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finals y3s1 > LRTI > Flashcards

LRTI Flashcards

1
Q

pathophysiology of pneumonia

A

inhale aerosolised droplets + susceptible host -> pneumonia

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2
Q

risk factors for pneumonia

A

1) smoking

2) COPD, lung cancer, asthma

3) immune suppression

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3
Q

clinical presentation of pneumonia - systemic

A

fever, chill, malaise, change in mental status (elderly), tachycardia, hypotension

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4
Q

clinical presentation of pneumoniae - locaslied

A

cough, chest pain (pruritic chest pain: pain from coughing), SOB, tachypnoea, hypoxia, increased sputum production

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5
Q

pneumonia diagnosis - physical examination

A
  • diminished chest sound over affected area
  • inspiratory cackles during lung expansion
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6
Q

pneumonia diagnosis - radiographic finding

A
  • require evidence of new infiltrates/dense consolidations (unilateral white patches)
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7
Q

pneumoniae diagnosis - lab findings

A

1) general (WBC, CRP, procalcitonin)

  • X specific to pneumonia

2) urinary antigen test

  • test for strep pneumoniae, legionella pneumophilla
  • can remain positive for days-wks despite treatment
  • recommend for severe CAP or hopistalised pt
  • X for outpatient
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8
Q

where to obtain culture for gram stain for pneumonia

A

1) sputum

  • hypotonic saline to induce pt to cough out sputum
  • low yield cuz prone to contamination by oropharyngeal secretion

2) LRTI samples

  • invasive sampling, less contamination
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9
Q

why take blood culture for diagnosis of pneumonia?

A

rule out bacteriaemia

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10
Q

ISDP guidelines for who needs pre-treatment culture & gramstain

A

1) Severe CAP
2) risk factors for drug resistant pathogens (MRSA, pseudo)

  • empirically treated for either
  • either infection in last 1 yr
  • hospitalised/IV Abx within last 90 days
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11
Q

definition of community acquired pneumonia

A

onset in community or < 48 hr after hospital admission

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12
Q

risk factors for community acquired pneumonia

A
  • history of pneumonia
  • normal pneumonia risk factors (Recite them.)
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13
Q

prevention of community acquired pneumonia

A

1) smoking cessation
2) immunisation (influenza, pneumococcal)

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14
Q

CAP: CURB-65: criteria

A

(each criteria 1 point)

1) new onset confusion
2) urea > 7 mmol/L
3) RR ≥ 30 breaths/min
4) BP (SBP > 90 or DBP ≤ 60)
5) age ≥ 65 yo

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15
Q

CAP: CURB-65: total score vs location of treatment

A
  • 0/1: outpatient
  • 2: inpatient
  • ≥ 3: inpatient (ICU)
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16
Q

classification of severe CAP

A

(≥ 1 major or ≥ 3 minor criterion)

major:
1) mechanical ventilation
2) septic shock requiring vasoactive medications to keep BP going

minor
1) RR ≥ 30 breaths/min
2) PaO2/FiO2 ≤ 250
3) multilobar infiltrates
4) confusion/disorientation
5) uraemia (urea > 7 mmol/L)
6) leukopenia (WBC < 4 x 10^9 /L)
7) hypothermia (< 36)
8) hypotension requiring aggressive fluid resuscitation -> vasopressors

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17
Q

types of pathogen causing outpatient CAP wo comorbidities

A

strep pneumoniae

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18
Q

empiric therapy for outpatient CAP wo comorbidities

A

1) beta lactam (amoxicillin)
2) respiratory fluoroquinolone

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19
Q

pathogen for outpatient CAP w comorbidities

A

1) Strep pneumoniae
2) haemophilus influenzae
3) atypical (mycoplasma, legionella, chlamydia)

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20
Q

empiric for outpatient CAP w comorbidities

A

1) beta lactam (augmentin) + macrolide (clarithro)
2) respi fluroquinolone

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21
Q

what are considered comorbidities for outpatient CAP

A

chronic heart/lung/liver/renal disease, DM, alcoholism, malignancy, asplenia

22
Q

type of pathogens for non severe inpatient CAP

A

1) strep pneumoniae
2) haemophilus influenzae
3) atypicals

23
Q

empiric therapy for non severe inpatient CAP

A

1) beta lactam (augmentin) + macrolide (clarithro)

2) respi fluroquinolone

24
Q

what are some MRSA risk factors CAP

A

1) respiratory isolation in MRSA in last 1 year
2) hospitalisation/parenteral Abx in past 90 days + MRSA PCR screen +ve (need to swab to see if colonised by MRSA)

25
Q

empiric therapy for non severe inpatient CAP w MRSA risk factor

A

add MRSA coverage to normal empiric
- IV vanco/linezolid

26
Q

pseudomonas risk factors for non severe inpatient CAP

A

respiratory isolation of pseudomonas in last 1 year

27
Q

empiric therapy for non severe inpatient CAP w pseudomonas risk

A

modify for pseudomonas coverage
- beta lactam: piperacillin/tazo or ceftazidime
- macrolide: levofloxacin

28
Q

for non severe inpatient CAP

A
  • start IV then step down to PO
  • test for influenza during season
29
Q

possible pathogen for severe inpatient CAP

A
  • all non severe
  • staph aureus
  • other gram -ve (klebsiella pneumoniae, burkholderia pseudomallei)
30
Q

burkholderia pseudomallei (severe inpatient CAP)

A
  • tropical countries
  • gram -ve rod found in soil (moist)
31
Q

empiric therapy for severe inpatient CAP

A

1) beta lactam (augmentin) + ceftazidime + macrolide (clarithromycin)

2) respiratory fluoroquinolone + ceftazidime

32
Q

empiric therapy for severe inpatient CAP w MRSA risk factors

A

normal empiric + MRSA coverage (IV vanco)

33
Q

pseudomonas risk factor for severe inpatient CAP

A
  • respiratory isolation of pseudomonas in last 1 year
  • hospitalisation/IV Abx use in last 90 days
34
Q

empiric therapy for severe inpatient CAP w pseudomonas risk

A

same as normal empiric for wo pseudomonas risk but already covered (ceftazidime, levoflox)

35
Q

anaerobic cover for CAP

A
  • if radiology report lung abscess/emphysema
  • add IV/PO metronidazole
36
Q

influenza management for CAP

A
  • add empiric oseltamivir to Abx regimen ASAP if suspected
  • +ve influenza PCR
    **5 day course
    ** discontinue Abx at 48-72 hr if X evidence of bacterial pathogen
37
Q

why respiratory fluoroquinolone X used as first line for CAP

A

1) increase AE

  • tendonitis, tendon rupture, neuropathy, QTc prolongation, CNS disturbances, hypoglycaemia

2) development of resistance w overuse
3) preserve activity for other gram -ve infection
4) delay diagnosis of tb
5) undesirable monotherapy if tb

38
Q

adjunctive corticosteroid therapy for CAP

A
  • reduce inflammation in lung
  • only if septic shock refractory to fluid resuscitation & vasopressor support
39
Q

when to de-escalate from IV to PO treatment for CAP

A

1) haemodynamically stable
2) improve clinically
3) can tolerate oral meds

40
Q

how to de-escalate from IV to PO

A

1) +ve culture

  • use AST to guide narrow spectrum

2) -ve culture

  • stop empiric for MRSA/pseudomonas/burkholderia pseudomallei after 48 hrs if pathogen X isolated & improving
  • same Abx from IV to PO or from same class
41
Q

what is nosocomial pneumonia

A

hospital acquired + ventilator associated

42
Q

definition for hospital acquired pneumonia (HAP)

A

onset ≥ 48 hrs after hospital admission

43
Q

definition for ventilator associated pneumonia (VAP)

A

onset ≥ 48 hrs after mechanical ventilation

44
Q

risk factors for nosocomial pneumonia

A

1) pt related

  • elderly
  • smoking, COPD, cancer, immunosuppresion
  • prolonged hospi, coma, impaired consciousness
  • malnutrition

2) infection control

  • X hand hygiene
  • contaminated respi care devices

3) healthcare related

  • prior Abx use (normal flora alr affected)
  • impaired deep breath & exhale (sedative, opioid analgesics, mechanical ventilation, supine position)
45
Q

prevention of nosocomial pneumonia

A
  • consistent hand hygiene
  • judicious Abx use & meds w sedative effect
  • VAP specific
    ** limit duration of mechanical ventilation
    ** minimise duration & deep levels of sedation
    ** elevate head of bed by 30%
46
Q

types of pathogen for nosocomial pneumonia

A

1) non-fermenting gram neg: pseudomonas, acinetobacter

2) enteric gram neg: enterbacter spp, klebsiella spp, e.coli

3) staph aureus

47
Q

when to cover MRSA for nosocomial pneumonia

A
  • prior IV Abx use within 90 days
  • hospitalisation in unit where > 90% staph aureus MRSA
48
Q

how many antipseudomonals for pseudomonas & GNR for nosocomial pnuemonia

A
  • normally 1 antipseudomonal (X aminoglycoside)
49
Q

when to use double pseudomonal for nosocomial pneumonia

A

1) Risk factor for antimicrobial resistance

  • prior IV Abx use within 90 days
  • acute renal replacement therapy prior to VAP onset
  • isolation of pseudomonas in last 1 year

2) hospitalisation in unit where > 10% pseudomonas isolate resistant to agent considered for monotherapy
3) prevalence of pseudomonas X known

50
Q

nosocomial pneumonia pathogen vs empiric

A

1) pseudomonas, other GNR (enterobacter spp, klebsiella spp, e coli)

  • antipseudomonal beta lactam (pip/tazo)
  • +/- antipseudomonal fluoroquinolone (levo, avoid if X MRSA cover)

2) MRSA

  • IV vanco
51
Q

nosocomial when to de-escalate/change from IV to oral

A

1) haemodynamic stability
2) improve clinically
3) able to ingest oral

52
Q

nosocomial how to de-escalate/change from IV to oral

A

1) +ve culture

  • use AST to guide culture-directed narrow spectrum
  • double to single antipseudomonal

2) -ve culture

  • maintain coverage according to local antibiogram
  • X possible if significant for MDRO
  • PO if tolerate.

finals y3s1 (10 decks)

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