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Pharmacotherapy > Pneumonia > Flashcards

Pneumonia Flashcards

1
Q

Pathophysiology of pneumonia

A

2 pics in ppt

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2
Q

Some s/sx of pneumonia

A 
Productive cough with rusty sputum
SOB, dypsnea
Fever, chills
Headaches
Pleuritis chest pain
Muscle pain

Increase HR, RR
Rales

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3
Q

Difference between pneumonia and CHF exacerbation

A

CHF shows:
Enlarged heart
Effusion (vs consolidation like pneumonia)

Effusion: fluid in the lung
Consolidation: mass of fibrin, WBC, RBC in the lung

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4
Q

Difference between pneumonia and asthma exacerbation

A

Asthma shows:

No fever, no increased WBC, no productive cough, no purulence, more dry cough

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5
Q

Difference between pneumonia and bronchitis and viral infection

A

Most bronchitis is caused by virus

So ABx will not work, just cough for 14-21 days, may use OTC

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6
Q

Difference between pneumonia and COPD exacerbation

A

COPD shows:

No fever, no increase WBC

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7
Q

Community-acquired pneumonia (CAP) def

A

pneumonia that occurs >48hrs after admission

not incubating at the time of admission

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8
Q

Bacteria associated with pneumonia

A

Streptococcus pneumoniae
Mycoplasma pneumonia
Haemophilus influenza

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9
Q

Things to know about Streptococcus pneumoniae

A

Used to be the main cause of pneumonia, but declined for the last several years due to vaccination.
Still leading cause of pneumonia

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10
Q

Things to know about Mycoplasma pneumoniae

A

Atypical bacteria
mostly infect children and adolescents
“Walking pneumonia”: mild pneumonia

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11
Q

Things to know about Haemophilus influenza

A

If there’s H. influenza, there’s almost always S. pneumo

50% will produce beta-lactamase

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12
Q

CURB-65

A 
Confusion (person, place, time)
Uremia (BUN>20mg/dL)
Respiratory rate (>30 breaths/min)
Blood pressure (systolic <90mmHg or diastolic <60mmHg)
65yo or greater
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13
Q

CURB score 0, 1 means

A

Mild

Outpatient

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14
Q

CURB score 2 means

A

Moderate

Inpatient, no ICU

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15
Q

CURB score 3, 4 means

A

Severe

Inpatient , ICU

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16
Q

Two Primary Mechanisms for Macrolide Resistance

A

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

17
Q

Reason for high dose Augmentin in some cases

A

To overload the efflux pump (which cause ABx resistance)

18
Q

Some classes are afftected by efflux pump bacterial resistance

A

FQ, AG, Tetra, B-lactam, Macrolide

19
Q

Macrolide Resistant S. pneumoniae Criteria

A

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

20
Q

Treatment for CAP with no risk factors

A

Cover for sensitive S. pneumoniae with Macrolide:
Azithromycin: 500mg x1 dose, then 250mg daily x4days
Clarithromycin: 500mg BID x5days

21
Q

Treatment for CAP if meet criteria for Macrolide Resistance Risk (efflux pump production)

A 
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 days
22
Q

Treatment for CAP inpatient (Non-ICU)

A 
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 Q24h
23
Q

Treatment for CAP inpatient (ICU)

A

IV Beta-Lactam
+
Azithromycin OR Respiratory Fluoroquinolone

24
Q

In ICU, why macrolide has lower mortality rate compared to FQ even though FQ is usually better in efficacy?

A

Immunomodulatory effects of macrolide

25
Q

What is immunomodulatory effect?

A

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

26
Q

Duration for CAP staying in ICU

A

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

27
Q

HAP/VAP organisms

A 
common gram (-)
P. aeruginosa
Escherichia coli
Klebsiella pneumoniae
Acinetobacter species
28
Q

HAP/VAP organisms

A

common gram (+)
Streptococcus pneumo
Staph. aureus (from diabetes mellitus, head trauma, those in ICUs)

29
Q

HAP treatment step 1

A

Beta-Lactam with Pseudomonas + MSSA coverage

_ Β-lactam/B-lactamase inhibitor:
Piperacillin-tazobactam (Zosyn) is preferred

_ Cephalosporins:
Cefepime is preferred

_ Carbapenem:
Imipenem/cilastin
Meropenem

30
Q

HAP treatment step 2 (If needed)

A

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

31
Q

HAP treatment step 3 (if needed)

A

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

32
Q

Monitoring for HAP

A

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

33
Q

Monitoring for test

A

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

34
Q

Zosyn dosing for HAP

A

4.5g Q6H

35
Q

Cefepime dosing for HAP

A

2g Q12H

36
Q

Fluoroquinolone dosing for HAP

A 
Levofloxacin IV (750mg Q24h)
Ciprofloxacin IV (400mg Q8h)
37
Q

Aminoglycoside dosing for HAP

A

Gentamicin 7 mg/kg
Tobramycin 7 mg/kg
Amikacin 20 mg/kg

Pharmacotherapy (27 decks)

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