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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
Q

What pts would you check for the above pathogens in a urine test?

A

ICU failed outpt meds, active alcohol abuse, or a pleural effusion

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26
Q

What is the blood titer looking for?

A

Mycoplasma spp. and Chlamydia spp

Bc it is IgM this is looking for acute infection

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27
Q

What are the components of CURB-65?

A

Confusion, blood urea nitrogen >20, RR >30, systolic BP 65

28
Q

What do the curb scores indicate?

A

0=low risk, outpt tx
1=same
2=admit to ward
3/4/5= severe PNA, hospitalize and consider ICU

29
Q

What is first line empirirc tx for outpt CAP with no risk factors and previously healthy?

A

Azithro PO 5 days

30
Q

What is first line is there is strep pneumo resistant bacteria in the above pt?

A

Doxycycline PO 7 days

31
Q

What is first line empiric tx for outpt CAP with comorbidities or risk factors?

A

1) levo or moxi- caution in elderly, c diff risk 7 days
2)Azithro PO
PLUS
Amox/clav or cefuroxime 7 days

32
Q

What is first line empiric tx for inpt CAP?

A

Azirtho Iv/PO PLUS ceftriaxone IV for 7 days

33
Q

What is second line tx for the above scenario?

A

Levo IV/PO 5 days or moxi IV/PO 7 days

34
Q

What is first line empiric tx for inpt CAP ICU?

A

Azithro IV 3 days plus ceftriaxone IV 7 days

35
Q

What is second line tx for the above pt?

A

Lveo IV 5-7 days or moxi IV 7-10 days with ceftriaxoneIV 7 days

36
Q

When should your pt expect to see a response to abx tx?

A

Within 3-5 days but cxr may take up to 4 weeks to show improvement

37
Q

What is the criteria that needs to be met in order to progress your pt from IV to PO?

A
  • able to take PO things with a normal GI tract

- clinical status improving or stable

38
Q

If your pt is on other drugs that contain Al,Mg, Ca, Fe, Zn, quinapril or sucralfate, how should you separate them?

A

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
Q

What is the duration of therapy fro CAP?

A

Minimum of 5 days and pt needs to be afebrile 48-72 hrs and clinically/hemodynamically stable to DC anx

40
Q

What is the recommended duration of therapy for infections caused by specific organisms?

A

5-10 days

41
Q

What is HAP?

A

Pneumonia that occurs >/=48 hrs after hospitalization

42
Q

What is VAP?

A

A type of HAP that occurs more than 48hrs after endotracheal intubation

43
Q

What is HCAP?

A

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
Q

How are these diagnosed?

A

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
Q

How is clinical infection defined?

A

•presence of at least 2 of the following symptoms:
Fever > 38OC
Leukocytosis or leukopenia
Purulent secretions

46
Q

Should empiric abx be started in these pts?

A

YES in all with suspected pneumonia ( HAP, VAP)

47
Q

What are the non invasive ways to obtain cultures from the lower resp tract?

A

Endotracheal aspirate

48
Q

What are invasive methods to obtain lower resp tract samples?

A 
Protected specimen brush ( PSB)
Bronchoalveolar lavage (BAL)
49
Q

Why are HAP, VAP, and HCAP all treated the same?

A

because all of these patients are at risk of infection from multi-drug resistant (MDR) pathogens

50
Q

What are the organisms responsible for HAP, VAP, and HCAP?

A 
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
Q

What are the risk factors for MDR pathogens?

A
  • 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
Q

How is this all tx empirically….?

A

He LOVES zosin and vanco combo (vitamin z) and said this one is basically always jumped to before the guidelines recommend.

53
Q

Should you double cover for pseudomonas in NM?

A

NO unless they are dying in the ICU and vented

54
Q

Which drug options can you prescribe for pseudomonas?

A

Amikacin, cefepime, cirpo, gent, levo, meropenem, zosin, and tobramycin…. Vanco NOT cover gram -

55
Q

What are the anti-pseudo agents and what are their clinical considerations?

A

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
Q

What are the anti-mrsa agents and their considerations?

A 
Vanco= nephrotoxic, need trough around 15-20
Linezolid= caution if pt on SSRI d/t serotonin syndrome risk
57
Q

Why cant you use daptomycin in MRSA pneumonia pts?

A

Inactivated by surfactant

58
Q

What is the duration of therapy for HAP, VAP, and HCAP?

A

7 days!

Unless P. aeruginosa, Staph, Acinetobacter spp. • Treat these at least 14 days

59
Q

If your pts cultures come back negative and they are showing improvement in 48-72 hours can you stop therapy?

A

Yes, it is reasonable to consider stopping tx at this point

60
Q

What are some reasons for non-response?

A

Wrong organism, wrong diagnosis, complication

61
Q

What are some complications?

A

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
Q

Is aspiration normal?

A

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
Q

What are risk factors for aspiration?

A 
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
Q

What is the clinical presentation of aspiration?

A

Chocking, pain with swallow, coughing, multiple swallows per mouthful, sensation of food sticking in the chest

65
Q

What are the pathogens associated with aspir PNA?

A
  • Anaerobes
  • Gram-positive cocci
  • S. pneumoniae
  • Gram- negative bacteria
66
Q

What are tx options for aspiration pneumonia?

A 
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
Q

What is the duration of therapy for the above drug options?

A

5-7 days unless an MDR pathogen is ID or highly suspicious

DOOS3 (12 decks)

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