Pneumonia

Question 1

Pathophysiology of pneumonia

Answer 1

2 pics in ppt

Question 2

Some s/sx of pneumonia

Answer 2

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

Increase HR, RR
Rales

Question 3

Difference between pneumonia and CHF exacerbation

Answer 3

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

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

Question 4

Difference between pneumonia and asthma exacerbation

Answer 4

Asthma shows:

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

Question 5

Difference between pneumonia and bronchitis and viral infection

Answer 5

Most bronchitis is caused by virus

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

Question 6

Difference between pneumonia and COPD exacerbation

Answer 6

COPD shows:

No fever, no increase WBC

Question 7

Community-acquired pneumonia (CAP) def

Answer 7

pneumonia that occurs >48hrs after admission

not incubating at the time of admission

Question 8

Bacteria associated with pneumonia

Answer 8

Streptococcus pneumoniae
Mycoplasma pneumonia
Haemophilus influenza

Question 9

Things to know about Streptococcus pneumoniae

Answer 9

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

Question 10

Things to know about Mycoplasma pneumoniae

Answer 10

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

Question 11

Things to know about Haemophilus influenza

Answer 11

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

50% will produce beta-lactamase

Question 12

CURB-65

Answer 12

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

Question 13

CURB score 0, 1 means

Answer 13

Mild

Outpatient

Question 14

CURB score 2 means

Answer 14

Moderate

Inpatient, no ICU

Question 15

CURB score 3, 4 means

Answer 15

Severe

Inpatient , ICU

Question 16

Two Primary Mechanisms for Macrolide Resistance

Answer 16

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

Question 17

Reason for high dose Augmentin in some cases

Answer 17

To overload the efflux pump (which cause ABx resistance)

Question 18

Some classes are afftected by efflux pump bacterial resistance

Answer 18

FQ, AG, Tetra, B-lactam, Macrolide

Question 19

Macrolide Resistant S. pneumoniae Criteria

Answer 19

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

Question 20

Treatment for CAP with no risk factors

Answer 20

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

Question 21

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

Answer 21

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

Question 22

Treatment for CAP inpatient (Non-ICU)

Answer 22

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

Question 23

Treatment for CAP inpatient (ICU)

Answer 23

IV Beta-Lactam
+
Azithromycin OR Respiratory Fluoroquinolone

Question 24

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

Answer 24

Immunomodulatory effects of macrolide

Question 25

What is immunomodulatory effect?

Answer 25

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

Question 26

Duration for CAP staying in ICU

Answer 26

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

Question 27

HAP/VAP organisms

Answer 27

``` common gram (-) P. aeruginosa Escherichia coli Klebsiella pneumoniae Acinetobacter species ```

Question 28

HAP/VAP organisms

Answer 28

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

Question 29

HAP treatment step 1

Answer 29

Beta-Lactam with Pseudomonas + MSSA coverage _ Β-lactam/B-lactamase inhibitor: Piperacillin-tazobactam (Zosyn) is preferred _ Cephalosporins: Cefepime is preferred _ Carbapenem: Imipenem/cilastin Meropenem

Question 30

HAP treatment step 2 (If needed)

Answer 30

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

Question 31

HAP treatment step 3 (if needed)

Answer 31

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

Question 32

Monitoring for HAP

Answer 32

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 cx negative consider switch to po for tx completion cx positive- ∆ to pathogen directed regimen

Question 33

Monitoring for test

Answer 33

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

Question 34

Zosyn dosing for HAP

Answer 34

4.5g Q6H

Question 35

Cefepime dosing for HAP

Answer 35

2g Q12H

Question 36

Fluoroquinolone dosing for HAP

Answer 36

``` Levofloxacin IV (750mg Q24h) Ciprofloxacin IV (400mg Q8h) ```

Question 37

Aminoglycoside dosing for HAP

Answer 37

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