LRI Exam 4 Flashcards
common pathogens for CAP
- Viral* (Most common)
- Streptococcus pneumoniae* (Most common bacterial cause)
- Haemophilus influenzae (less common than historically)
- Moraxella catarrhalis
- Mycoplasma pneumoniae
- Chlamydophila pneumoniae
- Legionella pneumophila
Who has a higher risk of CAP?
pts younger than 30 y/o
For CAP, if t has the following risk factors (chronic corticosteroids, severe bronchopulmonary disease, alcoholism, frequent antibiotic therapy) what are they more susceptible to?
- Enterobacteriaceae
- Pseud. aeruginosa
common pathogens for HAP / VAP
- Rarely due to viral or fungal pathogens in immunocompetent patients
- Enterobacteriaceae
- Pseudomonas aeruginosa
- Acinetobacter species (VAP)
- Stenotrophomonas maltophilia (VAP)
- Polymicrobial infection is especially common with ARDS
For HAP / VAP, if pt has the following risk factors (diabetes, head trauma, ICU admission, recent Abx, tobacco use), what are they more susceptible to?
MSSA/MRSA
For infleunza, we’re worried about development of secondary bacterial infection especially for high risk patients. What are those high risk patients?
- Young children
- Elderly >= 65
- Patients with chronic lung disease
What are some general risk factors for HAP / VAP?
- Severe underlying disease
- Preexisting pulmonary disease
- Prior surgery
- Intubation / Mechanical ventilation / Enteral feeding
- Exposure to IV antibiotics
Risk factors for MDR pathogens (MRSA, Pseudomonas) to cause HAP and VAP
Prior IV antimicrobial therapy in preceding 90 days
Additional risk factors for MDR VAP
- Septic shock at time of VAP
- ARDS preceding VAP onset
- Current hospitalization > 5 days before VAP onset
- Acute renal replacement therapy prior to VAP onset
timing of CAP
Happens before or within 48 hours of admission
timing of HAP
Pneumonia arising > 48 hours after hospital admission
timing of VAP
Pneumonia arising > 48-72 hours after endotracheal intubation
Who should receive antiviral treatment?
- Hospitalized patients with confirmed or suspected influenza*
- Children < 2 years*
- Adults >= 65 years*
- Pregnant women or post-partum (within 2 weeks of delivery)*
- People with chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, or metabolic (including diabetes mellitus) disorders
- People with immunosuppression (including medication-induced or HIV infection)
- People < 19 years receiving long-term aspirin therapy o American Indians/Alaska Natives
- Morbidly obese (BMI > 40)
- Nursing home/long-term care residents
Who should receive antiviral prophylaxis?
- young children
- elderly > 65
- chronic lung disease
candidates for influenza vaccine
- > 50 years old*
- Chronic lung disease (e.g., asthma, COPD)
- Chronic renal, hepatic, CVD
- Diabetes
- Neurologic disease (e.g., spinal cord injury, seizures)
- Immunosuppression (e.g., HIV, malignancy)
candidates for pneumococcal vaccine
- > = 65 years old*
- Chronic lung disease (e.g., asthma, COPD)
- Chronic renal, hepatic, CVD
- Diabetes
- Immunosuppression (e.g., HIV, malignancy)
- Asplenic (functional/anatomical)
- Alcoholism
role of palliative therapies in the treatment of acute and chronic bronchitis
- managing cough
- managing other symptoms
What can you use for cough suppression in bronchitis?
- Antitussives: Dextromethorphan, benzonatate (local anesthetic)
- Antihistamines for cough associated with allergic rhinitis; if viral infection, probably not the best choice
- Bronchodilators
- NSAIDS associated with improved cough control with rhinovirus infection; helps decrease severity of the cough: Highly effective in decreasing inflammation; high doses such as IBP 600-800mg TID scheduled
role of antibiotics in the treatment of acute and chronic bronchitis
- No proven benefit in acute bronchitis
- Used in CHRONIC bronchitis (because they have trouble clearing the infection by themselves): Improves clinical outcome
Pneumonia Severity Index (PSI)
- Class I-II: outpatient treatment
- Class III: observation in ED; consider hospitalization
- Class IV-V: hospitalization indicated
CURB-65 items
- Confusion
- Uremia (BUN >20 mg/dL)
- RR >30
- Low BP (SBP <90 or DBP <60)
- Age >65
CURB-65 interpretation
- Score 0-1: outpatient treatment
- Score >2: ospitalization
- Score 3: ± ICU
- Score >4: ICU
What is the preferred method for routine testing in pneumonia?
respiratory culture semiquantitative method
biomarkers (PCT, sTREM, CRP) in pneumonia
biomarkers are not sensitive or specific; there is not current use for them in treatment guidelines at the moment
CPIS in pneumonia
- Developed to assist with diagnosis of VAP
- does not reliably discriminate between patients with or without VAP
Out-pt treatment for CAP: Previously healthy/ No recent antibiotics
- Macrolide (azithromycin, clarithromycin, erythromycin)
- Doxycycline
Out-pt treatment for CAP: Recent Antibioticsa or Comorbidities
- Respiratory fluoroquinoloneb
- β-lactamc plus a macrolide
Out-pt treatment for CAP: Regions with High Rates (>25%) of MacrolideResistant Pneumococci (MIC >16 µg/mL)
β-lactam PLUS doxycycline
In-pt treatment for CAP: Medical ward
- Respiratory fluoroquinolone
- β-lactam plus a macrolide
In-pt ICU treatment for CAP: No concern for Pseudomonas
- β-lactam plus azithromycin
- β-lactam plus respiratory fluoroquinolone
In-pt ICU treatment for CAP: No concern for Pseudomonas, but β-lactam allergy
Aztreonam plus respiratory fluoroquinolone
In-pt ICU treatment for CAP: Concern for Pseudomonas
- Antipseudomonal β-lactam plus ciprofloxacin or levofloxacin (750 mg)
- Antipseudomonal β-lactam plus an aminoglycosidek plus azithromycin
- Antipseudomonal β-lactam plus an aminoglycosidek fluoroquinolone
In-pt ICU treatment for CAP: Concern for Pseudomonas, but β-lactam allergy
Aztreonam plus an aminoglycoside plus respiratory fluoroquinolone
In-pt ICU treatment for CAP: Concern for CA-MRSA
Add vancomycin or linezolid
What are the appropriate respiratory fluoroquinolones?
- Moxifloxacin
- levofloxacin (750 mg)
- gemifloxacin
What are antipseudomonal β-lactam?
- Piperacillin-tazobactam
- imipenem
- meropenem
- cefepime
- aztreonam (PCN-allergy)
β-lactam therapy for CAP out-pt
- High-dose amoxicillin (1 gm po TID)
- high-dose amoxicillin-clavulanate (2 gm po BID) preferred
- alternatives include ceftriaxone (if IV access available), cefpodoxime, or cefuroxime
β-lactam therapy for CAP in-pt
Cefotaxime, ceftriaxone, ampicillin-sulbactam, or ertapenem preferred
In which population should AMG be avoided in?
elderly
Examples of comorbidities
- Chronic obstructive pulmonary disease
- malignancy
- diabetes
- renal failure
- congestive heart failure
In-pt ICU treatment for HAP / VAP: low risk for mortality or MDR pathogens, no MRSA risk
- Penicillin (Piperacillin-Tazobactam)
- Cephalosporin (Cefepime)
- Fluoroquinolone (Levofloxacin)
- Carbapenem (Imipenem / Meropenem)
In-pt ICU treatment for HAP / VAP: low risk for mortality or MDR pathogens, MRSA risk
- Penicillin (Piperacillin-Tazobactam)
- Cephalosporin (Cefepime)
- Fluoroquinolone (Levofloxacin)
- Carbapenem (Imipenem / Meropenem)
- Monobactam (Aztreonam)
- WITH Linezolid or Vancomycin
In-pt ICU treatment for HAP / VAP: high risk for mortality or MDR pathogens
- Linezolid or Vancomycin
- WITH Zosyn or Cefepime / Ceftazidime or Imipenem / Meropenem or Aztreonam
- WITH Ciprofloxacin / Levofloxacin or Amikacin / Gentamicin / Tobramycin or Polymixin (colistin; VAP ONLY)
What is the vanc trough target for HAP / VAP?
15-20 µg/mL
Use of Amantadine for influenza virus
Not recommended due to high rates of resistance among Type A isolates (>99%)
Use of Rimantadine for influenza virus
Not recommended due to high rates of resistance among Type A isolates (>99%)
Use of Oseltamivir (Tamiflu®) for influenza virus
- used for both treatment and prophylaxis
- treatment at any age for both A and B
- prophylaxis not to be used in younger than 3 months
- ADE: Nausea/vomiting, neuropsychiatric effects
Use of Zanamivir (Relenza®) for influenza virus
- used for both treatment and prophylaxis
- NOT to be used if pt also has asthma / COPD, milk allergy
- treatment for >= 7 y/o
- prophylaxis for >= 5 y/o
- ADE: Allergic rxns, diarrhea, nausea, respiratory infections
Organism-Specific Therapy for Chronic Bacterial Bronchitis: Atypicals (Mycoplasma. pneumoniae, Chlamydophila pneumoniae)
- Macrolide (azithromycin, clarithromycin, erythromycin)
- Doxycycline
- Respiratory fluoroquinolone
Organism-Specific Therapy for Chronic Bacterial Bronchitis: Streptococcus pneumoniae
- High-dose amoxicillin
- Doxycycline
- Respiratory fluoroquinolone
- Not first line: Macrolide (azithromycin, clarithromycin, erythromycin)
- Not first line: 3rd Gen. Cephalosporin + Clindamycin
Organism-Specific Therapy for Chronic Bacterial Bronchitis: Haemophilus influenzae, Moraxella catarrhalis
- Amoxicillin / clavulanate
- Respiratory fluoroquinolone
- Not first line: 3rd Gen. Cephalosporin
- Not first line: Trimethoprim / sulfamethoxazole
