Pneumonia Flashcards
T or F: Pneumonia is the #1 cause of death from ID
true
types of pneumonia (3)
Community aquired
Hospital acquired (nosocomial)
Aspiration pneumonia
Two types of hospital acquired pneumonia
health care associated
ventilator associated
What type of pneumonia do we see most often?
community acquired
CURB-65 scoring system defined
C - confusion U - uremia or BUN > 20 mg/dL R - resp rate at least 30 B - blood pressure systolic < 90 or diastolic < 60 65 - Age at least 65
Each is worth one point
0-1: tx at home
2: consider inpt
>3: potential ICU
Organisms for community acquired pneumonia
strep pneumonia h inluenza legionella spp* mycoplasma pneumoniae* chlamoydophila pneumonia*
Less common: M Cat Klebsiella pneumoniae Staph aureus Viruses
*“atypical” organisms
DRSP
drug resistant strep pneumonia
Risk factors for drug resistant strep pneumonia (DRSP)
6
Age <2 or >65 abx within the last 3 months alcoholism medical comorbidities immunosuppressive illness or therapy exposure to child at day care
Guidelines from Infectious disease society of America/American thoracic society
(3)
- sputum and blood cultures are recommended for all community acquired pneumonia patients, not just those with severe CAP.
- especially for those receiving empirics for MRSA or pseudomonas
- recommending against steroids for pneumonia unless they are in refractory septic shock
- recommending against follow up routine chest imaging
IDSA/ATS therapy updates
- recommending against macrolide mono therapy bc of resistance
- beta lactam/macrolide and beta lactam/fluoroquinolone are both still acceptable for severe CAP but the evidence is stronger for beta lactam/macrolide
IDSA/ATA guidelines for initial treatment in outpatient CAP pts include
high dose amoxicillin- best
doxycycline* save for those with Qtc or allergy to amoxicillin
amoxicillin/clavulanate*
various cephalosporins
FQs
macrolides (at the bottom of the list bc of resistance)
high dose amoxicillin is
1g TID
outpatient regimen
most often tx for inpatient CAP
B lactam macrolide
it’s not likely to see staph aureus in CAP but if you do expect it
vanco
2 common options for empiric therapy in the non icu patient
macrolide plus beta lactam
FQ alone
macrolide plus beta lactam for empiric, non ICU CAP.
examples (3)
ceftriaxone
ampicillin
ertapenem
Fluroquinolone empiric therapy for the non ICU pt c CAP
example
levo or moxi
empiric therapy options for ICU patients with CAP
2
plus 1 if PCN allergic
ceftriaxone or cefotaxime
ampicillin sulbatam PLUS FQ
if PCN allergic: moxi or levo PLUS aztreonam
modifying factors of CAP treatment
structural lung disease
beta lactam allergy
community acquired MRSA
structural lung disease as a modifying factor for CAP tx
use an anti pseudomonal agent (like cefepime, pip/tazo, imipenem, or meropenem) PLUS macrolide or levo or cipro.
beta lactam allergy as a modifying factor for CAP
use FQ with or without vanco
Community acquired MRSA as a modifying factor for CAP tx
Vanco plus linezolid plus FQ
Hospital acquired pneumonia
developed at least 48 hours after admission, with no mechanical ventilation involved
ventilator associated pneumonia
pneumonia occurring 48 hours after intubation
can take place on top of existing hospital acquired.
how many HAPs per 1000 admissions
5 - 15
how much does being on a ventilator increase risk of HAP?
6 - 20 x
how many days does HAP increase a hospital stay?
7 - 9
Routes of entry for HAP
5
micro aspiration of oropharyngeal secretions
aspiration of gastric/esophageal contents
inhalation of infectious aerosol
hematogenous spread
direct inoculation from staff
organisms of HAP
enterobacteria like e coli and klebsiella staph aureus psuedomonas aeruginosa acinetobacter anaerobes due to aspiration
what do you need to watch for with HAP?
multi drug resistant organisms
risk factors for multi drug resistant pathogens (MDRO)
6
- abx in last 90 days
- current hospitalization > 5 days
- inc freq of community resistance
- immunosuppression
- ICU
- days on mech ventilation
risk factors for having increased frequency of community resistance (5)
hospitalized for longer than 2 days in the last 90 days home care dialysis nursing home family member with MDRO
if you use a drug that covers MRSA, chances are
it’ll also cover MSSA.
Does not work the other way around.
HAP Empiric Treatment if pt is not at high risk of mortality and no inc likelihood of MRSA
need single agent for psuedomonas *piper/tazo OR cefepime OR levo OR imipenem OR meropenem
HAP empiric treatment if not at high risk of mortality but at risk for MRSA
add vanco or linezolid
HAP empiric treatment if at high risk of mortality or received abx in the past 90 days
and concern for MRSA
Two of the following (but not 2 beta lactams)
- pip/tazo, cefepime, ceftazidime, levo, cipro, imipenem, meropenem, amikacin, gentamicin, tobramycin, aztreonam PLUS vanco or linezolid
HAP empiric treatment if at high risk of mortality or received abx in the past 90 days
without concern for MRSA
2 of the following:
pip/tazo, cefepime, levo, imipenem, meropenem for MSSA empiric coverage
save naf/ox/diclox for proven MSSA
VAP empiric treatment
want MRSA covered
want psuedomonas covered
One of each:
MRSA: Vanco, linezolid
Pseudomonas - Beta Lactam: pip/tazo OR cefepime or ceftazidime OR imipenem or meropenem OR aztreonam
pseudomonas - non beta lactam: cipro or levo* OR amikacin or gentamycin or tobramycin
VAP empiric treatment
cover pseudomonas
beta
de escalation of antibiotics as culture info comes available:
if cultures do not grow S aureus
stop vanco / linezolid
de escalation of antibiotics as culture info comes available:
if cultures grow MSSA
use an anti staph penicillin
de escalation of antibiotics as culture info comes available:
if cultures grow one/more of the enterobacteriaceae
try to use a more narrow apectrum agent based on susceptibility
de escalation of antibiotics as culture info comes available:
when susceptibility of GNR is available:
narrow and discontinue second agent like amino glycoside or FQ
Duration of therapy for HAP and VAP
7 days
Aspiration pneumonia occurs
typically as a result of altered consciousness or anatomic abnormalities
Asp Pneumonia, comm acquired is primarily ____ also may see ____, _____, ______
primarily anaerobic in nature
may also see S aureus, strep, or gram neg bacilli.
Therapy for asp pneumonia is directed at
mouth flora
Asp pneumonia, community acquired
regimens
clindamycin plus moxi or levo or cipro *
ampicillin/sulbactam IV or amox/clavulanate PO
imipenem
if CAP with question of aspiration
moxi or amp/sulb or amox/clav
treatment duration for aspiration pneumonia, community acquired
7-10 days
Asp pneumonia, hospital acquired
treatment is geared towards
covering nosocomial pathogens and anaerobes
Regimens for asp pneumonia, hospital acquired
add metronidazole to PCN or ceph
add clinda to FQ or aztreonam
or use drugs that already have anaerobic coverage:
- b lactam/b lactase inhibitors (pip/tazo)
- carbapenems (imipenem, meropenem)
- some FQs like moxi
