Pneumonia Flashcards
Pathophysiology of pneumonia
2 pics in ppt
Some s/sx of pneumonia
Productive cough with rusty sputum SOB, dypsnea Fever, chills Headaches Pleuritis chest pain Muscle pain
Increase HR, RR
Rales
Difference between pneumonia and CHF exacerbation
CHF shows:
Enlarged heart
Effusion (vs consolidation like pneumonia)
Effusion: fluid in the lung
Consolidation: mass of fibrin, WBC, RBC in the lung
Difference between pneumonia and asthma exacerbation
Asthma shows:
No fever, no increased WBC, no productive cough, no purulence, more dry cough
Difference between pneumonia and bronchitis and viral infection
Most bronchitis is caused by virus
So ABx will not work, just cough for 14-21 days, may use OTC
Difference between pneumonia and COPD exacerbation
COPD shows:
No fever, no increase WBC
Community-acquired pneumonia (CAP) def
pneumonia that occurs >48hrs after admission
not incubating at the time of admission
Bacteria associated with pneumonia
Streptococcus pneumoniae
Mycoplasma pneumonia
Haemophilus influenza
Things to know about Streptococcus pneumoniae
Used to be the main cause of pneumonia, but declined for the last several years due to vaccination.
Still leading cause of pneumonia
Things to know about Mycoplasma pneumoniae
Atypical bacteria
mostly infect children and adolescents
“Walking pneumonia”: mild pneumonia
Things to know about Haemophilus influenza
If there’s H. influenza, there’s almost always S. pneumo
50% will produce beta-lactamase
CURB-65
Confusion (person, place, time) Uremia (BUN>20mg/dL) Respiratory rate (>30 breaths/min) Blood pressure (systolic <90mmHg or diastolic <60mmHg) 65yo or greater
CURB score 0, 1 means
Mild
Outpatient
CURB score 2 means
Moderate
Inpatient, no ICU
CURB score 3, 4 means
Severe
Inpatient , ICU
Two Primary Mechanisms for Macrolide Resistance
Methylases encoded by erm (erythromycin ribosome methylase) genes:
_ alter macrolide binding site on bacterial ribosomal RNA, yield high degree resist
_ complete cross-resistance eryth to azith to clarith for gram-positive
Active macrolide efflux pumps, encoded by the mef (macrolide efflux), yield low to moderate resist
Reason for high dose Augmentin in some cases
To overload the efflux pump (which cause ABx resistance)
Some classes are afftected by efflux pump bacterial resistance
FQ, AG, Tetra, B-lactam, Macrolide
Macrolide Resistant S. pneumoniae Criteria
Avoid Azithromycin, Erythromycin, Clarithromycin as empiric first-line therapy:
_ Comorbidities (heart, lung, liver, kidney disease; DM; EtOHism)
_ Immunosuppressant drug therapy
_ Use of antibiotic in previous 3 months
_ <2 or >65yo
Treatment for CAP with no risk factors
Cover for sensitive S. pneumoniae with Macrolide:
Azithromycin: 500mg x1 dose, then 250mg daily x4days
Clarithromycin: 500mg BID x5days
Treatment for CAP if meet criteria for Macrolide Resistance Risk (efflux pump production)
Respiratory Fluoroquinolone:
_ Levofloxacin 750mg PO Q24h x 5 days
_ Moxifloxacin 400mg PO Q24h x 5 days
OR
High Dose Beta-Lactam + Macrolide
_ Amoxicillin 1gm TID x 5 days
_ Amoxicillin/clav XR 2gm BID x 5 daysTreatment for CAP inpatient (Non-ICU)
Pneumococcal fluoroquinolone x 7days
Levofloxacin 750mg IV/PO Q24h,
Moxifloxacin 400mg IV/PO Q24h
OR
Beta-Lactam + Macrolide
Ceftriaxone 1gm IV Q24h
Cefotaxime 2gm IV Q8h
\+
Azithromycin 500mg IV/PO Q24hTreatment for CAP inpatient (ICU)
IV Beta-Lactam
+
Azithromycin OR Respiratory Fluoroquinolone
In ICU, why macrolide has lower mortality rate compared to FQ even though FQ is usually better in efficacy?
Immunomodulatory effects of macrolide
What is immunomodulatory effect?
Increased mucociliary action, increased cilia movement, increase sputum movement, increase pleural edema clearance, increase oxygenation and O2 Sat
Decreased mucous secretion,
Reduced production of proinflammatory cytokines, reduce chance to go to shock
Duration for CAP staying in ICU
Minimum 5 days
Should be afebrile for 48-72h
Signs of clinical instability resolved
- HR> 100 bpm -RR> 24 bpm
- SBP< 90 mmHg -O2 sat< 90%
- unable to maintain oral intake (new)
- altered mental status (new)
Generally:
5 days for non-severe
7 days for severe
HAP/VAP organisms
common gram (-) P. aeruginosa Escherichia coli Klebsiella pneumoniae Acinetobacter species
HAP/VAP organisms
common gram (+)
Streptococcus pneumo
Staph. aureus (from diabetes mellitus, head trauma, those in ICUs)
HAP treatment step 1
Beta-Lactam with Pseudomonas + MSSA coverage
_ Β-lactam/B-lactamase inhibitor:
Piperacillin-tazobactam (Zosyn) is preferred
_ Cephalosporins:
Cefepime is preferred
_ Carbapenem:
Imipenem/cilastin
Meropenem
HAP treatment step 2 (If needed)
Unit >20% S. aureus is MRSA
Unit MRSA rate unknown
If met, then use drugs with MRSA coverage
_ Glycopeptide: Vancomycin
_ Oxazolidinone: Linezolid
All works on cell wall
HAP treatment step 3 (if needed)
IV Abx in last 90-days
Need Vent
Septic Shock
If met, then use Non Beta-Lactam (Psa and inconsistent MSSA):
Fluoroquinolone:
- Levofloxacin IV
- Ciprofloxacin IV
Aminoglycoside:
- Gentamicin
- Tobramycin
- Amikacin
Work intracellular
Monitoring for HAP
De-escalate within 48-72 hours with clinical improvement and culture results
Treat for 7 days (if clinical improvement)
Clinically unimproved
wrong bug, drug, dx, host factors
cx negative- look for alternative causes
cx positive- adjust abx accordingly
Clinically improved
cxnegative
consider switch to po for tx completion
cx positive- ∆ to pathogen directed regimen
Monitoring for test
fever, HR, RR- >daily
WBCs- daily
clinical improvement/progression- daily
SCr, renally adjusted medication- daily
cx’s/sensitivities- daily until final
drug tolerance, side effects, interaction
Zosyn dosing for HAP
4.5g Q6H
Cefepime dosing for HAP
2g Q12H
Fluoroquinolone dosing for HAP
Levofloxacin IV (750mg Q24h) Ciprofloxacin IV (400mg Q8h)
Aminoglycoside dosing for HAP
Gentamicin 7 mg/kg
Tobramycin 7 mg/kg
Amikacin 20 mg/kg
