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Pharmacology II > Pneumonia > Flashcards

Pneumonia Flashcards

1
Q

What pneumonia is associated with no recent hospitalization and lacking health care associated risk factors?

A

Community required pneumonia (CAP)

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2
Q

What type of pneumonia results from aspiration of oropharyngeal or gastric contents?

A

Aspiration pneumonia

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3
Q

What type of pneumonia occurs >48-72 hours after endotracheal intubation?

A

Ventilator-associated pneumonia (VAP)

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4
Q

What type of pneumonia occurs >48 hours after hospital admission?

A

Hospital acquired pneumonia (HAP)

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5
Q

What type of pneumonia results from Any patient who was hospitalized for >2 days in the last 90 days, Resided in nursing home or long-term care facility, Received recent IV antibiotic, chemotherapy or wound care within past 30 days, or is a Patient on hemodialysis?

A

Healthcare-associated pneumonia (HCAP)

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6
Q

What is the leading cause of death due to infection?

A

CAP

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7
Q

What are the microorganisms that are most associated with bacterial pneumonia?

A

Streptococcus pneumoniae most common pathogen
Mycoplasma pneumoniae- 2nd most common cause
Haemophilus influenzae- colonization increases in patients with COPD and cystic fibrosis
Moraxella catarrhalis a more common cause in young children and elderly
Community acquired methicillin resistant staphylococcus aureus-associated with necrotizing and more severe forms of CAP

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8
Q

What are the viral causes of pneumonia?

A

Often cause of CAP in children
RSV, influenza A, parainfluenza
Much less common in adults
Influenza A+B, adenoviruses, and even more less common others; rhinovirus, enterovirus, varicella zoster, herpes simplex.

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9
Q

What is the most common cause of CAP?

A

S. pneumoniae most common cause
Drug resistant S. pneumoniae (DRSP)
Strains resistant to at least 3 drugs
Becoming more and more common

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10
Q

What are the risk factors for drug resistance S. pneumonaie?

A 
Age < 2 years or > 65 years
Antibiotic therapy within previous 3 months
Alcoholism
Medical comorbidities
Immunospupression
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11
Q

What are the risk factors for CA-MRSA?

A 
Cavitary Pneumonia
Lung necrosis
Rapidly increasing pleural effusion
Gross hemoptysis
Neutropenia
Concurrent infection
Erythematous skin rash 
Previously healthy
Summer season
Prior conjugate pneumococcal vaccination
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12
Q

What are the risk factors associated with aspiration pneumonia?

A

Dysphagia
Stroke, seizures, alcoholics, and aging
Change in oropharyngeal colonization
Oral/dental disease, poor hydiene, tube feedings, medications
Gastroesophageal reflux
May allow gram (-) bacilli to colonize gastric contents
Decreased host defenses
Impaired mucus production or cilia function, decreased immunoglobulin in secretions, altered cough reflex

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13
Q

What are the oral contents that cause aspiration pneumonia?

A

Variety of anaerobes

Bacteroides spp., Fusobacterium spp,. Prevotella spp. and anaerobic gram cocci

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14
Q

What are the gastric contents that cause aspiration pneumonia?

A

Gram (-) bacilli and S. auerus

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15
Q

What is the 2nd most common nosocomial infection in the US?

A

Hospital acquired pneumonia

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16
Q

HAP accounts for ______ of all ICU infections and _____ of the antibiotics used

A

HAP accounts for 25% of all ICU infections and >50% of the antibiotics used

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17
Q

What are the risk factors for HAP?

A
  • -Intubation and mechanical ventilation
  • -Aspiration– Risk of aspiration increased in ICU patients
  • -Oropharyngeal colonization– Affected by antibiotics, and poor infection control measures
  • -Hyperglycemia–Directly and indirectly promote infections, Inhibit phagocytosis, provides nutrients for the bacteria
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18
Q

VAP occurs in ______% of all intubated patients

A

9-27

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19
Q

VAP are the highest in the 1st _____ days of intubation

A

5 days

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20
Q

VAP has the highest mortality in?

A

bacteremia caused by Pseudomonas and Acinetobacter
medical rather than surgical illness
treatment with ineffective antibiotic therapy

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21
Q

What is the etiology for pneumonia?

A 
Aerobic Gram-negative bacteria
Ps. aeruginosa
E. coli
K. pneumonia
Acinetobacter sp.

Gram-positive bacteria
S. aureus (MRSA)

Anaerobes: very rare

22
Q

What are the sx of pneumonia?

A

Cough, SOB, difficulty breathing

Fever, fatigue, headaches, myalgia, mental status change; confusion, lethargy, and disorientation

23
Q

What are the signs of pneumonia?

A

Fever, sustained or intermittent, cyanosis and use of accessory muscles, breath sounds may be diminished, rhales or rhonci may be heard

24
Q

What are the factors associated with poor prognosis/severe illness?

A 
RR > 30 breaths/min
DBP < 60 mmHg
SBP < 90 mmHg
HR > 125 bpm
Temp < 35C or > 40C
Chest-X ray
Multilobar infiltrates
Rapid progression infiltrates
Pleural effusion
Necrotizing pneumonia
25
Q

What is used to diagnosis pneumonia?

A

–Chest X-ray should reveal infiltrates
–O2 saturation should be over 90%
–CBC, elevated or drop in WBC, differential should show a predominance of neutrophils
–Sputum gram stain may or may not show a predominance of on organism
Not obtained in outpatient setting
–Blood cultures MUST be obtained in all patients hospitalized with pneumonia
In CAP blood cultures are positive 1-20% of the time

26
Q

What are the diagnostic considerations for pneumonia?

A

PCR- being used more to detect DNA of respiratory pathogen
Potential for more rapid diagnosis
Allows more rapid pathogen targeted therapy

Urinary Antigens (DFA)
Used to diagnose L. pneumophila
27
Q

PSI class I has a 30-d mortality Risk of what? and where is the site of care?

A

0.4% 30day mortality risk

Outpatient

28
Q

PSI class II has a 30-d mortality Risk of what? and where is the site of care?

A

0.7% 30day mortality risk

Outpatient

29
Q

PSI class III has a 30-d mortality Risk of what? and where is the site of care?

A

2.8% 30day mortality risk

Clinical judgement

30
Q

PSI class IV has a 30-d mortality Risk of what? and where is the site of care?

A

8.5% 30day mortality risk

Inpatient

31
Q

PSI class V has a 30-d mortality Risk of what? and where is the site of care?

A

31.1% 30day mortality risk

Inpatient-ICU

32
Q

What is the severity of assessment?

A 
Confusion, Uremia, Respiratory Rate, Blood Pressure (CURB-65)
Score 0-5, 1 point for each of the following:
Confusion
BUN > 7 mmol/L (19.6 mg/dL)
RR > 30
SBP < 90 mmHg or DBP < 60 mmHg
Age > 65 years
2 points; consider hospital admission
>3 points; consider ICU admission
33
Q

HAP/VAp chest xray should reveal what?

A 
A new infiltrate plus two of the following:
Temp > 38 C (100.4 F)
Leukocytosis or leukopenia
Purulent secretions
Cultures identifying pathogen
34
Q

What should the initial treatment for pneumonia be?

A

Empiric

35
Q

What is empiric therapy guided by to treat pneumonia?

A 
Type of pneumonia
Severity of pneumonia (ICU vs. non-ICU)
Time of onset
Specific risk factors
Patient factors
36
Q

If you are worried about MRSA what should be added to treatment?

A

Vancomycin or linezolid

37
Q

What is used to treat the healthy outpatient according to the CAP IDSA empiric treatment guidelines?

A

Macrolide or Doxycycline

38
Q

What is used to treat the outpatients at risk for DRSP according to the CAP IDSA empiric treatment guidelines?

A

Respiratory Fluoroquinolone
Or
Beta-lactam + Macrolide

39
Q

What is used to treat the inpatient, non-ICU according to the CAP IDSA empiric treatment guidelines?

A

Respiratory Fluoroquinolone
Or
Beta-lactam + Macrolide

40
Q

What is used to treat the inpatient ICU according to the CAP IDSA empiric treatment guidelines?

A

Beta-lactam + azithromycin
Or
Beta-lactam + respiratory flouroquinolone

41
Q

What is the JC/CMS recommendations for non-icu patients?

A

Beta-lactam +macrolide OR
Antipneumococcal quinolone OR
Beta-lactam + doxycycline or Tigecycline montherapy or Macrolide monotherapy

42
Q

What is the JC/CMS recommendations for ICU patients?

A

Macrolide and Beta-lactam * or antipneumococcal/antipsuedomonal Beta-Lactam OR
Antipneumococcal quinolone OR
Antipseudomonal quinolone + Beta-lactam or antipneumococcal/antipseudomonal beta lactam OR
Antipneumococcal/antipseudomonal beta-lactam + aminoglycoside + either antipneumococcal quinolone or macrolide

43
Q

What is the treatment for CAP?

A

If able to identify organism target therapy (24-72h after admission)

Duration of therapy 5-7 days

  • -Minimum 5 days until patients are afebrile for 48-72 hours
  • -Longer for S. auerus or Pseudomonas

When clinically stable switch to po

If admitted discharge patients when
–Vital signs and Oxygen status are stable and no unresolved comorbidities

44
Q

What is the treatment for oral contents aspiration pneumonia?

A

PCN G, ampicillin/sulbactam, and clindamycin all cover typical pathogens

45
Q

What is the treatment for oral and gastric treatment aspiration pneumonia?

A

Ampicillin/sulbactam, amoxicillin/clavulante piperacillin/tazobactam

46
Q

What are HAP treatment considerations?

A 
Dynamic
ICUs are important reservoirs
Prior antibiotic therapy
Broad spectrum antibiotics
Key concerns are:
MRSA, Pseudomonas aeruginosa, Acinetobacter spp., and Stenotrophomonas maltophilia
47
Q

What is the HAP treatment?

A

Early onset (< 5 days) most frequent pathogens S. pneumoniae, H. influenzae, MSSA, and enteric gram (-) bacilli
3rd generation cephalosporin +macrolide
or
Respiratory fluoroquinolone

48
Q

What are the risk factors for MDR?

A

Antimicrobial therapy in preceding 90 days
Current hospitalization of 5 days or more
High frequency of antibiotic resistance in the community or in the specific hospital unit
Presence of risk factors for HCAP:
Hospitalization for >2 days in the preceding 90 days
Residence in a nursing home or extended care facility
Home infusion therapy (including antibiotics)
Chronic dialysis within 30 days
Home wound care
Family member with multidrug-resistant pathogen
Immunosuppressive disease and/or therapy

49
Q

What do you treat early onset VAP and no risk for MDR?

A 
Cefotaxime 2 g IV q 8H
		or
	Ceftriaxone 2 g IV q 24H
		or
	Ampicillin/Sulbactam 3 g IV q 8H
		or
	Antipneumococcal fluoroquinolone
		Plus
	Vancomycin or linezolid (if high rates of MRSA)
50
Q

What are the pathogens associated with VAP?

A

S.aureus, S. pneumoniae, H. influenzae, gram-negative Enterobacteriaceae

Pharmacology II (23 decks)

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