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PR3151 Finals > LRTI (Bronchitis & CAP) > Flashcards

LRTI (Bronchitis & CAP) Flashcards

1
Q

What are the 2 types of LRTIs?

A

Acute bronchitis and Pneumonia

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2
Q

Define acute bronchitis

A

Acute cough < 3w due to inflammation of trachea and lower airways

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3
Q

How does acute bronchitis generally start? (viral/ bacterial)?

Is it self-limiting? How long does it usually last for?

A

> 92% of cases are viral

Self-limiting, lasts up to 1-3w, giving symptomatic relief is enough

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4
Q

Do we use abx for acute bronchitis?

A

No

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5
Q

When should pt with acute bronchitis see a doctor?

A

Pt should see a doctor if they develop:
- Fever
- SOB
- Chest pain
- Cough ↑ in extent or frequency/ cough persists beyond 3w

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6
Q

Is pneumonia typically a viral or bacterial infection?

A

Normally a bacterial infection

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7
Q

What are the risk factors for pneumonia? (4)

A
  • Smoking
  • Chronic lung conditions (eg COPD, asthma, lung cancer)
  • Immune suppression (eg HIV, sepsis, glucocorticoids, chemotherapy)
  • Exposure to pathogen via inhalation, aspiration, contiguous or haematological mechanism
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8
Q

Systemic and localised s/sx of pneumonia?

What is a s/sx that the elderly may experience?

A

Systemic s/sx:
- Fever
- Chills
- Malaise
- Mental status changes* (elderly)
- Tachycardia
- Hypotension

Localised s/sx:
- Cough
- Chest pains
- SOB
- Tachypnoea
- Hypoxia
- Increased sputum production

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9
Q

What results of a physical examination will result in the diagnosis of pneumonia? (2)

A
  • Diminished breath sounds over affected area
  • Inspiratory crackles during lung expansion
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10
Q

What type of test is NEEDED for diagnosis of pneumonia?

What are the findings of the test that are indicative of pneumonia?

A

CXR/ lung CT/ lung ultrasonography

Diagnosis of pneumonia requires evidence of NEW infiltrates or dense consolidations

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11
Q

What are the laboratory findings for pneumonia? (non-specific signs of systemic infection)

A

Signs of systemic infection (non-specific to pneumonia):
- WBC (normal: 4-10 x 109/L)
- C-reactive protein (infection > 40mg/L)
- Procalcitonin ≥ 0.25μg/L

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12
Q

On which type of pts do we perform urinary antigen tests?

What bacterial pathogens does it test for?

Limitations of urinary antigen tests?

A

Recommended for severe CAP or hospitalised pts

Streptococcus pneumonia
Legionella pneumophila

Limitation: may just indicate exposure to respective pathogens & remains +ve for days - weeks despite abx Tx

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13
Q

What are the different types of respiratory gram-stain and cultures that we can do for pneumonia? (3)

Comment on each of them

A
  1. Sputum
    - Low yield
    - Contamination by oropharyngeal secretions
  2. Lower respiratory tract samples
    - Invasive sampling
    - Less contamination
  3. Blood cultures
    - To rule out bacteremia
    - Esp done for hospitalised pts
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14
Q

What are the 2 types of pts we should obtain pre-treatment blood and respiratory gram-stain and cultures for pneumonia?

A

Pts managed in the hospital who are:
- Classified as severe CAP
- Have risk factors for drug-resistant pathogens like MRSA and P. aeruginosa

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15
Q

What are the risk factors for drug-resistant pathogens like MRSA and P. aeruginosa

A
  • Empirically treated for MRSA or P. aeruginosa
  • Previously infected with MRSA or P. aeruginosa in last 1 year
  • Hospitalised or received parenteral abx in last 90 days (weak, low quality of evidence)
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16
Q

Define CAP

A

Onset in community or < 48h after hospital admission

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17
Q

What are the risk factors of CAP? (4)

A
  • History of pneumonia
  • Smoking
  • Chronic respiratory diseases
  • Immunosuppression
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18
Q

Prevention of CAP? (2)

A
  • Smoking cessation
  • Immunisations (influenza, pneumococcal)
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19
Q

List the CURB-65 criterions (5- 1 point each)

A
  1. New onset confusion
  2. Urea > 7 mmol/L
  3. RR ≥ 30 breaths/min
  4. Blood pressure (SBP < 90 mmHg or DBP ≤ 60 mmHg)
  5. Age ≥ 65 y/o
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20
Q

What are the scores for CURB-65? (which scores mean outpatient, inpatient etc)

A

Score: 0 or 1 → outpatient
Score: 2 → inpatient
Score: ≥ 3 → inpatient, consider ICU

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21
Q

Other than CURB-65, what is another risk stratification guideline that is more preferred to categorise pts into outpatient/ inpatient?

Name the different classes and what they mean

A

Pneumonia Severity Index (PSI)

Class I and II: outpatient
Class III: short hospitalisation or observation (can be managed as outpatient)
Class IV and V: inpatients

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22
Q

What is the risk stratification method for severe CAP? (2 major and 8 minor criteria)

How many major or minor criterias are needed for diagnosis of severe CAP?

A

Major criteria:
- Mechanical ventilation
- Septic shock requiring vasoactive medications

Minor criteria:
- RR ≥ 30 breaths/min
- PaO2/ FiO2 ≤ 250
- Multilobar infiltrates
- Confusion/ disorientation (esp elderly)
- Uremia (urea > 7 mmol/L)
- Leukopenia (WBC < 4 x 109/L)
- Hypothermia (temp < 36°C)
- Hypotension requiring aggressive fluid resuscitation

Severe CAP: ≥ 1 major criterion or ≥ 3 minor criteria

23
Q

Key pathogens for outpatient CAP, no co-morbidities? (1)

A

Streptococcus pneumoniae

24
Q

Do we give IV or PO abx for outpatient CAP (non-severe and severe?)

A

Give PO

25
Q

Empiric regimen for outpatient CAP, no co-morbidities?

A

β-lactam:
- PO amoxicillin 1g tds

OR

Respiratory FQ (if penicillin allergy):
- PO levofloxacin 750mg od
- PO moxifloxacin

26
Q

What are the type of co-morbidities that CAP outpatients may have which warrants greater abx coverage and Tx?

A
  • Chronic heart, lung, liver, renal disease
  • DM
  • Alcoholism
  • Malignancy
  • Asplenia
27
Q

What pathogens must we cover for outpatient CAP with comorbidities (chronic heart, lung, liver, renal disease, DM, alcoholism, malignancy, asplenia)? (3 types)

A
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Atypicals (Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella pneumophila)
28
Q

Empiric regimen for outpatient CAP, with co-morbidities?

What ADRs must you take note of for doxycycline?

A

β-lactam:
- PO amoxicillin-clavulanate 625mg tds
- PO cefuroxime 500mg bd
PLUS
Macrolide or Tetracycline:
- PO clarithromycin 500mg bd
- PO azithromycin 500mg od
- PO doxycycline 100mg bd (ADRs: esophagitis (concerning, make sure pt can stay upright and drink a lot of water to flush down drug), photosensitivity)

OR

Respiratory FQ:
- PO levofloxacin 750mg od
- PO moxifloxacin

29
Q

Key pathogens for CAP inpatient, non-severe? (3)

Without MRSA or P. aeruginosa risk factors yet

A
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Atypicals (Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella pneumophila)
30
Q

Do we give PO or IV for CAP inpatient, non-severe?

A

Can initiate IV, step down to PO later

May also give PO if pt well

31
Q

Tx for CAP inpatient, non-severe?

Without MRSA or P. aeruginosa risk factors yet

What must you take note of for doxycycline?

A

β-lactam:
- IV amoxicillin-clavulanate 1.2g tds
- IV cefuroxime 500mg bd
- IV ceftriaxone 1-2g od
PLUS
Macrolide or Tetracycline:
- IV clarithromycin 500mg bd
- IV azithromycin 500mg od
- PO Doxycycline 100mg bd (ADRs: esophagitis (concerning, make sure pt can stay upright and drink a lot of water to flush down drug), photosensitivity)

OR

Respiratory FQ:
- IV levofloxacin 750mg od
- IV moxifloxacin

32
Q

What are the MRSA risk factors to consider for CAP inpatient non-severe? (2)

How is it different from CAP inpatient severe?

A

MRSA risk factors:
1. Resp isolation of MRSA in last 1 year
2. Hospitalisation or parenteral abx use in last 90 days PLUS MRSA PCR screen +ve

Different regarding factor no. 2: inpatient non-severe need the additional MRSA PCR screen +ve test but inpatient severe don’t need

33
Q

For inpatient CAP non-severe, Tx for additional MRSA coverage?

A

Add on:
- IV vancomycin 25-30mg/kg loading dose, 15mg/kg bd-tds
- IV/PO linezolid 600mg bd

34
Q

What are the P. aeruginosa risk factors to consider for CAP inpatient non-severe? (1)

A

P. aeruginosa risk factors:
Resp isolation of P. aeruginosa in last 1 year

35
Q

For inpatient CAP non-severe, Tx for additional P. aeruginosa coverage?

A

Modify regimen to include P. aeru coverage:
- Piperacillin-tazobactam
- Ceftazidime
- Cefepime
- Meropenem
- Levofloxacin

36
Q

Key pathogens for CAP inpatient severe?

A

All of outpatient:
- Streptococcus pneumoniae
- Haemophilus influenzae
- Atypicals (Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella pneumophila)

AND

  • Staphylococcus aureus
  • Other gram -ve (Klebsiella pneumonia, Burkholderia pseudomallei*)
37
Q

Do we give PO or IV for CAP inpatient, severe?

A
  • Initiate IV, step down to PO later
  • May give PO if pt well
38
Q

Tx for CAP inpatient severe?

Without MRSA or P. aeruginosa risk factors yet

A
  1. β-lactam:
    - IV amoxicillin-clavulanate 1.2g tds
    - Penicillin G
    PLUS
    - IV ceftazidime 2g tds (covers burkholderia)
    PLUS
    Macrolide:
    - IV clarithromycin 500mg bd
    - IV azithromycin 500mg od

OR

  1. Respiratory FQ:
    - IV levofloxacin 750mg od
    - IV moxifloxacin
    PLUS
    - IV eftazidime 2g tds
39
Q

What are the MRSA risk factors to consider for CAP inpatient severe? (2)

A

MRSA risk factors:
1. Resp isolation of MRSA in last 1 year
2. Hospitalisation or parenteral abx use in last 90 days

(unlike inpatient non-severe, don’t need MRSA PCR +ve screen test)

40
Q

For inpatient CAP severe, Tx for additional MRSA coverage?

A

Add on:
- IV vancomycin
- IV/PO linezolid

41
Q

What are the P. aeruginosa risk factors to consider for CAP inpatient severe? (2)

A
  • Resp isolation of P. aeruginosa in last 1 year
  • Hospitalisation or parenteral abx use in last 90 days
42
Q

For inpatient CAP severe, Tx for additional P. aeruginosa coverage?

A

Ensure regimen includes P. aeru coverage:
- Ceftazidime
- Levofloxacin

43
Q

For CAP, when do we modify empiric Tx to include anaerobic cover?

A

If CT scan reports lung abscess/ empyema

44
Q

What can we give to include anaerobic cover for CAP? (in the case CT scan reports lung abscess/ empyema)

A

First-line:
- Add IV/PO metronidazole

If metronidazole contraindicated:
- Add IV/PO clindamycin

45
Q

What to take note of regarding use of respiratory FQs in Tx for CAP?

A

Respiratory FQs are not first-line for CAP:

  • ↑ ADEs (eg tendonitis/ tendon rupture, neuropathy, QTc prolongation, CNS disturbances, hypoglycemia)
  • If overuse → resistance
  • Undesirable monoTx if pt ends up having TB
  • Preserve activity for other gram -ve infections (Levo and cipro → alternative P. aeruginosa coverage for severe penicillin allergies +
    Only PO options for P. aeruginosa)
46
Q

What Tx should we add if we suspect that the pt has influenza?

When is the best time to initiate?

A
  • Add PO Oseltamivir if suspicious for influenza
  • Initiate ASAP (best within 48h, up to 5 days) of s/sx onset
47
Q

Tx duration for suspected influenza?

A

If positive influenza PCR:
- Complete 5 day course
- Consider discontinuing abx at 48 - 72h if no evidence of bacterial pathogen (ie -ve cultures, low procalcitonin levels, early clinical stability)

48
Q

Comment on the use of adjunctive corticosteroid Tx for CAP (what it does + whether we should add)

A
  • ↓ lung inflammation
  • DO NOT routinely add, only if shock refractory to fluid resuscitation and vasopressor support

No benefit for non-severe CAP
Conflicting mortality benefit in severe CAP

49
Q

Duration of Tx for CAP?

When are longer courses of abx needed?

A
  • Minimum 5 days Tx
  • 7 days if suspected MRSA or P. aeruginosa

Longer courses of abx for:
- CAP complicated with other deep-seated infections (eg meningitis, lung abscess)
- Infection with less common pathogens (Burkholderia pseudomallei, Mycobacterium tuberculosis, endemic fungi)

50
Q

When can we de-escalate Tx of CAP? (3)

A

When pt is:
- Hemodynamically stable (labs, vital signs)
- Improving clinically
- Able to ingest PO

51
Q

How should we de-escalate Tx for CAP following a positive culture?

A

Use AST to guide selection of lower spectrum abx

52
Q

How should we de-escalate Tx for CAP following no positive culture?

A
  • Empiric cover for MRSA, P. aeruginosa or Burkholderia pseudomallei can be stopped in 48h if pathogen not isolated + pt improving
  • IV-to-PO: use same abx or same class abx
53
Q

How long do most pts take to achieve clinical stability for CAP?

Should we escalate abx in the first 72 hours?

A

Most pts achieve clinical stability within first 48 - 72h (hence should not escalate abx in the first 72 hours unless culture-directed or significant clinical deterioration)

Elderly/ pts with co-morbs may take longer

PR3151 Finals (11 decks)

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