LRTIs

Question 1

Community-acquired pneumonia (CAP) definition

Answer 1

Pneumonia not caused by exposure to the healthcare system

Question 2

Hospital-acquired pneumonia (HAP) definition

Answer 2

Pneumonia not incubating at the time of hospital admission and occurs 48 hours or more after admission. Could include patients coming from the community who have received IV ABX within 90 days of admission and LTC

Question 3

Ventilator-associated pneumonia definition

Answer 3

Pneumonia occurring >48 hours after endotracheal intubation

Question 4

Legionella pneumonia definition

Answer 4

Pneumonia caused by legionella

Question 5

Risks for legionella pneumonia

Answer 5

Water exposure, being male, smokers

Question 6

Extrapulmonary legionella pneumonia symptoms

Answer 6

Severe hypophosphatemia, hyponatremia, diarrhea, confusion, LFT elevations, pulse-temperature dissociation

Question 7

Aspiration pneumonia definition

Answer 7

Pneumonia following loss of consciousness after alcohol/drug overdose, post-seizure, gingival disease, esophageal motility disorder

Question 8

Pathogens associated with outpatient CAP

Answer 8

S. pneumoniae, H. influenzae

Question 9

Pathogens associated with inpatients not in the ICU but have CAP

Answer 9

S. pneumoniae, H. influenzae, legionella

Question 10

Pathogens associated with ICU patients with CAP

Answer 10

S. pneumoniae, S. aureus, legionella

Question 11

Signs/symptoms of outpatient CAP and S. pneumoniae

Answer 11

Rust-colored sputum, fever, infiltrates on x-ray, cough, chest pain in about 24 hours

Question 12

H. influenzae in outpatient CAP is more common in patients with what disease states?

Answer 12

COPD, alcohol abuse, cystic fibrosis, HIV, impaired humoral immunity

Question 13

Gram-positive pathogens associated with HAP

Answer 13

Staph aureus

Question 14

Gram-negative pathogens associated with HAP

Answer 14

Klebsiella pneumoniae, pseudomonas aeruginosa

Question 15

Signs and symptoms of pneumonia

Answer 15

Cough, sputum production, dyspnea, fever/chills, hemoptysis, pleuritic chest pain, tachypnea, tachycardia, diminished breath sounds, egophony, increased WBC

Question 16

Typical pneumonia signs/symptoms

Answer 16

Abrupt onset, unilateral well-defined infiltrate, significant fever, chills, sweats, dyspnea, purulent sputum production, primarily pulmonary symptoms

Question 17

Atypical pneumonia signs/symptoms

Answer 17

Gradual onset, diffuse infiltrates, ground-glass appearance, mild fever and dyspnea, dry cough, myalgias, diarrhea, abdominal pain

Question 18

When do you use a gram stain?

Answer 18

Use for more severe cases and to guide empiric therapy

Question 19

Sputum culture details

Answer 19

Reserve for severe cases

Try to obtain before ABX

Question 20

Other pneumonia diagnostic tools

Answer 20

BAL, blood cultures, procalcitonin, oxygen saturation, urinary antigen testing, viral panel, CURB-65, PSI

Question 21

Pretreatment tests for CAP

Answer 21

Blood cultures and expectorated sputum samples for gram stain and culture should be sent for all patients with anti-MRSA and antipseudomonal ABX orders; severe CAP should have urinary antigen test for legionella and strep pneumoniae

Check for ABX allergies and QTc prolongation

Question 22

ABX that cause QTc prolongation

Answer 22

quinolones and azithromycin

Question 23

HAP cultures

Answer 23

noninvasive sputum sample, then BAL if necessary

Question 24

VAP cultures

Answer 24

endotracheal aspiration (noninvasive)

Question 25

Outpatient treatment of CAP for patients who are previously healthy and no risk factors of drug resistance

Answer 25

PO amoxicillin, PO doxycycline, PO macrolide (azithromycin, clarithromycin)

Question 26

Outpatient treatment of CAP for patients who have comorbidities

Answer 26

PO amox/clav or cephalosporin (cefpodoxime, cefdinir, cefuroxime) PLUS a macrolide (azithromycin, clarithromycin)

PO respiratory quinolone (levo, moxi)

Question 27

Inpatient treatment of CAP: hospitalization that includes respiratory complications +/- systemic inflammation +/- comorbidities: non-severe

Answer 27

IV beta lactam (amp/sulbac, ceftriaxone) PLUS macrolide (azithro, clarithro) or respiratory quinolone (levo, moxi)

Question 28

Inpatient treatment of CAP: hospitalization that includes respiratory complications +/- systemic inflammation +/- comorbidities: severe

Answer 28

IV beta-lactam PLUS macrolide

IV beta-lactam PLUS respiratory quinolone

(Basically the same thing as non-severe treatment)

Question 29

Legionella lab findings

Answer 29

Gram-negative atypical pathogen, 4+ WBC, no organisms, elevated SCr, elevated serum LDH

Question 30

Legionella treatment

Answer 30

Levofloxacin for 10-21 days

Azithromycin is an alt

Question 31

Duration of ABX for CAP

Answer 31

Minimum of 5 days, generally 7 days

Question 32

When to switch from IV to PO

Answer 32

Hemodynamically stable and improving clinically, able to tolerate PO medications, normally functioning GI tract

Question 33

Potential pathogens for HAP

Answer 33

S. pneumoniae, H. influenzae, MSSA, E. coli, Klebsiella, Enterobacter, Proteus, Serratia

Question 34

Treatment options for potential pathogens

Answer 34

Ceftriaxone, levofloxacin, moxifloxacin, amp/sulbac, ertapenem

Question 35

When to cover empiricially for MRSA in HAP

Answer 35

Prior IV ABX use within the last 90 days, >20% MRSA, severe presentation, previous infection/co-infection

Question 36

How to cover for MRSA in HAP

Answer 36

Vanco, linezolid

Question 37

When to cover empirically for pseudomonas in HAP

Answer 37

Prior IV ABX use in the last 90 days, severe presentation, previous infection/colonization, immunosuppression

Question 38

How to cover for pseudomonas in HAP

Answer 38

CEFEPIME, pip/tazo, ceftazidime, imipenem, meropenem, aztreonam, cipro, levo, AGs, colistin and polymixin B as a last resort

Question 39

Duration of therapy for HAP and VAP

Answer 39

7 days regardless of pathogen