Lower Respiratory Tract Infections Flashcards
Cough dry/hacking persisting more than 5 days
Cough dry/hacking persisting more than 5 days
what pathogens cause acute bronchitis?
Viral is most common: (Para)influenza, RSV, corona/adeno/rhinovirus
Rare bacteria; B. Pertussis, M. Pneumoniae, C. Pneumoniae
should you use antibiotics to create acute bronchitis?
NO DO NOT
because it does not affect the severity, duration of illness and increases risk of antibiotic resistance
How should you treat acute bronchitis?
SYMPTOMATICALLY
- bronchodilators: albuterol inhaler
- Antitussives: dextromethorphan
- Hydration, humidification
- eliminate cough triggers
what does AECB stand for?
Acute exacerbations of Chronic Bronchitis
define chronic bronchitis
any patient who reports coughing up sputum on most days on 3 or more consecutive months for 2 consecutive years.
what defines AECB?
a distinct event superimposed on chornic bronchitis, characterized by
increased cough
increased sputum production
increased dyspnea
what are some risk factors/triggers for AECB?
smoking
occupational dusts or fumes
environmental pollution
viral or bacterial infections
which pathogens are involved in AECB?
Virus: influenza, parainfluenza, RSV, adenovirus
Bacteria:
H. Influenzae, S. Pneumoniaes, M. Catarrhalis, H. Parainfluenza, Klebsiella spp
Chlamydia pneumoniae, mycoplasma pneumoniae
Severe bronchitis, recent antibiotics, nosocomial: enterobacteriacea, P. aeriginosa, S.sureas
what are the clinical features of AECB?
increased dyspnea*
increased sputum production*
increased sputum purulence*
cough acute onset, first dry then mucoid sputum production
what defines mild AECB?
patient with 1 of 3 above sypmtoms
what defines moderate to severe AECB?
2-3 symptoms and this means that you may consider antimicrobial treatment
what are your options for AECB treatment?
- Macrolides: azithromycin, clarithromycin
- Doxycycline
- Cephalosporins: cefuroxime, cefpodoxime
- TMP/SMX
- —- - Amox/Clav
- Fluoroquinolones: levo/moxifloxacin
when should you use amoxicillin/clav or a respiratory quinolone for AECB?
If one of the following is true
- if patient is 65 or older
- FEV1 is less that 50% predicted
- Has 4 or more AECB per year
- Patient has comorbidities
when should you used the macrolides, doxycycline, cephalosporins or TMP/SMX for AECB?
IF both of the following conditions are met:
- patient has moderate-severe AECB as defined by 2-3 symptoms mentioned previously
- The patient does not meet the criteria outlined for when to use amox/clave or respiratory quinolone
what adjunctive therapy can you used for AECB?
- bronchodilator: albuterol
- corticosteroids: fluticasone
- oxygen
- chest physical therapy
what can you use to prevent ACEB?
- vaccinations
- smoking cessation
- mucolytics
what are risk factors for getting community acquired pneumonia?
poor gag reflex smoking/alchohol viral infections chronic lugn diseases AIDS, immunosupressed vomiting dysphagia aging, elderly DM malnutrition
which organism are the atypicals?
Mycoplasma pneumoniae
chlamydophilia pneumniae
legionella
what are the likely pathogens in CAP outpatient?
Streptococcus pneumoniae
Hameophillus influenza
Atypicals
viruses
what are the likely pathogens in CAP inpatient Non-ICU?
Streptococcus pneumoniae haemophilus influenza atypicals anaerobes viruses
what are the likely pathogens in CAP inpatient ICU?
Streptococcus pneumoniae haemophilus inflenza community acquired staph aureus Gram negative bacilli legionella viruses
what are the two most common organisms involved in CAP
streptococcus pneumoniae
h. Influenza
what are the signs and symptoms of CAP?
cough, fever and chills wheezing/dyspnea increased sputum production Pleuretic chest pain tachypnea, tachycardia fatigue N/V/D crackles/ rales pulmonary consolidation infiltrate on chest x ray: lovar or segmental infiltrates
how do you diagnose CAP?
- clinical presentation
- Chest x ray (gold standard)
- Blood cultures and CBC
- Serologic tests for pneumococcus and atypical organisms
How do you determine whether a patient should be hospitalized for CAP?
used the CURB-65 score
what is the CURB 65 score? and how does it work?
C = Confusion or altered mental state 1pt U = blood Urea Nitrogen > 20mg/dL 1pt R = Respiratory rate of >30/min 1pt B = SBP <60mmhg 1pt 65 = Above 65 yo 1pt
if you get 2 points: consider hospitalizations
3 or more points: hospitalize
what is the criteria for Severe CAP ICU admission?
One of the following:
1. Septic shock requiring vasopressors
2. need for tracheal intubation/mechanical ventilation
Three or more minor criteria
1. RR>30, PaO2/FIO2 <36C
8. Hypotension requiring agressive fluid resuscitation.
what defines hospital acquired pneumonia? HAP
developing 48h or more after admission to hospital
what defines ventilator associated pneumonia?VAP
developing 48h or more after endotracheal intubation
what defines healthcare associated pneumonia? HCAP?
- hospitalized for >2days within 90 days of the infection
- resident of nursing home or long-term care facility
- received recent abx, wound care, dialysis within past 30 days
- family member with MDR pathogen
what are some of the risk factors for HAP and VAP?
- prolonged hospitalization
- elderly
- intubation
- lying flat increases aspiration
- pulmonary disease
- immunosuppresion
- acid suppression
- major surgery, trauma
- antimicrobial therapy
- GNR colonization
what is the difference between early onset HAP and late onset HAP?
early onset develops <5 days and is community acquired organisms that colonize the patient at time of hospital admission. Late-onset on day 5 or later is caused by more resistant bacteria likely from the hospital
which organisms are common with early onset HAP?
s. Pneumnia
H. influenza
S. aureus MSSA> MRSA
PEK, Enterobacter
which organisms are common with late-onset HAP?
same as above plus pseudomans aerigoinosa acinetobacer baumanii ESBL producing E and K S. aureus MRSA>MSSA
how do u differentiate between HAP and other possible clinical conditions such as PE, Pulmonary edema, HF, autoimmune sz etc?
1. new or persistent pulmonary infiltrate on Xray AND 2. at least two of a. T >38C or < 4000 or >11000 c. pulmonary secrestion purulent
what are the three diagnostic labs you can do for HAP?
- Endotracheal aspirate
- Bronchoscopy
- protected specimen brus: alveolar sample*most accurate
how do you trreat a patient with HAP/VAP (initial empire therapy, no risk factors for MDR, early onset)?
- ceftriaxone
- ampicillin/sulbactam
- levofloxacin or moxi
- ertapenem
how do you treat a patient with HAP/VAP (late onset or risk factors for MDR pathogens)?
- [cefepime or ceftazidime] or [imi/mero/doripenem] or pipe/tazo
PLUS - [ami/genta/tobramycin] or [cipro/levoflox]
PLUS - vancomycin or linezolid
how long should you treat patients with HAP/VAP
7-8 days
if pseudomonas: 14-15 days
what does it mean that there are modifying factors for CAP?
they are things that the patient could have that would make you want to treat the patient more aggressively. They are at risk for having drug resistant organisms
what are the modifying factors?
Pen resistant S. pneumo
1. age 65
2. b-lactam/macorlide/tmp/smx/fq therapy w/in past 3 months
3. alcoholosim
4. immunosuppression inc corticosteroid tx
5. many comorbidities:DM, CHF, CAD, Malignancy, chronic lieve dz, CRI
6. exposure to child in day care
Enteric GNR:PEK
1. nursing home residence
2. multiple comorbidities
3. recent antibiotic tehrapy
4. hospitalization w/in last 90 days
5. alcoholism
Pseudomonas
1. bronchiectasis, cystic fibrosis
2. corticosteriod therapy >10mg prednison/day
3. broad spectrum abc >7day duration in past month
4. malnutrition
what classifies a person into group 1 for CAP?
they are outpatient and have not modifying factors
what organisms are likely in a group 1 patient of CAP?
S. Pneumoniae
H. Influenzae
Atypicals
what agents can you use for group 1 patent of CAP?
one agent:
Azithromycin or
Clarithromycin or
doxycycline
what classifies a person into group 2 for CAP?
outpatient and modifying factors for drug resistant s. pneumo
what organisms are likely in a group 2 patient of CAP?
S. pneumo h. influenza atypicals (not legionella) enteric gram N Anaerobes
what agents can you use for group 2 patient of CAP?
use one option below:
1. oral beta lactam + [macrolide or doxycycline]
beta lactam: cefpodoxime, cefuroxime, amoxicillin 1g TID, amox/clav 2g BID
2. [levofloxacin or moxifloxacin]antipn.cc
3. telithromycin
what classifies a patient for group 3 in CAP?
score of 71-90 in the PSI, non-ICU
what agents can you use for group 3 patients of CAP?
Chose one option below
1. IV beta lactam + [macrolide or doxycycline]
b-lactam: ceftriaxone, cefotaxmne, amp/sulb, ertapenem
2. [levofloxacin or moxifloxacin] antipn.cc
what classifies a patient in group 4 for CAP?
score 91-130 in PSI, ICU
what agents can you use for group 4 patients of CAP?
Chose one option:
- IV beta lactam + [IV or oral macrolide]
- Iv beta lactam + [levofloxacin or moxi]
- PCN allergy: FQ + aztreonam
- Suspect MRSA: add [vanco or linezolid]
how long should treatment be with all thee agents?
treat minimum of 5 days if
- afebrile for 48 to 72 hours
- less than 1 sign of clinical instability: hr>100, rr>24, Pa0238C, normal mental status, unable to maintain oral intake
extended ruction of 10-14 days or more if therapy not effective, extra pulmonary complications or bacteria present
how long does it take for paeitns to be clinical stable
3-7 days
5-10 day usually adequate
who should receive influenza vaccine for CAP prevention?
> 50
risk for influenza complications
household contacts with high risk ppl
HCW: healthcare workers
who should receive the pneumococcual polysaccharide vaccine?
65 or more yo and chronic lung/heart/renal/liver disease, dm
smokers
immunocompromised: hiv ,cacner ,transplant, corticosteroids
asplenia
doxycycline
Brand: vibramycin I= CAP MOA=inhibits bacterial protein synthesis D= 100mg po bid x 7 days (CAP OP) DDI= antacids, warfarin SE= Common: diarrhea Serious: SJS PK=hepatic and renal C= sunscreen, antacids avoid, decrease oral contraceptive effectiveness, take with full glass of water
zithromax
azithromycin
MOA=Macrolide antibiotic, binds to 50S ribosomal subunit, disrupting protein synthesis
D= CAP OP 500mg x1, 250mg x 4
DDI= warfarin, fluoroquinolones
SE= Common: diarrhea Serious: prolonged QT
PK=major excretion biliary , 35% hepatic met
C= avoid magnesium contain antacids, report serious diarrhea
amoxicillin
Amoxicillin
I= CAP
MOA=Inhibits bacterial cell wall synthesis
D= CAP OP 1gram po tid + Zpack for 5-10 days (with comorbidities)
DDI= Venlafaxine SS, warfarin inc INR, methotrexate tox
SE= Common: diarrhea Serious: anaphylaxis
PK=Renal elimination 60%
C= diarrhea, shake well before giving dose, decreases birth control effectiveness
levaquin
levofloxacin
I=UTI, CAP, HAP
D=CAP 750mg q 24h x 5 days - 10days, HAP 750 q 24h x 7-14 days
DDI=antacids, calcium salts, iron (dec absorption), warfarin (inc INR), NSAIDs (inc seizure potentiating, sulfonylureas ( enhance hypoglecemia)
MOA= inhibit DNA gyrase, promotes brekage of DNA strands
PK= 99% oral bioavailability, urine excretion
SE= headache, nausea, diarrhea
precaution/BBW (fluroquinolones) Risk of Muscle Weakness in Patients with Myasthenia Gravis
C=report muscle weakens if pt also has myasthenia gravis, avoid antacids, calcium or iron supplements
Avelox
moxifloxacin I=sinusitis, conjunctivitis D=400mg IV/PO once daily for 5-10 days DDI=calcium, antacids, iron, MOA=fluoroquinolones inhibt DNA gyrase and cause breaks in the DNA PK=hepatic and renal SE=diarrhea, precaution/BBW: tendonitis C=sun sensitivity so wear sunscreen, avoid antacids, calcium, iron
Rocephin
ceftriaxone I= CAP inpatient D= 1-2 grams IV q d + Azithromycin 500mg IV/ po QD (CAP IP) DDI= Calcium(probable), warfarin MOA: inhibit cell wall synthesis peptidoglycan PK: fecal and kidney SE: Painful at injection site C: report sever diarrhea
