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Therapeutics > Lower Respiratory Tract Infections > Flashcards

Lower Respiratory Tract Infections Flashcards

1
Q

Cough dry/hacking persisting more than 5 days

A

Cough dry/hacking persisting more than 5 days

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2
Q

what pathogens cause acute bronchitis?

A

Viral is most common: (Para)influenza, RSV, corona/adeno/rhinovirus

Rare bacteria; B. Pertussis, M. Pneumoniae, C. Pneumoniae

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3
Q

should you use antibiotics to create acute bronchitis?

A

NO DO NOT

because it does not affect the severity, duration of illness and increases risk of antibiotic resistance

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4
Q

How should you treat acute bronchitis?

A

SYMPTOMATICALLY

  1. bronchodilators: albuterol inhaler
  2. Antitussives: dextromethorphan
  3. Hydration, humidification
  4. eliminate cough triggers
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5
Q

what does AECB stand for?

A

Acute exacerbations of Chronic Bronchitis

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6
Q

define chronic bronchitis

A

any patient who reports coughing up sputum on most days on 3 or more consecutive months for 2 consecutive years.

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7
Q

what defines AECB?

A

a distinct event superimposed on chornic bronchitis, characterized by
increased cough
increased sputum production
increased dyspnea

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8
Q

what are some risk factors/triggers for AECB?

A

smoking
occupational dusts or fumes
environmental pollution
viral or bacterial infections

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9
Q

which pathogens are involved in AECB?

A

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

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10
Q

what are the clinical features of AECB?

A

increased dyspnea*
increased sputum production*
increased sputum purulence*
cough acute onset, first dry then mucoid sputum production

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11
Q

what defines mild AECB?

A

patient with 1 of 3 above sypmtoms

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12
Q

what defines moderate to severe AECB?

A

2-3 symptoms and this means that you may consider antimicrobial treatment

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13
Q

what are your options for AECB treatment?

A
  1. Macrolides: azithromycin, clarithromycin
  2. Doxycycline
  3. Cephalosporins: cefuroxime, cefpodoxime
  4. TMP/SMX
    - —-
  5. Amox/Clav
  6. Fluoroquinolones: levo/moxifloxacin
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14
Q

when should you use amoxicillin/clav or a respiratory quinolone for AECB?

A

If one of the following is true

  1. if patient is 65 or older
  2. FEV1 is less that 50% predicted
  3. Has 4 or more AECB per year
  4. Patient has comorbidities
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15
Q

when should you used the macrolides, doxycycline, cephalosporins or TMP/SMX for AECB?

A

IF both of the following conditions are met:

  1. patient has moderate-severe AECB as defined by 2-3 symptoms mentioned previously
  2. The patient does not meet the criteria outlined for when to use amox/clave or respiratory quinolone
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16
Q

what adjunctive therapy can you used for AECB?

A
  1. bronchodilator: albuterol
  2. corticosteroids: fluticasone
  3. oxygen
  4. chest physical therapy
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17
Q

what can you use to prevent ACEB?

A
  1. vaccinations
  2. smoking cessation
  3. mucolytics
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18
Q

what are risk factors for getting community acquired pneumonia?

A 
poor gag reflex
smoking/alchohol
viral infections
chronic lugn diseases
AIDS, immunosupressed
vomiting
dysphagia
aging, elderly
DM
malnutrition
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19
Q

which organism are the atypicals?

A

Mycoplasma pneumoniae
chlamydophilia pneumniae
legionella

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20
Q

what are the likely pathogens in CAP outpatient?

A

Streptococcus pneumoniae
Hameophillus influenza
Atypicals
viruses

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21
Q

what are the likely pathogens in CAP inpatient Non-ICU?

A 
Streptococcus pneumoniae
haemophilus influenza
atypicals
anaerobes
viruses
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22
Q

what are the likely pathogens in CAP inpatient ICU?

A 
Streptococcus pneumoniae
haemophilus inflenza
community acquired staph aureus
Gram negative bacilli
legionella
viruses
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23
Q

what are the two most common organisms involved in CAP

A

streptococcus pneumoniae

h. Influenza

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24
Q

what are the signs and symptoms of CAP?

A 
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
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25
Q

how do you diagnose CAP?

A
  1. clinical presentation
  2. Chest x ray (gold standard)
  3. Blood cultures and CBC
  4. Serologic tests for pneumococcus and atypical organisms
26
Q

How do you determine whether a patient should be hospitalized for CAP?

A

used the CURB-65 score

27
Q

what is the CURB 65 score? and how does it work?

A 
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

28
Q

what is the criteria for Severe CAP ICU admission?

A

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.

29
Q

what defines hospital acquired pneumonia? HAP

A

developing 48h or more after admission to hospital

30
Q

what defines ventilator associated pneumonia?VAP

A

developing 48h or more after endotracheal intubation

31
Q

what defines healthcare associated pneumonia? HCAP?

A
  1. hospitalized for >2days within 90 days of the infection
  2. resident of nursing home or long-term care facility
  3. received recent abx, wound care, dialysis within past 30 days
  4. family member with MDR pathogen
32
Q

what are some of the risk factors for HAP and VAP?

A
  1. prolonged hospitalization
  2. elderly
  3. intubation
  4. lying flat increases aspiration
  5. pulmonary disease
  6. immunosuppresion
  7. acid suppression
  8. major surgery, trauma
  9. antimicrobial therapy
  10. GNR colonization
33
Q

what is the difference between early onset HAP and late onset HAP?

A

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

34
Q

which organisms are common with early onset HAP?

A

s. Pneumnia
H. influenza
S. aureus MSSA> MRSA
PEK, Enterobacter

35
Q

which organisms are common with late-onset HAP?

A 
same as above plus
pseudomans aerigoinosa
acinetobacer baumanii
ESBL producing E and K
S. aureus MRSA>MSSA
36
Q

how do u differentiate between HAP and other possible clinical conditions such as PE, Pulmonary edema, HF, autoimmune sz etc?

A 
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
37
Q

what are the three diagnostic labs you can do for HAP?

A
  1. Endotracheal aspirate
  2. Bronchoscopy
  3. protected specimen brus: alveolar sample*most accurate
38
Q

how do you trreat a patient with HAP/VAP (initial empire therapy, no risk factors for MDR, early onset)?

A
  1. ceftriaxone
  2. ampicillin/sulbactam
  3. levofloxacin or moxi
  4. ertapenem
39
Q

how do you treat a patient with HAP/VAP (late onset or risk factors for MDR pathogens)?

A
  1. [cefepime or ceftazidime] or [imi/mero/doripenem] or pipe/tazo
    PLUS
  2. [ami/genta/tobramycin] or [cipro/levoflox]
    PLUS
  3. vancomycin or linezolid
40
Q

how long should you treat patients with HAP/VAP

A

7-8 days

if pseudomonas: 14-15 days

41
Q

what does it mean that there are modifying factors for CAP?

A

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

42
Q

what are the modifying factors?

A

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

43
Q

what classifies a person into group 1 for CAP?

A

they are outpatient and have not modifying factors

44
Q

what organisms are likely in a group 1 patient of CAP?

A

S. Pneumoniae
H. Influenzae
Atypicals

45
Q

what agents can you use for group 1 patent of CAP?

A

one agent:
Azithromycin or
Clarithromycin or
doxycycline

46
Q

what classifies a person into group 2 for CAP?

A

outpatient and modifying factors for drug resistant s. pneumo

47
Q

what organisms are likely in a group 2 patient of CAP?

A 
S. pneumo
h. influenza
atypicals (not legionella)
enteric gram N 
Anaerobes
48
Q

what agents can you use for group 2 patient of CAP?

A

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

49
Q

what classifies a patient for group 3 in CAP?

A

score of 71-90 in the PSI, non-ICU

50
Q

what agents can you use for group 3 patients of CAP?

A

Chose one option below
1. IV beta lactam + [macrolide or doxycycline]
b-lactam: ceftriaxone, cefotaxmne, amp/sulb, ertapenem
2. [levofloxacin or moxifloxacin] antipn.cc

51
Q

what classifies a patient in group 4 for CAP?

A

score 91-130 in PSI, ICU

52
Q

what agents can you use for group 4 patients of CAP?

A

Chose one option:

  1. IV beta lactam + [IV or oral macrolide]
  2. Iv beta lactam + [levofloxacin or moxi]
  3. PCN allergy: FQ + aztreonam
  4. Suspect MRSA: add [vanco or linezolid]
53
Q

how long should treatment be with all thee agents?

A

treat minimum of 5 days if

  1. afebrile for 48 to 72 hours
  2. 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

54
Q

how long does it take for paeitns to be clinical stable

A

3-7 days

5-10 day usually adequate

55
Q

who should receive influenza vaccine for CAP prevention?

A

> 50
risk for influenza complications
household contacts with high risk ppl
HCW: healthcare workers

56
Q

who should receive the pneumococcual polysaccharide vaccine?

A

65 or more yo and chronic lung/heart/renal/liver disease, dm
smokers
immunocompromised: hiv ,cacner ,transplant, corticosteroids
asplenia

57
Q

doxycycline

A 
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
58
Q

zithromax

A

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

59
Q

amoxicillin

A

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

60
Q

levaquin

A

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

61
Q

Avelox

A 
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
62
Q

Rocephin

A 
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

Therapeutics (23 decks)

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