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PR3151_Pharmacotherapeutics > LRTI - Acute Bronchitis and Pneumonia > Flashcards

LRTI - Acute Bronchitis and Pneumonia Flashcards

1
Q

Describe the clinical presentation of acute bronchitis

A

Acute cough of less than or equals to 3 weeks
- Happens due to inflammation of the lower airways

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2
Q

Is a bacterial culture needed for acute bronchitis?

A

No. Acute bronchitis is usually self limiting. Only needed if there are complications of bacterial infection suspected

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3
Q

Describe the pathogenesis of pneumonia

A

Exposure to particles happen due to inhalation, aspiration or hematogenous secretions from bacteremia.

Pathogen then enters susceptible host and virulent pathogen

Proliferation of microbe in lower airway/ alveoli then causes pneumonia

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4
Q

What are the risk factors and how are they associated with pneumonia?

A

Smoking: suppress neutrophil function and damage the lung epithelium

Chronic lung conditions such as COPD, Asthma and lung cancer. Destroys lung tissue and offer pathogen routes for infection

Immune suppression from HIV, sepsis, glucocorticoid use and chemotherapy

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5
Q

What are the general systemic presentations of pneumonia?

A

Fever and chills
Malaise
Change in mental status (elderly)
Tachycardia
Hypotension

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6
Q

What are the localised symptoms of those with pneumonia?

A

Cough
Shortness of breath
Chest pain
Tachypnoea
Hypoxia
Increased sputum production

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7
Q

What are some diagnostic tools to consider to help us confirm the presence of infection?

A

Radiological findings: Chest xray, lung CT and lung ultrasonography
- Findings include new infiltrates / dense consolidates

Lab findings: general and non-specific

Urinary antigen tests: detect S.pneumoniae and legionella pneumophilla only

Respiratory, gram stain and culture

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8
Q

Which subgroup is suitable for conducting pre-treatment blood and respiratory gram stain and cultures?

A

Severe CAP

Those with risk factors of drug resistent pathogens
- Being empirically treated for MRSA / P.Aeruginosa
- Previously infected with MRSA / P.Aeruginosa in a year
- Hospitalized / received parenteral antibiotics in last 90 days

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9
Q

Define the three types of pneumonia

A

Community acquired pneumonia: Onset in community / <48h upon hospital admission

Healthcare associated pneumonia: Onset > 48h after hospital admission

Ventilator associated pneumonia: Onset >48h after mechanical ventilation

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10
Q

What are the types of pathogen in outpatient and inpatient (non severe) cases of community acquired pneumonia?

A

S.Pneumoniae
H.Influenzae
Atypical organisms: Mycoplasma pneumoniae, chlamydia pneumoniae and legionella pneumoniae

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11
Q

What are the types of pathogen in inpatient (severe) cases of community acquired pneumonia?

A

S.Pneumoniae
H.Influenzae
Atypical organisms: Mycoplasma pneumoniae, chlamydia pneumoniae and legionella pneumoniae

S.Aureus
Gram negative bacilli: Klebsiella pneumoniae, burkholderia pseudomallei

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12
Q

Why is it important for risk stratification of CAP?

A

Determines the
- Location of treatment
- Organism
- Type of empiric antibiotics
- Route of administration

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13
Q

How is risk stratification of CAP decided?

A

Pneumonia severity index (PSI)

CURB-65

IDSA/ATS criteria

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14
Q

How is PSI scoring used to
stratify patients?

A

Class I and II (0-70): Outpatients

Class III (71-90): Short hospitalization / observations

Class IV / V (91 and above): Inpatient

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15
Q

How is CURB-65 used to stratify patients?

A

0-1: Outpatient
2: Inpatient
>3: Inpatient and severe (i.e. consider ICU)

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16
Q

How is the IDSA/ATS criteria used to determine severe CAP?

A

It is severe CAP if more than 1 major criteria or more than 3 minor criterias are achieved

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17
Q

What are the major and minor criteria of IDSA/ATS criteria?

A

Major: mechanical ventilation, septic shock requiring vasoactive medications

Minor: RR> 30 bpm, PaO2/FiO2 < 250, multilobar infiltrates, confusion, uremia, leukopenia, hypothermia, hypotension requiring aggressive fluid resuscitation

18
Q

How is an antibiotic chosen?

A

Risk stratification
Any comorbidities
MRSA/ P.Aeruginosa risk factors

19
Q

What is the empiric therapy for outpatients with no comorbidities? What is the pathogen of concern?

A

PO Amoxicillin 1g q8h
- Pathogen: S.Pneumoniae

If allergic, take levofloxacin / moxifloxacin

20
Q

What is the empiric therapy for outpatients with comorbidities? What is the pathogen of concern?

A

PO Amoxicillin clavulanate / cefuroxime + clarithromycin/azithromycin/doxycycline
- Pathogen: S.Pneumoniae, H.Influenzae, Atypical microorganisms

If allergic take levofloxacin / moxifloxacin

21
Q

What are some of the possible MDRO risk factors to consider for patients with CAP ?

A

MRSA
- Resp isolation of MRSA in last 1 year
- Hospitalization/ parenteral antibiotics in last 90 days + MRSA PCR positive

Pseudomonas aeruginosa
- Resp isolation of P.Aeruginosa in last 1 year

22
Q

What empiric antibiotics to consider adding for those with Pseudomonas and MRSA risk factors?

A

MRSA: IV Vancomycin/ PO Linezolid

Pseudomonas Aeruginosa:
- Piperacillin tazobactam
- Cefepime
-Meropenem
- Levofloxacin

23
Q

What is the empiric therapy for inpatients non severe CAP? What is the pathogen of concern?

A

PO Amoxicillin clavulanate / cefuroxime + clarithromycin/azithromycin/doxycycline
- Pathogen: S.Pneumoniae, H.Influenzae, Atypical microorganisms

If allergic take levofloxacin / moxifloxacin

24
Q

Why are respiratory fluoroquinolones generally not recommended?

A

Increase adverse effects

Development of resistance

Preserve activity for other gram-negative infections

Delay diagnosis of tuberculosis

25
Q

What is the empiric therapy for inpatients severe CAP? What is the pathogen of concern?

A

Amoxicillin clavulanate / Penicillin G + Ceftazidime + Clarithromycin / Azithromycin

Alternative: Levofloxacin / Moxifloxacin + Ceftazidime

Pathogens: S.Pneumoniae, H.Influenzae, Atypicals, S.Aureus, Burkholderia pseudomallei

26
Q

Is there a need for P.Aeruginosa coverage for inpatient and severe cases?

A

Not really as current regimen already covers Pseudomonas aeruginosa

27
Q

What are some special considerations to consider with regards to empiric therapy?

A

Anaerobic coverage

Additional influenza management

Adjunctive corticosteroid therapy

28
Q

What are the indications of anaerobic coverage?

A

Lung abscess and emphysema

Current regimen already cover amoxicillin clavulanate and ceftazidime

If regimens do not cover clarithromycin metronidazole

29
Q

What is the influenza management for current treatment regimens?

A

Providing influenza management which is best within 48h, up to 5 days.

Consider discontinuing antibiotics at 48-72 hours if no evidence of bacterial pathogen

30
Q

What are the indications for adjunctive corticosteroid therapy?

A

Shock refractory to fluid resuscitation

Vasopressor support

31
Q

When should deescalation of therapy?

A

Hemodynamically stable
- resolution of vital signs abnormalities
- baseline mental status

Improving clinically

Able to ingest oral

32
Q

What is the ideal duration of therapy?

A

5 - 7 days (longer if suspected MRSA/ P.Aeruginosa)

33
Q

When should longer courses of antibiotics be considered?

A

CAP complicated with deep-seated infections

Infection with other less common pathogen

34
Q

How should monitoring of response be done for CAP?

A

Clinical stability in first 48-72 hours

No need microbiological test clearance

Advice ADR of antibiotics

35
Q

What are the risk factors of HAP/ VAP?

A

Patient factors: elderly, smoking, COPD, cancer, immunosuppression, prolonged hospitalization, coma, impaired consciousness and malnutrition

Infection control related: lack of hand hygiene compliance, contaminated respiratory care devices

Healthcare related: Prior antibiotic use, sedative, opioid analgesics, mechanical ventilation and supine position

36
Q

What are some preventive techniques to counter HAP/ VAP?

A

Practise consistent hand hygiene

Use of antibiotics and medications with sedative effects

Limit duration of mechanical ventilation and deep levels of sedation

Elevate head of bed by 30 deg

37
Q

How are the pathogens for HAP/VAP identified? What pathogens need to be covered for HAP/ VAP?

A

Each hospital have different microbiota

Coverage should be done for Pseudomonas aeruginosa and S.Aureus

38
Q

When should I consider for double antipseudomonal therapy in HAP/ VAP?

A

Prior IV antibiotics use in last 90 days

Isolation of MRSA in last 1 year

Hospitalization in unit where >20% S.Aureus are MRSA

Prevalence of MRSA in hospitals not known but patient at high risk of mortality

39
Q

What are some anti-pseudomonal beta lactams?

A

Piperacillin tazobactam
Cefepime
Ceftazidime (Avoid if no MRSA risk)
Meropenem
Imipenem

40
Q

What are the anti-pseudomonal fluoroquinolones to consider for double antipsuedomonal therapy?

A

Levofloxacin
Ciprofloxacin

PR3151_Pharmacotherapeutics (9 decks)

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