PNEUMONIA 2 Flashcards
Risk Stratification: Low Risk CAP
Therapy: W/o Comorbid illness
Amoxicillin or
Extended macrolides: azithromycin or clarithromycin
Risk Stratification: Low Risk CAP
Therapy: W/ stable Comorbid illness
- B-lactam combination or
2nd gen cephalosporin +/- extended macrolides - Co amoxiclav or sultamicillin or
Cefuroxime axetil +/- azithromycin or clarithromycin
Risk Stratification: Moderate Risk CAP
Therapy:
- IV non-antipseudomonal β-lactamd (BLIC, cephalosporin)
+ extended macrolidesa
or
respiratory fluoroquinolonese (PO)
- Ampicillin-Sulbactam IV OR Cefuroxime IV OR Ceftriaxone OD \+ Azithromycin PO OR Clarithromycin BID PO OR Levofloxacin PO OR Moxifloxacin OD PO
Risk Stratification: Moderate Risk CAP
If aspiration pneumonia is suspected.
Therapy:
A regimen containing ampicillin-sulbactam and/or moxifloxacin is used,
there is no need to add another antibiotic for additional anaerobic coverage.
If another combination is used may add clindamycin to the regimen to cover microaerophilic streptococci.
Risk Stratification: High Risk CAP
Therapy: No risk for P. aeruginosa
- IV non-antipseudomonal β-lactam
+ IV extended macrolidesa
or
IV respiratory fluoroquinolonese - Ceftriaxone OD OR
Ertapenem OD + Azithromycin dihydrate OD IV OR
Levofloxacin OD IV OR
Moxifloxacin OD IV
Risk Stratification: High Risk CAP
Therapy: Risk for P. aeruginosa
- IV antipneumococcal antipseudomonal β-lactam (BLIC, cephalosporin or carbapenem) + IV extended macrolidesa
+ aminoglycoside Piperacillin-tazobactam
OR
Cefepime 8-12h
OR
Meropenem q8h + Azithromycin dihydrate OD IV + Gentamicin OD OR
Amikacin OD
Risk Stratification: High Risk CAP
Therapy: MRSA pneumonia is suspected
Vancomycin q8-12 h OR Linezolid q12h IV OR Clindamycin q8h IV
Indications For Streamlining of Antibiotic Therapy
- Resolution of ___ for > 24 hours
- Less ___ & resolution of respiratory distress (normalization of respiratory rate)
- Improving ____, no bacteremia.
- Etiologic agent is not a ___ (virulent/resistant) pathogen e.g. Legionella, S. aureus or Gram-negative enteric bacilli
- No _____ such as myocardial infarction, congestive heart failure, complete heart block, new atrial fibrillation, supraventricular tachycardia, etc.
- No sign of organ dysfunction such as ____
- Patient is clinically ___, taking oral fluids and is
able to take oral medications
- fever
- cough
- white blood cell count
- high-risk
- unstable comorbid condition or life-threatening complication
- hypotension, acute mental changes, BUN to creatinine ratio of >10:1, hypoxemia, and metabolic acidosis
- hydrated
A significant pleural effusion should be tapped if – fluid pH – glucose level – lactate dehydrogenase concentration – bacteria
– fluid has a pH of <7
– glucose level of <2.2 mmol/L
– lactate dehydrogenase concentration of >1000 U/L
– bacteria are seen or cultured
During the 24 hours before discharge, the patient should have the following characteristics (unless this represents the baseline status):
- Temperature
- Pulse
- Respiratory rate
- Systolic BP
- Blood oxygen saturation
- gastrointestinal tract
- Temperature of 36-37.5C
- Pulse < 100/min
- Respiratory rate between 16-24/minute
- Systolic BP >90 mmHg
- Blood oxygen saturation >90%
- Functioning gastrointestinal tract
FOLLOW-UP
■ Fever and leukocytosis usually resolve
■ Chest radiographic abnormalities are slowest to resolve
■ Follow-up radiograph
■ Fever and leukocytosis usually resolve within 2–4 days
■ Chest radiographic abnormalities are slowest to resolve (4–12 weeks)
■ Follow-up radiograph ~4–6 weeks later is recommended.
Follow Up CPG: ■ 1 week: ■ 4 weeks: ■ 6 weeks: ■ 3 months: ■ 6 months:
■ 1 week: fever should have resolved
■ 4 weeks: chest pain and sputum production should have substantially reduced
■ 6 weeks: cough and breathlessness should have substantially reduced
■ 3 months: most symptoms should have resolved but fatigue may still be present
■ 6 months: most people will feel back to normal.
Prevention of CAP
■ pneumococcal polysaccharide vaccine (PPSV23)
– contains capsular material from 23 pneumococcal serotypes
■ protein conjugate pneumococcal vaccine (PCV13)
– produces T cell–dependent antigens that result in long-term immunologic memory
■ Influenza vaccine
– available in an inactivated or recombinant form
MDR Pathogens/ Microbiologic Causes of Ventilator- Associated Pneumonia
- P. aeruginosa
- MRSA
- Acinetobacter spp.
- ARE (Antibiotic-resistant Enterobacteriaceae
ESBL-positive strains an Carbapenem-resistant strains - Legionella pneumophila
- Burkholderia cepacia
- Aspergillus spp.
Three factors are critical in the pathogenesis of VAP:
– colonization of the oropharynx with pathogenic microorganisms,
– aspiration of these organisms from the oropharynx into the lower respiratory tract,
– compromise of normal host defense mechanisms.
