas, inspiratory crackles during lung expansion

Question 21

Pna CXR? lab tests?

Answer 21

dense lobar or segmental infiltrate

leukocytosis w/ predominance of polymorphonuclear cells

low O2 sat

Question 22

Most common cause of CAP in adults?

Answer 22

S. pneumoniae

other causes: m. pneumoniae, legionella species, C. pneumonia, H. influenzae

Question 23

Tx for CAP?

Answer 23

humidified oxygen for hypoxemia

bronchodilators when bronchospasm present

fluids

chest physiotherapy

abx (based on presumed causative pathogens)

Question 24

Recommended empiric abx for healthy pts with CAP, no abx in last 3 months?

Answer 24

Macrolide or Doxycycline

Question 25

Recommended empiric abx for CAP pt with comorbid conditions?

Answer 25

respiratory fluoroquinolone or macrolide + beta lactam

Question 26

Recommended empiric abx for pts living in regions with high rates of macrolide resistant to S. pneumoniae?

Answer 26

respiratory fluoroquinolone or macrolide + beta lactam

Question 27

Inpt therapy for CAP, for pt not in ICU?

Answer 27

respiratory fluoroquinolone or macrolide + beta lactam ( for fluoroquinolone allergy)

Question 28

CAP tx for pts admitted to ICU?

Answer 28

Azithromycin or respiratory fluoroquinolone + anti-pneumococcal beta lactam PCN all: fluoroquinolone + Aztreonam

Question 29

Tx of CAP for pts at risk for pseudomonas infection ?

Answer 29

antipneumococcal, antipseudomonal beta lactam + aminoglycoside (gentamicin, tobramicin) +Azithromycin or respiratory fluoroquinolone

Question 30

Tx for CAP in pts at risk for MRSA

Answer 30

antipneumococcal, antipseudomonal beta lactam + aminoglycoside (gentamicin, tobramicin) +Azithromycin or respiratory fluoroquinolone + Vancomycin or Linezolid ???

Question 31

Risk factors for multi drug resistant pathogens (MDR)?

Answer 31

abx therapy within the last 3 mos, septic shock, ARDS, 5+ days in hospital prior to HAP/VAP, acute renal replacement, tx in a unit where local susceptibility rates are not known

Question 32

Risk factors for MRSA in pts with HAP and VAP?

Answer 32

abx therapy in the last 3 mos, renal replacement therapy, use of gastric acid suppressive agents,+ culture or MRSA in the past 3 mos, hospitalized in unit where prevalence of MRSA is not known

Question 33

Risk factors for pseudomonas aeruginosa and other gram - bacilli?

Answer 33

abx therapy in the last 90 days structural lung disease recent hospitalizations + culture within the past yr

Question 34

Recommended initial empiric abx for HAP and VAP?

Answer 34

one of the following: Piperacillin-tazobactam (Zosin) Cefepime Levofloxacin Imipenem Meropenem

Question 35

Recommended initial empiric tx for HAP/VAP in pts with risk factors for MRSA?

Answer 35

Pick one: Piperacillin-tazobactam (Zosin), Cefepime, Ceftazidime, Levofloxin, Aztreonam, etc. + one: Vancomycin or Linezolid

Question 36

Recommended initial empiric abx tx for HAP with risk factors for pseudomonas?

Answer 36

Pick one: Piperacillin-tazobactam (Zosin), Cefepime, Ceftazidime, Levofloxin, Aztreonam, etc. + one: Levofloxacin, Gentamicin, Tobramycin, Aztreonam

Question 37

Recommended initial empiric abx for HAP/VAP with risk factors for MRSA, MDR, pseudomonas and other gram - bacilli?

Answer 37

Pick one: Piperacillin-tazobactam (Zosin), Cefepime, Ceftazidime, Levofloxin, Aztreonam, etc. + one: Levofloxacin, Gentamicin, Tobramycin, Ciprofloxacin +one: Vancomycin or Linezolid

Question 38

which organisms cause pna in peds?

Answer 38

RSV, parainfluenza, adenovirus M. pneumoniae in older children

Question 39

Name a first generation cephalosporin. Use?

Answer 39

Cephalexin skin, soft tissue, UTIs

Question 40

Name a second generation cephalosporin. Use?

Answer 40

Cefotetan Cefoxitin Cefuroxime more active v. S pneumoniae and H influenzae, B fragilis

Question 41

Name a third generation cephalosporin. Use?

Answer 41

Ceftriazone Cefixime Cefotaxine Ceftazidime many uses including pna, meningitis and gonorrhea. Broad activity, beta lactamase stable

Question 42

Name a 4th generation cephalosporin. Use?

Answer 42

cefipime pseudomonas coverage

Question 43

Name a 5th generation cephalosporin. Use?

Answer 43

ceftaroline skin, CAP

Question 44

PK of cephalosporins

Answer 44

oral use for older drugs, mostly IV for newer drugs renal elimination, short half lives third gen. drugs enter CNS

Question 45

ADEs of cephalosporins

Answer 45

hypersensitivity rxn first gen. partial cross reactivity with penicillins GI upset

Question 46

Name a carbapenem. Use?

Answer 46

Imipenem-cilastatin (a beta lactam) broad spectrum, some PRSP strains, gram negative rods, pseudomonas sp