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Antibiotics > LRTI > Flashcards

LRTI Flashcards

1
Q

Symptoms of acute bronchitis?

A

Acute cough <3w

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2
Q

Should antibiotics be used for treatment of bronchitis?

A

No

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3
Q

What is pneumonia?

A

Infection of lung parenchyma, affects alveolar level

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4
Q

How can bacteria enter the lower respiratory tract to cause pneumonia?

A
  • aspiration of oropharyngeal secretion
  • inhalation of aerosols
  • bacteremia from extra-pulmonary sources
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5
Q

Risk factors of pneumonia?

A
  • smoking: suppress neutrophil function & damage lung epithelium
  • chronic lung conditions: COPD, asthma, lung cancer
  • immunosuppression: e.g. HIV, chemotherapy, steroids
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6
Q

What radiographic tests can be done to diagnose pneumonia? What would be seen in pneumonia?

A

Chest X-ray, lung CT, lung ultrasonography

New infiltrates or dense consolidations (unilateral white patches)

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7
Q

What lab test is recommended for severe CAP or hospitalised patients? What is its limitation?

A

Urinary antigen tests for strep pneumo, legionella

Limitation: remains +ve for days-weeks despite abx tx

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8
Q

What sample should be collected for gram-stain and culture?

A

Respiratory gram-stain and culture
- sputum (but usually contaminated by oropharyngeal secretions)
- lower respiratory tract samples (invasive sampling)

Blood cultures: rule out bacteraemia

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9
Q

When should samples be collected for gram-stain and cultures?

A

Hospitalised:
- severe CAP
- risk factors for drug-resistant pathogens (MRSA, pseudomonas) -> empirically treated for pathogens, prev infected with pathogens in last 1y, hospitalised or received parenteral abx in last 90 days

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10
Q

What are the classifications of pneumonia?

A
  • Community-acquired pneumonia (CAP): onset in community or <48h after hospital admission
  • Hospital-acquired pneumonia (HAP): onset ≥48h after hospital admission
  • Ventilator-associated pneumonia (VAP): onset ≥48h after mechanical ventilation
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11
Q

How to prevent CAP?

A
  • smoking cessation
  • immunisations (influenza, pneumococcal)
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12
Q

What are the common pathogens that cause CAP (outpatient, inpatient non-severe)?

A
  • strep pneumo
  • H influenzae
  • atypicals (e.g. mycoplasma pneumo, chlamydophila pneumo, legionella)
  • inpatient: includes MRSA & pseudomonas based on risk factors
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13
Q

What are the common pathogens that cause CAP (inpatient severe)?

A
  • strep pneumo
  • H influenzae
  • atypicals (e.g. mycoplasma pneumo, chlamoydophila pneumo, legionella)
  • MRSA & pseudomonas based on risk factors
  • staph aureus
  • gram -ve: Klebsiella, burkholderia pseudomallei
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14
Q

For inpatients with suspected pneumonia, what else should they be tested for?

A

Influenza during circulating seasons

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15
Q

Risk stratification for CAP?

A
  • pneumonia severity index (PSI)
  • CURB-65
  • major and minor (IDSA)
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16
Q

What is CURB-65?

A

1 point each:
- confusion (new onset)
- urea > 7mmol/L
- RR ≥30
- BP < 90/60
- ≥65y
[0-1: outpatient; 2: inpatient; ≥3: inpatient, ICU]

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17
Q

What are the major and minor criterias for CAP? What would be considered severe CAP?

A

Major:
- mechanical ventilation
- septic shock requiring vasoactive meds

Minor
- RR ≥30
- PaO2 / FiO2 ≤250
- multi lobar infiltrations
- confusion / disorientation
- urea > 7mmol/L
- WBC < 4 x 10^9
- < 36C temp
- hypotension requiring aggressive fluid resuscitation

Severe CAP: ≥1 major criteria OR ≥3 minor criteria

18
Q

Empiric treatment for pneumonia outpatient, no comorbidities? Target what organism?

A

Target: strep pneumo

Either one:
- PO amoxicillin (high dose)
- PO levofloxacin/moxifloxacin

19
Q

Empiric treatment for CAP outpatient, with comorbidities? Target what organism?

A

Target: strep pneumo, H influenzae, atypicals

Either one:
- PO augmentin/cefuroxime + PO clarithromycin/azithromycin/doxycycline
- PO levofloxacin/moxifloxacin

20
Q

Empiric treatment for CAP inpatient, non-severe? Target what organism?

A

Target: strep pneumo, H influenzae, atypicals + MRSA/pseudomonas if have risk factors

Either one:
- IV augmentin/cefuroxime/ceftriaxone + IV clarithromycin/azithromycin/doxycycline (PO)
- IV levofloxacin/moxifloxacin

If MRSA:
- IV vancomycin OR linezolid
- risk factors: resp isolation of MRSA in last 1y, hospitalisation/parenteral abx in last 90 days + MRSA PCR screen +ve

If pseudomonas:
- modify regimen to include pseudomonas coverage: pip-taco, ceftazidime, cefepime, meropenem, levofloxacin
- risk factors: resp isolation of pseudomonas in last 1y

21
Q

Empiric treatment for CAP inpatient, severe? Target what organism?

A

Target: strep pneumo, H influenzae, atypicals, S aureus, gram -ve (Klebsiella, Burkholderia pseudomallei) + MRSA/pseudomonas if have risk factors

Either one:
- IV augmentin/penicillin G + IV clarithromycin/azithromycin + IV ceftazidime
- IV levofloxacin/moxifloxacin + IV ceftazidime

If MRSA:
- IV vancomycin OR linezolid
- risk factors: resp isolation of MRSA in last 1y, hospitalisation/parenteral abx in last 90 days

If pseudomonas:
- regimen already covers (ceftazidime)
- risk factors: resp isolation of pseudomonas in last 1y, hospitalisation/parenteral abx in last 90 days

22
Q

What covers Burkholderia pseudomallei?

A

Ceftazidime

23
Q

Can you double cover bacteria?

A

No -> double check regimen if there is double coverage!!

24
Q

When to include anaerobic coverage for CAP?

A

Lung abscess or empyema in radiology investigations

25
Q

What to add for anaerobic coverage if no anaerobic coverage in regimen?

A

Metronidazole, clindamycin

26
Q

If suspect influenza, what to add?

A

Oseltamivir within 48h of onset, up to 5 days

27
Q

For CAP, if no positive cultures and patient improving, what to do with abx?

A

Stop empiric cover for MRSA, pseudomonas and burkholderia pseudomallei in 48h

For the other abx, convert to PO (of same class if no PO form)

28
Q

Treatment duration of CAP?

A

5 days (7 days if suspect MRSA or pseudomonas)

29
Q

Should abx therapy be escalated in the first 72h?

A

No, unless culture-directed or significant clinical deterioration

30
Q

Need to repeat radiographic investigations?

A

No need if patient improves clinically, need if clinical deterioration

31
Q

How to prevent HAP/VAP?

A
  • Hand hygiene
  • VAP: limit duration of mechanical ventilation, minimise duration & deep levels of sedation, elevate head of bed by 30 degrees
32
Q

What to cover for HAP/VAP?

A
  • pseudomonas
  • S aureus
    + MRSA
    + gram -ve (E coli, Enterobacter, Klebsiella)
33
Q

When to cover MRSA for HAP/VAP?

A
  • prior IV abx use within 90D
  • isolation of MRSA in last 1y
  • hospitalisation in a unit where >20% of S aureus is MRSA
  • prevalence of MRSA In hospital is not known but pt is at high risk for mortality (need ventilatory support due to HAP & septic shock)
34
Q

Empiric treatment for HAP/VAP?

A
  • antipseudomonal beta lactam (pip-tazo, cefepime, ceftazidime, meropenem, imipenem)
  • antipseudomonal FQ (levofloxacin, ciprofloxacin)
  • aminoglycoside (amikacin, gentamicin)

+ MRSA if have risk factor: vancomycin, linezolid

double antipseudomonal agents if have risk factors

35
Q

When to use 2 antipseudomonal abx from diff classes?

A
  • risk factor for antimicrobial resistance (prior IV use within 90D, acute renal replacement therapy prior to VAP onset, isolation of Pseudomonas in last 1y)
  • hospitalisation in a unit where >10% pseudomonas isolates are resistant to an agent being considered for monotherapy
  • prevalence of pseudomonas is unknown but pt is at high risk for mortality (need for ventilatory support due to HAP & septic shock)
36
Q

Can use aminoglycosides as sole antipseudomonal agent for HAP/VAP?

A

No

37
Q

Why avoid ceftazidime and ciprofloxacin for pseudomonas cover in HAP/VAP if MRSA cover is omitted?

A

No gram +ve cover (MSSA)

38
Q

For HAP/VAP, if have positive culture for pseudomonas, what to de-escalate to?

A

One anti-pseudomonal agent that bacteria is susceptible to

39
Q

For HAP/VAP, if no positive cultures, what to de-escalate to?

A

Maintain coverage according to local HAP/VAP antibiogram

40
Q

Duration of treatment for HAP/VAP?

A

7 days

Antibiotics (11 decks)

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