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PR3124 > Pneumonia > Flashcards

Pneumonia Flashcards

1
Q

Pathogenesis of Pneumonia

A 
Most commonly: Bacteria infection
Mechanism:
- Aspiration of oropharyngeal secretions
- Inhalation of aerosols
- Hematogenous spreading
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2
Q

Clinical presentation & diagnosis of Pneumonia

A

Signs & symptoms:

  • Cough, chest pain, SOB, hypoxia, Fever > 38C, chills
  • Tachypnea, tachycardia, hypotension
  • Leukocytosis
  • Fatigue, anorexia, nausea, changes in mental status

Physical examination
- Diminished breaths & inspiratory crackles

Radiographic findings
- New infiltrates/ dense consolidations

Laboratory findings
- Non-specific so NOT RECOMMENDED as guide for antibiotic initiation/discontinuation

Respiratory cultures

  • Sputum: Low yield; frequent contamination (NOT RECC)
  • LRT samples: Less contamination but invasive sampling

Blood cultures
- To rule out bacteremia

Urinary antigen tests
- NOT RECC as indicates exposure to respective pathogen, but not necessarily infection

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3
Q

Classifications of pneumonia

A

1) Community-acquired (CAP): < 48h after hospital admission
2) Hospital-acquired (HAP): >= 48h after hospital admission
3) Ventilator-associated (VAP): > 48h after mechanical ventilation

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4
Q

Risk factors for CAP

A
  • Age >= 65yo
  • Previous hospitalisation for CAP
  • Smoking
  • COPD, DM, HF, cancer, immunosupression
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5
Q

Prevention of CAP

A
  • Smoking cessation

- Immunization (Influenza, pneumococcal)

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6
Q

Microbiology of OUTPATIENT bacterial CAP

A
  • Streptococcus penumoniae
  • Haemophilus influenzae
  • Atypical (Mycoplasma, Chlamydophilia)
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7
Q

Microbiology of INPATIENT (NON-SEVERE) bacterial CAP

A
  • Streptococcus penumoniae
  • Haemophilus influenzae
  • Atypical (Mycoplasma, Chlamydophilia, Legionella)
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8
Q

Microbiology of INPATIENT (SEVERE) bacterial CAP

A
  • Streptococcus penumoniae
  • Haemophilus influenzae
  • Atypical (Mycoplasma, Chlamydophilia, Legionella)

PLUS

  • Staph. aureus
  • Gram (-) (Klebsiella, Burkholderia Pseudomallei)

Burkholderia Pseudomallei: Can cause Meliodosis

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9
Q

Risk stratification for Pneumonia

A

1) IDSA/ ATS Criteria for Severe CAP
- >= 1 major criteria/ >= 3 minor criteria

Major: Mechanical ventilation
Septic shock requiring vasoactive meds

Minor: RR >= 30 breaths/min
           PaO2/FiO2 <= 250 (Hypoxia marker)
           Multilobar infiltrates
           Confusion/disorientation
           Uremia (Urea > 7mmol/L)
           Leukopenia (WBC < 4 x 10^9)
           Hypothermia ( < 36C )
           Hypot/s requiring aggressive fluid resuscitation

2) Pneumonia Severity Index (PSI)
3) CURB-65

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10
Q

Empiric treatment model for CAP

A

ALL CAP Patiients:
1) Standard regimen - Min coverage based on location (inpatient/outpatient) & risk stratification

For inpatients only:

2) Anaerobic coverage
3) MRSA coverage
4) Pseudomonal coverage

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11
Q

Antibiotic regimen for OUTPATIENT CAP

A

If generally healthy:

1) B-lactam (Amoxicillin) OR
2) Respiratory FQ (Levofloxacin/Moxifloxacin)

If chronic heart/lung/liver/renal disease/DM/Alcoholism/Malignancy/Asplenia:
1) B-lactam (Augmentin/Cefuroxime)
+ Macrolide (Clarithromycin/Azythromycin) OR
Doxycycline
2) Respiratory FQ (Levofloxacin/Moxifloxacin)

Route: PO

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12
Q

Antibiotic regimen for INPATIENT CAP (Non-Severe)

A

1) IV B-lactam (Augmentin/Ceftriaxone)
+ PO Macrolide (Clarithromycin/Azythromycin) OR
PO Doxycycline
2) IV Respiratory FQ (Levofloxacin/Moxifloxacin)

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13
Q

Antibiotic regimen for INPATIENT CAP (Severe)

A

1) IV B-lactam (Augmentin) + Ceftazidime
+ PO Macrolide (Clarithromycin/Azythromycin) OR
PO Doxycycline
2) IV Respiratory FQ (Levofloxacin/Moxifloxacin)
+ Ceftazidime

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14
Q

Indication for ANAEROBIC COVERAGE for Inpatient CAP

A
  • Lung abscess

- Empyema (collection of pus in alveoli space)

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15
Q

Common anaerobes for Inpatient CAP

A
  • Bacteriodes fragilis
  • Prevotella spp.
  • Porphyromas spp.
  • Fusobacterium spp.
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16
Q

Antibiotic to add for ANAEROBIC COVERAGE

A

IV/PO Clindamycin OR IV/PO Metronidazole

Note: Augmentin & Moxifloxacin have anaerobic coverage

17
Q

Indication for MRSA COVERAGE for Inpatient CAP

A
  • Prior respiratory isolation of MRSA in last 1 year

- Severe CAP only: Hospitalization & received IV antibiotics within last 90 days

18
Q

Antibiotic to add for MRSA COVERAGE

A

IV Vancomycin or IV/PO Linezolid

19
Q

Indication for PSEUDOMONAL COVERAGE for Inpatient CAP

A
  • Prior respiratory isolation of Pseudomonas aeruginosa in last 1 year
20
Q

Antibiotic to add for PSEUDOMONAL COVERAGE

A

Options:

  • IV Piperacillin/Tazobactam
  • IV Cefepime
  • IV Meropenem (Not preferred)
  • IV/PO Levofloxacin (Severe)

BUT usually will already give IV Ceftazidime

  • Only case to consider to modify standard regimen to include Pseodomonal coverage is in INPATIENT, NON-SEVERE case
  • > i) Use anti-pseudomonal B-lactam instead
    (eg. IV Piperacillin/Tazobactam) + Macrolide (Clarithromycin or Azithromycin) OR Doxycycline
    ii) IV Respiratory FQ (Levofloxacin
21
Q

Treatment considerations for CAP

A
  • Respiratory FQ not 1st line
  • -> Increased adverse effects (ie. tendonitis, tendon rupture, neuropathy, arthropathy, QTc prolongation, CNS disturbances, hypoglycemia)
  • -> Delay diagnosis for TB
  • -> Resistance, preserve activity for other Gram (-)
22
Q

Why consider adjunctive corticosteroid therapy?

Not routinely recommended

A
  • Decrease inflammation in lungs
  • May decrease length of stay & time to clinical stability
  • Any impact is small & likely outweighed by increased hyperglycaemia
23
Q

Monitoring of CAP therapy

A

1) Safety
- Adverse effects & renal function

2) Efficacy
- Clinical improvements expected in 48-72 hrs
- Should not escalate antibiotic therapy in 1st 72 hours
- Radiographic improvement lags behind, up to 4-6 weeks for resolution (Repeat only if clinical deterioration)

24
Q

Treatment modifications for CAP

A
  • Empiric coverage for MRSA/ Pseudomonas aeruginosa may be stopped in 48hrs if no MRSA or Pseudomonas aeruginosa
25
Q

When to step down therapy?

A
  • Hemodynamically stable
  • Clinically improved/improving
  • Afrebile >= 24hrs
  • Normally functioning GIT
  • Able to ingest PO
26
Q

HOW to step down therapy

A

Positive cultures:
- Susceptibility results to guide selection of PO antibiotics

No positive cultures:

  • Same antibiotic/ another antibiotic from same class
  • Usually stop coverage for Burkholderia pseudomallei if organism is not cultured in sample
  • Empiric therapy may be stopped in 48h if no MRSA/P. Aeruginosa & pt improving

PR3124 (16 decks)

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