Pneumonia

Question 1

What is pneumonia?

Answer 1

An acute infection of the pulmonary parenchyma

Question 2

How soon do you want to begin antibiotics for pneumonia and what other care should be supplied?

Answer 2

Want to have PROMPT antibiotic initiation with appropriate spectrum of activity is an essential step in pneumonia management.

• supportive care with bronchodilators, symptomatic management and fluids

Question 3

CAP definition

Answer 3

Microbiological therapy is usually successful, and knowledge of which pathogen does not usually change therapy

• empiric Abx therapy is usually successful and knowledge of which pathogen does not usually change therapy

Question 4

Important bacteria to cover empirically for CAP

Answer 4

1. S. pneumoniae and H. influenzae (typical)
2. M catarrhalis, MSSA ( higher suspicioni in smokers, elderly, recent Abx use, those with comorbidities)
3. Enterobacteriaceae such as K. pneumonie, E.coli (higher suspicioisn in structural lung diseases like COPD)
   
   1. Atypical bacteria- mycoplasma pneumoniae, legionella pneumophila, and chlamydia pneumoniae

Question 5

Mainstay of therapy for CAP

Answer 5

beta- lactams are the mainstay of therapy

Question 6

Which populations would likely have M. catarrhalis and MSSA

Answer 6

Higher suspicion in:

1. smokers
2. elderly
3. recent Abx use
4. those with comorbidities

Question 7

Which populations would likely have enterobacteriaceae such as k.pneumoniae, e.coli

Answer 7

Higher suspicion in structural lung diseases such as COPD

Question 8

CAP treatment for healthy individuals, under 65, with no recent antibiotic use

Answer 8

1. Amoxicillin (GP, GN, Anaerobes, Atypical) - covers most strains of s. pneumoniae and h. influenzae
2. +/- AZITHROMYCIN (PREFERRED) or doxycycline - targets the atypicals
3. PCN allergy but tolerate cephalosporins - 3rd generation cephalosporin (cefdinir)
4. Last- line : Levofloxacin (covers atypicals and normal pathogens)

Question 9

CAP Treatment with comorbidities, 65+, recent antibiotics, smokers- expand coverage a bit

Answer 9

1. amoxicillin/ clauvulanic acid (augmentin) + azithromycin or doxycycline
2. alternative- 3rd generation - cefdinir + azithromycin OR doxycyline
   
   1. last line: Levofloxacin

Question 10

Duration of therapy for CAP treatment

Answer 10

typically 5 days - afebrile > 48 hours and clinically stable (exception: high dose Azithromycin)

Question 11

Pathogenic organisms in CAP typically a/w severe illness

Answer 11

Pseudomonas, Klebsiella, MRSA

Question 12

Amoxicillin use

Answer 12

1. first line treatment usually with azithromycin for healthy individuals and CAP treatment
2. treating those with CAP and comorbidities. Usually combined with clavulanic acid (augmentin) then combined with azithromycin AND doxycyline

Question 13

ADR of amoxicilliin

Answer 13

1. allergic reaction- PCN allergies
   
   1. Cdiff and AAD (antibiotic associated diarrhea)

Question 14

Augmentin is which drugs?

Answer 14

Amoxicillin and clavulanic acid

Question 15

ADR of augmentin

Answer 15

More AAD than amoxicillin alone

Question 16

Adjustment for augmentin

Answer 16

Renal adjusment is needed

Question 17

Azithromycin indications

Answer 17

CAP and GP, GN, Atypicals

NO MRSA and Pseudomonas

Question 18

Contraindications of azithromycin

Answer 18

Hx of cholestatic jaundice/ hepatic dysfunction a/w prior azithromycin use

Question 19

Z pack

Answer 19

Aztithromycin

2 tabs 500mg day 1, then 250 mg qd x 4 days

Question 20

ADR of azithromycin

Answer 20

1. QT prolongation- increased risk of fatal heart rhythms

Question 21

Doxycycline Contraindications

Answer 21

relative - children <8 years of age d/t discoloration of teeth - can use if no other alternative therapies

Question 22

ADR of doxycyline

Answer 22

1. GI disturbances
2. AAD
3. Photosensitivity

Question 23

Levofloxacin Indications

Answer 23

Covers pseudomonas (no MRSA)

Question 24

Levofloxacin US Box Warnings

Answer 24

1. Tendinitis
   
   1. Exacerbation of myasthenia gravis

Levofloxacin is a fluoroquinolone that covers MSSA, GP, GN, Pseudomonas and atypicals

Question 25

Adjustments of Levofloxacin

Answer 25

1. Requires a renal adjustment 1. Absorption is decreased by cations - Ca, Zn, Al, Mg, Fe- give 2 hours before and 6 hours after

Question 26

What is HAP

Answer 26

A pneumoniae that occurs 48 hours or more AFTER admission and does NOT appear to be incubating at the time of admission

Question 27

VAP

Answer 27

a type of HAP that develops more than 48 hour after ET intubations

Question 28

Treatment for HAP and VAP

Answer 28

1. Cefepime + Vanco, +/- Levofloxacin 2. Zosyn + Vanco, +/- Levofloxacin 3. If they have a PCN/ Cephalosporing allergy- Meropenem + Vanco, +/- Levofloxacin 4. Can consider adding **azithromycin or doxycycline** if high suspicion of atypical but do NOT want to use levofloxacin

Question 29

Cefepime inidications

Answer 29

1. pneumonia (pseudomonal coverage)

Question 30

Routes of cefepime

Answer 30

IV (only use this in the hospital)

Question 31

ADR of Cefepime

Answer 31

1. c.diff associated diarrhea 2. antibiotic associated diarrhea 3. neurotoxicity- encephalopathy, aphasia, myoclonus, seizures- rare!

Question 32

Vancomycin indications

Answer 32

MRSA coverage

Question 33

Routes of Vanco

Answer 33

1. IV- all systemic infections 1. Oral- C. Diff infections

Question 34

ADR of Vanco

Answer 34

1. Nephrotoxic- Renal Failure 2. Red Man Syndrome- Rapid infusion can cause histamine release- flushing, rash, pruritis, tachycardia, hypotension 3. thrombocytopenia- decreased platelets

Question 35

Metabolism / excretion of Vanco

Answer 35

Dosed by nomogram- kidney function and weight based

Question 36

Zosyn is which drugs

Answer 36

Piperaciillin and tazobactam

Question 37

Indications of Zosyn

Answer 37

Pneumonia (pseudomonal coverage)

Question 38

Route of zosyn

Answer 38

IV

Question 39

ADR of Zosyn

Answer 39

AKI- particularly in combo with Vanco and other nephrotoxic drugs

Question 40

HCAP comes from which places

Answer 40

1. dialysis 2. residing in nursing home 3. previous hospitalization 4. immunocompromised state

Question 41

What is aspiration pneumonia

Answer 41

Type of pneumonia that results from the entry of gastric OP fluids which may contain bacteria * leads to a pneumonia that may be aerobic, anaerobic or a mixture

Question 42

Aspiration Pneumonia Outpatient Treatment

Answer 42

Augmentin (GP, GN and Anaerobes)

Question 43

Aspiration Pneumonia- Inpatient therapy for those who are not severely ill

Answer 43

Unasyn (Ampicillin - sulbactam) | (GP, GN, Anaerobes, Atypicals)

Question 44

Aspiration Pneumonia- Inpatient therapy for those who are severely ill

Answer 44

Zosyn (piperacillin and tazobactam) * might use if someone is choking and can't speak or has an unclear history. Could even add **vanco** to cover HAP, VAP or HCAP

Question 45

3 treatments for aspiration pneumonia bring:

Answer 45

**anaerobic coverage** in addition to covering the normal suspected pathogens

Question 46

What to do with a mixed etiology pneumonia

Answer 46

May have to cover a broader spectrum empirically and narrow * unsure if it is aspiration or HCAP - lean toward Zosyn