LRTI Flashcards
Lower Respiratory Tract Infections
What is the difference between CAP and HAP/VAP?
- CAP is pneumonia that developed outside the hospital or < 48 hours after admission
- HAP is pneumonia that developed > 48 hours after hospital admission
- VAP is pneumonia that developed > 48 hours after endotracheal intubation
Which microorganism class is the most common pathogenic organism for CAP?
virus
What are the most common bacterial pathogens for CAP?
- streptococcus pneumonia (GP)
- haeomophilus influenza (GN)
- mycoplasma pneumoniae (atyp)
- legionella pneumophila (atyp)
What are the risk factors for MRSA?
- 2-14 days post-influenza
- previous MRSA infection/isolation
- previous hospitalization and use of IV abx w/in the last 90 days
What is the significance of getting a MRSA nasal PCR?
- The results can confirm that the patient does NOT have MRSA
- This would allow us to d/c abx that were only be using to cover MRSA
Which pathogens are commonly seen in patients with recent antibiotic exposure?
- staphylococcus aureus
- pseudomonas aeruginosa
What would dense lobar consolidation or infiltrates suggest on a chest X-ray?
bacterial origin
What would patchy, diffuse, interstitial infiltrates suggest on a chest X-ray?
atypical or viral pathogens
What are the major criteria for severe CAP?
If patients present with one of these, then they have severe CAP
- septic shock requiring vasopressors
- respiratory failure requiring mechanical ventilation
What are the minor criteria for severe CAP?
If a patient presents with at least 3 of these, then they have severe CAP.
- Confusion/disorientation
- Respiratory rate > 30
- Uremia (BUN > 20 mg/dL)
- Multilobar infiltrates
- Platelets <100,000 (thrombocytopenia)
- Pao2/Flo2 <250 (rare)
- Hypothermia (<36 C)
- hypotension requiring fluids
- leukopenia (WBC < 4,000 cells/uL)
CRUMPPHHL
What are the empiric therapy options to treat CAP for a healthy outpatient adult w/o comorbidities or risk factors for abx resistance?
- amoxicillin 1 gm PO Q8H
- doxycycline 100 mg PO BID
If macrolide resistance is < 25%, then azithromycin could be used. Macrolide resistance is too high most of the time.
What are the empiric therapy options to treat CAP for an outpatient adult with comorbidities?
- monotherapy: levofloxacin 750 mg PO QD
- monotherapy: moxifloxacin 400 mg PO QD
- combo: B-lactam + macrolide
- combo : B-lactam + doxycycline
B-lactam options:
- amox/clav
- cefpodoxime
- cefuroxime
What are the risk factors for pseudomonas aeruginosa?
- previous p. aeruginosa respiratory infection
- previous hospitalization and use of IV abx w/in the last 90 days
- structural lung disease
Structural lung disease includes cystic fibrosis and bronchiectasis
What are the empiric therapy treatment options for inpatient non-severe CAP?
no MRSA/Pseudomonas aeruginosa risk factors
- monotherapy: levofloxacin
- monotherapy: moxifloxacin
- combo therapy: B-lactam + macrolide
B-lactam options:
- ampicillin/sulbactam
- ceftriaxone
- May use doxycycline if FQ or macrolides are contraindicated
What are the empiric therapy treatment options for inpatient severe CAP?
no MRSA/pseudomonas aeruginosa risk factors present
- combo therapy: B-lactam + macrolide
- combo therapy: FQ + B-lactam
- FQs: levo or moxi
- B-lactams: ampicillin/sulbactam or ceftriaxone
- Doxy may be used if FQ or macrolide is contraindicated
Which drugs can be added on for the treatment of CAP in the inpatient setting if MRSA risk factors are present?
Risk factors include:
- 2-14 days post influenza
- previous MRSA respiratory infection/isolation
- previous hospitalization and use of IV abx w/in the last 90 days
- vancomycin
- linezolid
Which drugs can be added on for treatment of CAP in the inpatient setting if risk factors for pseudomonas aeruginosa are present?
Risk factors:
- previous pseudomonas aeruginosa respiratory infection
- previous hospitalization and use of IV abx w/in the last 90 days
- piperacillin/tazobactam
- cefepime
- meropenem
What are the preferred therapy options for streptococcus pneumoniae that’s penicillin-susceptible (MIC < 2)?
- PenG
- Amoxicillin
What are the preferred therapy options for streptococcus pneumoniae that’s pcn-resistant (MIC > 2)?
- ceftriaxone
- levofloxacin, moxifloxacin
What are the preferred therapy options for MSSA?
- cefazolin
- nafcillin
What are the preferred therapy options for MRSA?
- vancomycin
- linezolid
When is the use of corticosteroids recommended for CAP?
- only recommended with Surviving Sepsis Guidelines when patient has CAP and septic shock
What is the minimum duration of CAP therapy?
5 days
What are the common pathogens for HAP/VAP?
- pseudomonas aeruginosa
- acinetobacter baumannii
- staphylococcus aureus
What are the empiric therapy options for a patient who has HAP, but is not at high risk for mortality?
Goal is to provide coverage for MSSA + p. aeruginosa
- piperacillin-tazobactam
- cefepime
- imipenem
- meropenem
- levofloxacin
What are the empiric therapy options for a patient with HAP that does not have a high risk for mortality, but has MRSA risk?
- piperacillin-tazobactam, cefepime, imipenem, meropenem, or levofloxacin
PLUS - vancomycin or linezolid
What are the empiric therapy options for a patient with HAP and has a high risk for mortality along with MRSA risk?
Goal is to provide coverage for MRSA + MDR p. aeruginosa
- pick a B-lactam and a non-B-lactam IN ADDITION to vancomycin or linezolid
- pip-taz
- cefepime
- imipenem
- meropenem
- levofloxacin
- tobramycin or amikacin
Same options for VAP
What is the duration for HAP/VAP therapy?
7 days
What is the duration of CAP therapy?
minimum of 5 days
