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DOOS3 > Lower respitory tract infection -Table 1 > Flashcards

Lower respitory tract infection -Table 1 Flashcards

1
Q

What is the clinical presentation of bronchitits?

A

Cough with purulent sputum lasting at least 5 days up to 3 weeks
Dyspnea, Wheezing, Chest pain, Fever, Headache, Malaise, Rhonchi, Rales

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2
Q

What should you make sure your pts doesn’t have when considering acute brocnhitits?

A

Pertussis and pneumonia

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3
Q

What does pertussis present like?

A

violent, rapid cough, which eventually depletes the lungs of air, forcing them to inhale with a loud “whooping” sound

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4
Q

What are s/s of pneumonia that wouldn’t be present in bronchitits?

A

Systemic signs of infx- fever
X-ray severity
•Interstitial disease
•Parenchymal infiltrates
•Pleural effusion
More profound WBC elevation w/ “left shift”
Bronchitis can have mild WBC elevation but it is much higher in PNA

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5
Q

Is acute bronchitits more commonly caused by virus or bacteria?

A

Virus

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6
Q

What are the viral origins of acute bronch?

A 
Influenza A and B viruses
Parainfluenza virus 
Respiratory syncytial virus
Coronavirus
Adenovirus
Rhinovirus
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7
Q

What are the bacterial origins of acute bronch?

A

Mycoplasma pneumoniae , Chlamydia pneumoniae, Bordatella pertussis

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8
Q

Is microbiologic testing recommended in acute bronch?

A

Nope

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9
Q

How is acute bronch tx?

A

Supportive, no abx unless

  • there is a tx pathogen
  • persistent fever for several days
  • B pertussis
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10
Q

If it is b pertussis, what is the DOC for tx?

A

Macrolide

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11
Q

If influenza virus is confirmed what can you tx with and when do you have to initial tx?

A

Neuraminidase inhibitors- oseltamivir/zanamivir

Need to be initiated within 48 hours of onset of symptoms

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12
Q

What is the single best method for reducing the risk of contracting influenza and preventing its complications?

A

Vaccination

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13
Q

What are the 5 categories of pneumonia?

A 
Community-acquired pneumonia (CAP) 
Healthcare-associated pneumonia (HCAP) 
Ventilator-associated pneumonia (VAP) 
Hospital-acquired pneumonia (HAP) 
Aspiration pneumonia
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14
Q

What are the clinical s/s of CAP?

A

•Typically 2 of the following symptoms are present in patients with pneumonia:
Fever or hypothermia
Chills or rigors
Sweating
New cough (with or without sputum production)- dry and worse at night
Changes in color or volume of respiratory sections
Chest discomfort
Shortness of breath (SOB) or dyspnea

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15
Q

What are nonspecific findings of CAP?

A

Fatigue, myalgias, abdominal pain, diarrhea, Anorexia, Headache

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16
Q

What atypical CAP organisms are associated with a more gradual onset of symptoms?

A

Mycoplasma spp.

Chlamydia spp.

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17
Q

What does “walking pneumonia” typically mean?

A

Pt with mild symptoms that are not hospitalized or bed ridden

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18
Q

What imaging should be done when considering a diagnosis of PNA?

A

Chest x ray- looking for infiltrated and consolidation

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19
Q

What findings on chest xray indicate bacterial PNA?

A

Lobar infiltrates confined to a specific lobe such as right lower lobe (RLL), right upper lobe (RUL), or left lower lobe (LLL)

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20
Q

What findings indicate viral infections, atypical pathogens, or heme spread?

A

Diffuse B/L infiltrates

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21
Q

What are lab findings in PNA?

A

Left shift with elevated WBC count

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22
Q

When would you do a blood culture for a pt with suspected PNA?

A

Only if they are hospitalized… usually comes back negative 40-60% of the time

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23
Q

What are other ways can you culture for PNA?

A

Sputum with gram stain
Urine antigen
Blood titer IgM

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24
Q

When is a urine antigen test helpful in PNA?

A

To diagnose legionella or s pneumo

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25
What pts would you check for the above pathogens in a urine test?
ICU failed outpt meds, active alcohol abuse, or a pleural effusion
26
What is the blood titer looking for?
Mycoplasma spp. and Chlamydia spp | Bc it is IgM this is looking for acute infection
27
What are the components of CURB-65?
Confusion, blood urea nitrogen >20, RR >30, systolic BP 65
28
What do the curb scores indicate?
0=low risk, outpt tx 1=same 2=admit to ward 3/4/5= severe PNA, hospitalize and consider ICU
29
What is first line empirirc tx for outpt CAP with no risk factors and previously healthy?
Azithro PO 5 days
30
What is first line is there is strep pneumo resistant bacteria in the above pt?
Doxycycline PO 7 days
31
What is first line empiric tx for outpt CAP with comorbidities or risk factors?
1) levo or moxi- caution in elderly, c diff risk 7 days 2)Azithro PO PLUS Amox/clav or cefuroxime 7 days
32
What is first line empiric tx for inpt CAP?
Azirtho Iv/PO PLUS ceftriaxone IV for 7 days
33
What is second line tx for the above scenario?
Levo IV/PO 5 days or moxi IV/PO 7 days
34
What is first line empiric tx for inpt CAP ICU?
Azithro IV 3 days plus ceftriaxone IV 7 days
35
What is second line tx for the above pt?
Lveo IV 5-7 days or moxi IV 7-10 days with ceftriaxoneIV 7 days
36
When should your pt expect to see a response to abx tx?
Within 3-5 days but cxr may take up to 4 weeks to show improvement
37
What is the criteria that needs to be met in order to progress your pt from IV to PO?
- able to take PO things with a normal GI tract | - clinical status improving or stable
38
If your pt is on other drugs that contain Al,Mg, Ca, Fe, Zn, quinapril or sucralfate, how should you separate them?
Levo- 2 hrs before or after Moxi- 4 hrs before or 8 hrs after Gemi- 3 hrs before or 2 hrs after Doxy- 2 hrs before or 2 hrs after
39
What is the duration of therapy fro CAP?
Minimum of 5 days and pt needs to be afebrile 48-72 hrs and clinically/hemodynamically stable to DC anx
40
What is the recommended duration of therapy for infections caused by specific organisms?
5-10 days
41
What is HAP?
Pneumonia that occurs >/=48 hrs after hospitalization
42
What is VAP?
A type of HAP that occurs more than 48hrs after endotracheal intubation
43
What is HCAP?
Pt hospitalized for more than 2 days within 90 days prior to infection, received tx within 30 days prior to infection, resided in LTCF or SNIFF… eh iffy
44
How are these diagnosed?
Clinical strategy defines pneumonia as the presence of a new or progressive lung infiltrate on CXR and clinical evidence that the infiltrate is due to infection
45
How is clinical infection defined?
•presence of at least 2 of the following symptoms: Fever > 38OC Leukocytosis or leukopenia Purulent secretions
46
Should empiric abx be started in these pts?
YES in all with suspected pneumonia ( HAP, VAP)
47
What are the non invasive ways to obtain cultures from the lower resp tract?
Endotracheal aspirate
48
What are invasive methods to obtain lower resp tract samples?
``` Protected specimen brush ( PSB) Bronchoalveolar lavage (BAL) ```
49
Why are HAP, VAP, and HCAP all treated the same?
because all of these patients are at risk of infection from multi-drug resistant (MDR) pathogens
50
What are the organisms responsible for HAP, VAP, and HCAP?
``` MSSA/MRSA Pseudomonas aeruginosa Gram negative enterics •E coli •Klebsiella pneumoniae •Enterbacter sp. •Serratia marcescens Acinetobacter baumanni – pansensative or panresistant depending on location Rarely fungal: immunocompetent hosts ```
51
What are the risk factors for MDR pathogens?
* Broad antimicrobial therapy in preceding 90 days- he says No * Current hospitalization of 5 or more days * Hospitalized for 2 days or more in the preceding 90 days- he says No * Immunosuppressive disease and/or therapy (including chemotherapy) * Residing in a nursing home or extended care facility * Receiving home infusion therapy or home wound care in preceding 30 days * Receiving chronic dialysis in the preceding 30 days= Staph A bacteremia and pneumonia
52
How is this all tx empirically….?
He LOVES zosin and vanco combo (vitamin z) and said this one is basically always jumped to before the guidelines recommend.
53
Should you double cover for pseudomonas in NM?
NO unless they are dying in the ICU and vented
54
Which drug options can you prescribe for pseudomonas?
Amikacin, cefepime, cirpo, gent, levo, meropenem, zosin, and tobramycin…. Vanco NOT cover gram -
55
What are the anti-pseudo agents and what are their clinical considerations?
Carbapenems: etra doesn’t cover Cefepime= great Pip/taz= renal adjust FQ= higher resistance rates than the rest Aminos= nephro and oto toxic, closely monitor
56
What are the anti-mrsa agents and their considerations?
``` Vanco= nephrotoxic, need trough around 15-20 Linezolid= caution if pt on SSRI d/t serotonin syndrome risk ```
57
Why cant you use daptomycin in MRSA pneumonia pts?
Inactivated by surfactant
58
What is the duration of therapy for HAP, VAP, and HCAP?
7 days! | Unless P. aeruginosa, Staph, Acinetobacter spp. • Treat these at least 14 days
59
If your pts cultures come back negative and they are showing improvement in 48-72 hours can you stop therapy?
Yes, it is reasonable to consider stopping tx at this point
60
What are some reasons for non-response?
Wrong organism, wrong diagnosis, complication
61
What are some complications?
Empyema or abscess- need to drain this C diff- this can lead to elevated WBC count…not necessarily ill or not improving in the lungs you just gave them c diff Drug fever Occult infection
62
Is aspiration normal?
Yes it kinda is…. Approximately ½ of healthy adults aspirate small amounts of oropharyngeal secretions during sleep •Forceful coughing, active ciliary transport, and a functioning immune system clear this potentially infectious material
63
What are risk factors for aspiration?
``` Neuro disorders: AD, PD, altered mental status Impaired swallowing or cough reflex Esophageal dysfxn Periodontal dz/ bad oral hygiene Use of H2 blockers and PPI ```
64
What is the clinical presentation of aspiration?
Chocking, pain with swallow, coughing, multiple swallows per mouthful, sensation of food sticking in the chest
65
What are the pathogens associated with aspir PNA?
* Anaerobes * Gram-positive cocci * S. pneumoniae * Gram- negative bacteria
66
What are tx options for aspiration pneumonia?
``` Amp/sulb ceftriaxone plus clinda= high c diff risk ceftriaxone plus metro moxi- seeing resistnace now amox/clav ertapenem- NO DO NOT USE THIS ```
67
What is the duration of therapy for the above drug options?
5-7 days unless an MDR pathogen is ID or highly suspicious

DOOS3 (12 decks)

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