LRTIs Flashcards
Community-acquired pneumonia (CAP) definition
Pneumonia not caused by exposure to the healthcare system
Hospital-acquired pneumonia (HAP) definition
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
Ventilator-associated pneumonia definition
Pneumonia occurring >48 hours after endotracheal intubation
Legionella pneumonia definition
Pneumonia caused by legionella
Risks for legionella pneumonia
Water exposure, being male, smokers
Extrapulmonary legionella pneumonia symptoms
Severe hypophosphatemia, hyponatremia, diarrhea, confusion, LFT elevations, pulse-temperature dissociation
Aspiration pneumonia definition
Pneumonia following loss of consciousness after alcohol/drug overdose, post-seizure, gingival disease, esophageal motility disorder
Pathogens associated with outpatient CAP
S. pneumoniae, H. influenzae
Pathogens associated with inpatients not in the ICU but have CAP
S. pneumoniae, H. influenzae, legionella
Pathogens associated with ICU patients with CAP
S. pneumoniae, S. aureus, legionella
Signs/symptoms of outpatient CAP and S. pneumoniae
Rust-colored sputum, fever, infiltrates on x-ray, cough, chest pain in about 24 hours
H. influenzae in outpatient CAP is more common in patients with what disease states?
COPD, alcohol abuse, cystic fibrosis, HIV, impaired humoral immunity
Gram-positive pathogens associated with HAP
Staph aureus
Gram-negative pathogens associated with HAP
Klebsiella pneumoniae, pseudomonas aeruginosa
Signs and symptoms of pneumonia
Cough, sputum production, dyspnea, fever/chills, hemoptysis, pleuritic chest pain, tachypnea, tachycardia, diminished breath sounds, egophony, increased WBC
Typical pneumonia signs/symptoms
Abrupt onset, unilateral well-defined infiltrate, significant fever, chills, sweats, dyspnea, purulent sputum production, primarily pulmonary symptoms
Atypical pneumonia signs/symptoms
Gradual onset, diffuse infiltrates, ground-glass appearance, mild fever and dyspnea, dry cough, myalgias, diarrhea, abdominal pain
When do you use a gram stain?
Use for more severe cases and to guide empiric therapy
Sputum culture details
Reserve for severe cases
Try to obtain before ABX
Other pneumonia diagnostic tools
BAL, blood cultures, procalcitonin, oxygen saturation, urinary antigen testing, viral panel, CURB-65, PSI
Pretreatment tests for CAP
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
ABX that cause QTc prolongation
quinolones and azithromycin
HAP cultures
noninvasive sputum sample, then BAL if necessary
VAP cultures
endotracheal aspiration (noninvasive)
Outpatient treatment of CAP for patients who are previously healthy and no risk factors of drug resistance
PO amoxicillin, PO doxycycline, PO macrolide (azithromycin, clarithromycin)
Outpatient treatment of CAP for patients who have comorbidities
PO amox/clav or cephalosporin (cefpodoxime, cefdinir, cefuroxime) PLUS a macrolide (azithromycin, clarithromycin)
PO respiratory quinolone (levo, moxi)
Inpatient treatment of CAP: hospitalization that includes respiratory complications +/- systemic inflammation +/- comorbidities: non-severe
IV beta lactam (amp/sulbac, ceftriaxone) PLUS macrolide (azithro, clarithro) or respiratory quinolone (levo, moxi)
Inpatient treatment of CAP: hospitalization that includes respiratory complications +/- systemic inflammation +/- comorbidities: severe
IV beta-lactam PLUS macrolide
IV beta-lactam PLUS respiratory quinolone
(Basically the same thing as non-severe treatment)
Legionella lab findings
Gram-negative atypical pathogen, 4+ WBC, no organisms, elevated SCr, elevated serum LDH
Legionella treatment
Levofloxacin for 10-21 days
Azithromycin is an alt
Duration of ABX for CAP
Minimum of 5 days, generally 7 days
When to switch from IV to PO
Hemodynamically stable and improving clinically, able to tolerate PO medications, normally functioning GI tract
Potential pathogens for HAP
S. pneumoniae, H. influenzae, MSSA, E. coli, Klebsiella, Enterobacter, Proteus, Serratia
Treatment options for potential pathogens
Ceftriaxone, levofloxacin, moxifloxacin, amp/sulbac, ertapenem
When to cover empiricially for MRSA in HAP
Prior IV ABX use within the last 90 days, >20% MRSA, severe presentation, previous infection/co-infection
How to cover for MRSA in HAP
Vanco, linezolid
When to cover empirically for pseudomonas in HAP
Prior IV ABX use in the last 90 days, severe presentation, previous infection/colonization, immunosuppression
How to cover for pseudomonas in HAP
CEFEPIME, pip/tazo, ceftazidime, imipenem, meropenem, aztreonam, cipro, levo, AGs, colistin and polymixin B as a last resort
Duration of therapy for HAP and VAP
7 days regardless of pathogen
